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Papsmear.html
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Papsmear.html
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<html>
<head>
<meta name="viewport" content="width=device-width, initial-scale=1">
<link href="css/bootstrap.min.css" rel="stylesheet">
<link href="css/muzima.css" rel="stylesheet">
<link href="css/ui-darkness/jquery-ui-1.10.4.custom.min.css" rel="stylesheet">
<script src="js/jquery.min.js"></script>
<script src="js/jquery-ui-1.10.4.custom.min.js"></script>
<script src="js/jquery.validate.min.js"></script>
<script src="js/additional-methods.min.js"></script>
<script src="js/muzima.js"></script>
<title>Papsmear Form v 0.01</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<form class="relevant-female" id="papsmear_form" name="papsmear_form">
<h2 class="text-center">Papsmear Form v 0.01</h2>
<div class="section">
<h3>Demographics</h3>
<div class="form-group">
<input class="form-control" id="patient.uuid" name="patient.uuid" type="hidden" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.medical_record_number">AMRS ID Number:</label>
<input class="form-control" id="patient.medical_record_number" name="patient.medical_record_number"
type="text" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.family_name">Family Name:</label>
<input class="form-control" id="patient.family_name" name="patient.family_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.given_name">Given Name:</label>
<input class="form-control" id="patient.given_name" name="patient.given_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.middle_name">Middle Name:</label>
<input class="form-control" id="patient.middle_name" name="patient.middle_name" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.sex">Gender:</label>
<select class="form-control" id="patient.sex" name="patient.sex" disabled="disabled">
<option value="">...</option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</div>
<div class="form-group">
<label for="patient.birth_date">Date Of Birth:</label>
<input class="form-control" id="patient.birth_date" name="patient.birth_date" type="text"
readonly="readonly" disabled="disabled">
</div>
</div>
<div class="section">
<h3>Encounter Details</h3>
<div class="form-group">
<label for="encounter.location_id">Name of Dispensary:<span class="required">*</span></label>
<input class="form-control valid-location-only" id="encounter.location_id" type="text" placeholder="Start typing something..." required="required">
<input class="form-control" name="encounter.location_id" type="hidden">
</div>
<div class="form-group hidden">
<label for="encounter.location_id_select">Screening Site:<span class="required">*</span></label>
<select class="form-control" id="encounter.location_id_select" required="required">
<option>...</option>
<option value="84" data-location="AMPATH-MTRH">AMPATH-MTRH</option>
<option value="19" data-location="Busia">Busia</option>
<option value="7" data-location="Chulaimbo">Chulaimbo</option>
<option value="17" data-location="Iten">Iten</option>
<option value="11" data-location="Kitale">Kitale</option>
<option value="2" data-location="Mosoriot Health Centre">Mosoriot Health Centre</option>
<option value="20" data-location="Port Victoria">Port Victoria</option>
<option value="12" data-location="Teso District Hospital">Teso District Hospital</option>
<option value="3" data-location="Turbo Health Centre">Turbo Health Centre</option>
<option value="8" data-location="Webuye">Webuye</option>
</select>
</div>
<div class="form-group">
<label for="encounter.encounter_datetime">Encounter Date:<span class="required">*</span></label>
<input class="form-control datepicker nonFutureDate past-date" id="encounter.encounter_datetime"
name="encounter.encounter_datetime" type="text" readonly="readonly"
required="required">
</div>
<div class="form-group">
<input class="form-control" id="encounter.form_uuid" name="encounter.form_uuid" type="hidden"
required="required">
</div>
</div>
<div class="section">
<h3>Observation Details </h3>
<div class="form-group">
<label for="obs.last_menstrual_period_date">First day of your last menstrual period (LMP)
<span class="required">*</span>
</label>
<input class="form-control datepicker nonFutureDate past-date" id="obs.last_menstrual_period_date"
name="last_menstrual_period_date" type="text" data-concept="1836^LAST MENSTRUAL PERIOD DATE^99DCT"
required="required" readonly="readonly">
</div>
<div class="section">
<h4>Select all symptoms that best describe complaints</h4>
