/
Via.html
1485 lines (1398 loc) · 71.8 KB
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Via.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>CCSP VIA Form v 0.01</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<h2 class="text-center">CCSP VIA Form v 0.01</h2>
<form class="relevant-female" id="via_form" name="via_form">
<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" disabled="disabled">
</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"
disabled="disabled">
</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"
disabled="disabled">
</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"
disabled="disabled">
</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 relevant_female">
<div class="form-group">
<label for="current_visit_type">
What is the current visit type?<span class="required">*</span>
</label>
<select class="form-control" id="current_visit_type" name="current_visit_type"
data-concept="1839^CURRENT VISIT TYPE^99DCT" required="required">
<option value="">...</option>
<option value="7850^INITIAL VISIT ^99DCT">New Visit</option>
<option value="2345^FOLLOW-UP^99DCT">Revisit</option>
</select>
</div>
<div class="form-group">
<label for="menstruation_status">How are your menstrual periods?<span class="required">*</span></label>
<div>
<small><i>Screener to select one best option.</i></small>
</div>
<select class="form-control" id="menstruation_status" name="menstruation_status"
data-concept="2061^MENSTRUATION STATUS^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="1116^ABNORMAL^99DCT">Abnormal periods</option>
<option value="2060^AMENORRHEA^99DCT">Completely absent</option>
<option value="7023^PRE-MENOPAUSAL^99DCT">Pre-menopausal</option>
<option value="5990^MENOPAUSAL^99DCT">Menopausal</option>
<option value="6496^POST-MENOPAUSAL^99DCT">Post-menopausal</option>
<option value="6497^DYSFUNCTIONAL UTERINE BLEEDING^99DCT">Abnormal bleeding not related to periods</option>
</select>
</div>
<div class="form-group last_menstrual_period_date">
<label for="last_menstrual_period_date">First day of your last period (LMP)<span
class="required">*</span></label>
<input class="form-control datepicker nonFutureDate past-date" id="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="form-group urine_pregnancy_test_qualitative">
<label for="urine_pregnancy_test_qualitative">Urine pregnancy test<span class="required">*</span></label>
<div>
<small><i>Test that determines pregnancy status through measure of hormone content in urine.</i></small>
</div>
<select class="form-control" id="urine_pregnancy_test_qualitative" name="urine_pregnancy_test_qualitative"
data-concept="45^URINE PREGNANCY TEST, QUALITATIVE^99DCT" required="required">
<option value="">...</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="1138^INDETERMINATE^99DCT">Indeterminate</option>
<option value="1304^POOR SAMPLE QUALITY^99DCT">Poor sample quality</option>
<option value="1118^NOT DONE^99DCT">Not Done</option>
<option value="1958^REFUSAL^99DCT">Refusal</option>
</select>
</div>
<div class="section reason_for_lack_of_period" data-concept="9169^REASON FOR LACK OF PERIOD, DETAILED^99DCT">
<div class="form-group">
<label for="reason_for_lack_of_period">
Do you know why you are not having your period?<span class="required">*</span>
</label>
<select class="form-control has-freetext" id="reason_for_lack_of_period" name="reason_for_lack_of_period"
data-concept="8252^REASON FOR LACK OF PERIOD^99DCT" required="required">
<option value="">...</option>
<option value="1484^PREGNANT^99DCT">Pregnant</option>
<option value="1402^BREASTFED^99DCT">Breastfeeding</option>
<option value="6496^POST-MENOPAUSAL^99DCT">Due to age</option>
<option value="1624^DO NOT KNOW^99DCT">Do not know</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group freetext">
<label for="freetext_general_1">Specify</label>
<input class="form-control" id="freetext_general_1" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</div>
<div class="form-group">
<label for="gravida">Number of previous pregnancies<span class="required">*</span></label>
<div>
<small><i>If client has never been pregnant, enter '0'.</i></small>
</div>
<input class="form-control gravida" id="gravida" name="gravida" type="number" data-concept="5624^GRAVIDA^99DCT"
required="required">
</div>
<div class="form-group">
<label for="parity">Number of previous deliveries<span class="required">*</span></label>
<div>
<small><i>The number of children a woman has delivered?</i></small>
</div>
<input class="form-control " id="parity" name="parity" type="number"
data-concept="1053^PARITY^99DCT" required="required">
</div>
<div class="form-group">
<label for="hiv_status">HIV status</label>
<select class="form-control" id="hiv_status" name="hiv_status"
data-concept="6709^HIV STATUS^99DCT">
<option value="">...</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="1067^UNKNOWN^99DCT">Unknown</option>
</select>