<fieldset name="5219^CHIEF COMPLAINT^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.pain" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="6613^PAIN^99DCT">
Pain
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.asymptomatic" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="5006^ASYMPTOMATIC^99DCT">
Asymptomatic
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.having_hypoglycemia_symptoms_in_past_month" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT"
value="8008^HAVING HYPOGLYCEMIA SYMPTOMS IN PAST MONTH^99DCT">
Hypoglycemia symptoms in past month
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.vaginal_discharge" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="5993^VAGINAL DISCHARGE^99DCT">
Vaginal discharge
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.vaginal_bleeding" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="1489^VAGINAL BLEEDING^99DCT">
Vaginal bleeding
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.dysfunctional_uterine_bleeding" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="6497^DYSFUNCTIONAL UTERINE BLEEDING^99DCT">
Dysfunctional uterine bleeding
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.menorrhagia" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="1461^MENORRHAGIA^99DCT">
Menorrhagia
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.postmenopausal_bleeding" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="8274^POSTMENOPAUSAL BLEEDING^99DCT">
Postmenopausal bleeding
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.postcoital_bleeding" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="8273^POSTCOITAL BLEEDING^99DCT">
Postcoital bleeding
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="chief_complaint.none" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="chief_complaint.other_non_coded" type="checkbox"
data-concept="5219^CHIEF COMPLAINT^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="chief_complaint.freetext_general">Specify:<span class="required">*</span></label>
<textarea class="form-control" name="chief_complaint.freetext_general"
id="chief_complaint.freetext_general"
data-concept="1915^FREETEXT GENERAL^99DCT"></textarea>
</div>
</fieldset>
</div>
<div class="section">
<h4>Current family planning method</h4>
<fieldset name="374^METHOD OF FAMILY PLANNING^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.condoms" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="190^CONDOMS^99DCT">
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.female_sterilization" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="5276^FEMALE STERILIZATION^99DCT">
Sterilization / Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.intrauterine_device" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="5275^INTRAUTERINE DEVICE^99DCT">
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.diaphragm" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="5278^DIAPHRAGM^99DCT">
Diaphragm / Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.family_planning_via_oral_contraceptive_pills" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="780^ORAL CONTRACEPTION^99DCT">
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.natural_family_planning" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="5277^NATURAL FAMILY PLANNING^99DCT">
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.injectable_contraceptives" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="5279^INJECTABLE CONTRACEPTIVES^99DCT">
Injectable hormonesa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.contraceptive_implant" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="6220^CONTRACEPTIVE IMPLANT^99DCT">
Implant / Patching
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.none" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.do_not_know" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT" value="1624^DO NOT KNOW^99DCT">
Do not know
</label>
</div>
</fieldset>
</div>
<div class="section">
<h4>Prior PAP results</h4>
<fieldset name="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.normal" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.atypical_squamous_cells_of_undetermined_significance" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7417^ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE ^99DCT">
Atypical squamous cells of undetermined significance
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.atypical_glandular_cells_of_undetermined_significance" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7418^ATYPICAL GLANDULAR CELLS OF UNDETERMINED SIGNIFICANCE ^99DCT">
Atypical glandular cells of undetermined significance
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.low_grade_squamous_intraepithelial_lesion" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7419^LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION^99DCT">
Low grade squamous intraepithelial lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.high_grade_squamous_intraepithelial_lesion" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7420^HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION^99DCT">
High grade squamous intraepithelial lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.squamous_cell_carcinoma_not_otherwise_specified" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7421^SQUAMOUS CELL CARCINOMA, NOT OTHERWISE SPECIFIED ^99DCT">
Squamous cell carcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.adenocarcinoma" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7422^ADENOCARCINOMA ^99DCT">
Adenocarcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.do_not_know" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="1624^DO NOT KNOW^99DCT">
Do not know
</label>
</div>
<div class="form-group" id="date_most_recent_papanicolaou_smear_performed_div" >
<label for="date_most_recent_papanicolaou_smear_performed">Date of most recent PAP result</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_most_recent_papanicolaou_smear_performed"
name="date_most_recent_papanicolaou_smear_performed" type="text" readonly="readonly"
data-concept="6727^DATE MOST RECENT PAPANICOLAOU SMEAR PERFORMED^99DCT">
</div>
</fieldset>
</div>
</div>
<div class="section">
<div class="form-group">
<label for="encounter.provider_id_select">Provider Name:</label>
<input class="form-control valid-provider-only" id="encounter.provider_id_select" type="text"
placeholder="Start typing provider name here ...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group hidden">
<select id="select_providers">
<option data-provider = "Daurine Achieng Agumba" value = "3419-9">Daurine Achieng Agumba</option>
<option data-provider = "Irene Chepkosgei Kurgat" value = "3420-7">Irene Chepkosgei Kurgat</option>
<option data-provider = "Rose Cheruto Toroitich" value = "3421-5">Rose Cheruto Toroitich</option>
<option data-provider = "Mary Kipkurui Kimosop" value = "3422-3">Mary Kipkurui Kimosop</option>
<option data-provider = "Jacqueline Chemom Ndiema" value = "3423-1">Jacqueline Chemom Ndiema</option>
<option data-provider = "Grace Wanjiru Mwangi" value = "3424-9">Grace Wanjiru Mwangi</option>
<option data-provider = "Collette Mabia Palapala" value = "3425-6">Collette Mabia Palapala</option>
<option data-provider = "Dorice Erima Wekesa Female" value = "3426-4">Dorice Erima Wekesa Female</option>
<option data-provider = "Agnes Kagure Boen" value = "120-6">Agnes Kagure Boen</option>
<option data-provider = "Linet Kerubo Onyancha" value = "3427-2">Linet Kerubo Onyancha</option>
<option data-provider = "Delinah Muchai Tanui" value = "1208-8">Delinah Muchai Tanui</option>
<option data-provider = "Hellen Mushimbi Indumbwe" value = "3321-7">Hellen Mushimbi Indumbwe</option>
<option data-provider = "Lydia Cherugut Samoei" value = "1525-5">Lydia Cherugut Samoei</option>
<option data-provider = "Ruth Kalunda Nzili" value = "1529-7">Ruth Kalunda Nzili</option>
<option data-provider = "Lucy Cheruto Birgen" value = "3428-0">Lucy Cheruto Birgen</option>
<option data-provider = "Gratiah Nafuna Khaemba" value = "1409-2">Gratiah Nafuna Khaemba</option>
<option data-provider = "Leonida Chemutai Mengich" value = "1357-3">Leonida Chemutai Mengich</option>
<option data-provider = "Ann Wangoi Maina" value = "1412-6">Ann Wangoi Maina</option>
<option data-provider = "Elkanah Omenge Orango" value = "1474-6">Elkanah Omenge Orango</option>
<option data-provider = "Peter Mukhanadale Istura" value = "1478-7">Peter Mukhanadale Istura</option>
<option data-provider = "Hillary Mabeya" value = "1476-1">Hillary Mabeya</option>
<option data-provider = "Astrid Christoffersen Deb" value = "1237-7">Astrid Christoffersen Deb</option>
<option data-provider = "Philip Kipkirui Tonui" value = "1485-7">Philip Kipkirui Tonui</option>
<option data-provider = "Ann Jebet Ngelel" value = "3613-7">Ann Jebet Ngelel</option>
<option data-provider = "Job Wekesa Wamukaya" value = "3614-5">Job Wekesa Wamukaya</option>
<option data-provider = "Joyce Chepkorir Chessum" value = "3615-2">Joyce Chepkorir Chessum</option>
<option data-provider = "Monica Chelimo Rotich" value = "3616-0">Monica Chelimo Rotich</option>
<option data-provider = "Penina Jerotich Biwott" value = "3617-8">Penina Jerotich Biwott</option>
<option data-provider = "Peter Gachingi Kamau" value = "3618-6">Peter Gachingi Kamau</option>
<option data-provider = "Phanice Jepkemoi Tomu" value = "3619-4">Phanice Jepkemoi Tomu</option>
<option data-provider = "Phyllis Jelagat Bartilol" value = "3620-2">Phyllis Jelagat Bartilol</option>
<option data-provider = "Roselyne Yatich" value = "3621-0">Roselyne Yatich</option>
<option data-provider = "Ruth Sego" value = "3622-8">Ruth Sego</option>
<option data-provider = "Yosabia Osebe Monari" value = "3623-6">Yosabia Osebe Monari</option>
<option data-provider = "Philip Kipkirui Tonui" value = "1485-7">Philip Kipkirui Tonui</option>
</select>
</div>
<div class="form-group show_provider_id_text">
<label for="encounter.provider_id">Provider's system-id:<span class="required">*</span></label>
<input class="form-control checkDigit" id="encounter.provider_id" name="encounter.provider_id" type="text"
required="required" disabled="disabled">
</div>
<div class="form-group">
<label for="freetext_general">Comments</label>
<input class="form-control" id="freetext_general" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</div>
</form>
</body>
<script type="text/javascript">
$(document).ready(function () {
var dateFormat = "dd-mm-yy";
var currentDate = $.datepicker.formatDate(dateFormat, new Date());
var encounterDatetime = $('#encounter\\.encounter_datetime');
if ($(encounterDatetime).val() == "") {
$(encounterDatetime).val(currentDate);
}
$('#save_draft').click(function () {
$(this).prop('disabled', true);
document.saveDraft(this);
$(this).prop('disabled', false);
});
$('#submit_form').click(function () {
$(this).prop('disabled', true);
document.submit();
$(this).prop('disabled', false);
});
var locationName = [
{"val": "7", "label": "Chulaimbo"},
{"val": "3", "label": "Turbo"},
{"val": "17", "label": "Iten"},
{"val": "2", "label": "Mosoriot"},
{"val": "8", "label": "Webuye"},
{"val": "84", "label": "Ampath MTRH"},
{"val": "11", "label": "Kitale"},
{"val": "19", "label": "Busia"}
];
document.setupAutoCompleteData('encounter\\.location_id');
document.setupAutoCompleteDataForProvider('encounter\\.provider_id_select');
$('#encounter\\.provider_id_select').change(function () {
if ($('#encounter\\.provider_id_select').val() === '') {
$('#encounter\\.provider_id').val('');
$('.show_provider_id_text').show();
}
});
var $patientSex = $('#patient\\.sex');
$patientSex.change(function () {
var $womenOnly = $('.relevant-female');
if ($patientSex.val() != 'F') {
$womenOnly.hide();
$('body').html("<div class='section text-center'><h4>This form is only applicable to female patient. " +
"Please press back to close the form.</h4></div>");
} else {
$womenOnly.show();
}
});
$patientSex.trigger('change');
$('#papsmear_form').validate({});
$.fn.customValidationCheck = function () {
return true;
};
document.disableDate = function(testResult,testResultDate){
$('#' + testResult).change(function() {
if($(this).is(":checked")) {
$("#" + testResultDate).hide();
} else{
$("#" + testResultDate).show();
}
});
}
document.disableDate('papanicolaou_result\\.do_not_know','date_most_recent_papanicolaou_smear_performed_div');
var noneAndDontKnowValues = ["1107^NONE^99DCT", "1624^DO NOT KNOW^99DCT"];
var noneAndDontKnowMessage = "If None or Don't Know is selected, it should be the only option.";
$(':checkbox[data-concept="374^METHOD OF FAMILY PLANNING^99DCT"]').change(function () {
toggleValidationMessages(validateAlone($(this), noneAndDontKnowValues, noneAndDontKnowMessage));
});
var noneValues = ["1107^NONE^99DCT"];
var noneMessage = "If None is selected, it should be the only option.";
$(':checkbox[data-concept="5219^CHIEF COMPLAINT^99DCT"]').change(function () {
toggleValidationMessages(validateAlone($(this), noneValues, noneMessage));
});
var papanicolaouValues = ['1115^NORMAL^99DCT', '1624^DO NOT KNOW^99DCT'];
var papanicolaouMessage = "If Normal or Don't Know is selected, it should be the only option.";
$(':checkbox[data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"]').change(function () {
toggleValidationMessages(validateAlone($(this), papanicolaouValues, papanicolaouMessage));
});
/* End - Example of calling above validation */
document.setupValidationForLocation("$('#encounter\\.location_id').val()","encounter\\.location_id");
document.setupValidationForProvider("$('#encounter\\.provider_id_select').val()","encounter\\.provider_id");
});
</script>
</html>