</div>
<div class="form-group relevant_hiv_status hidden">
<label for="last_cd4_by_facs">Latest CD4 count</label>
<input class="form-control" id="last_cd4_by_facs" name="last_cd4_by_facs" type="number"
data-concept="1871^LAST CD4, BY FACS^99DCT">
</div>
<div class="form-group relevant_hiv_status hidden">
<label for="date_of_last_cd4_by_facs">Date of latest CD4 count</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_of_last_cd4_by_facs" name="date_last_cd4_by_facs"
type="text" data-concept="1871^LAST CD4, BY FACS^99DCT^DATE">
</div>
<div class="form-group relevant_current_visit_type">
<label for="most_recent_via">Prior Visual Inspection with Acetic Acid (VIA)</label>
<div>
<small><i>Patient's most recent Visual Inspection with Acetic Acid (VIA) screening.</i></small>
</div>
<select class="form-control" id="most_recent_via" name="most_recent_via"
data-concept="7381^MOST RECENT VISUAL INSPECTION WITH ACETIC ACID RESULT^99DCT">
<option value="">...</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="1175^NOT APPLICABLE^99DCT">Not Applicable</option>
</select>
</div>
</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" data-concept="8916^CHIEF COMPLAINT, DETAILED^99DCT">
<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="freetext_general_2">Specify</label>
<input class="form-control" id="freetext_general_2" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
</div>
<div class="section" data-concept="9170^VISUAL CERVICAL EXAM FINDINGS, DETAILED^99DCT">
<h4>Visual cervical exam findings</h4>
<div class="help-block">
<small><i>Findings on the cervix based on a performed exam.</i></small>
</div>
<fieldset name="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.normal" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.cervical_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7424^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Cervical intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.cervical_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Cervical intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.cervical_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3 ^99DCT">
Cervical intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.cervical_cancer" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="6537^CERVICAL CANCER^99DCT">
Cervical cancer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.positive_via_with_aceto_white_area" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7507^POSITIVE VISUAL INSPECTION WITH ACETIC ACID WITH ACETO WHITE AREA^99DCT">
Positive visual inspection with acetic acid with aceto white area
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.positive_via_with_suspicious_lesion" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7508^POSITIVE VISUAL INSPECTION WITH ACETIC ACID WITH SUSPICIOUS LESION^99DCT">
Positive visual inspection with acetic acid with suspicious lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="cervical_exam.other_non_coded" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>
<div class="section" data-concept="9171^VISUAL VAGINAL EXAM FINDINGS, DETAILED^99DCT">
<h4>Visual vaginal exam findings</h4>
<div class="help-block">
<small><i>Findings on the vagina based on a performed exam.</i></small>
</div>
<fieldset name="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.normal" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.suspicion_of_cancer_vaginal_lesion" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="9181^SUSPICIOUS OF CANCER, VAGINAL LESION^99DCT">
Vaginal lesion suspicious of cancer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.vaginal_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7492^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Vaginal intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.vaginal_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7491^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 2 ^99DCT">
Vaginal intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.vaginal_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7435^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Vaginal intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="vaginal_exam.other_non_coded" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="freetext_general_3">Specify</label>
<input class="form-control" id="freetext_general_3" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
</div>
<div class="section" data-concept="9172^VISUAL VULVAL EXAM FINDINGS, DETAILED^99DCT">
<h4>Visual vulval exam findings</h4>
<div class="help-block">
<small><i>Findings on the vulva based on a performed exam.</i></small>
</div>
<fieldset name="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="vulval_exam.normal" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vaginal_exam.suspicion_of_cancer_vulva_lesion" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="9177^SUSPICIOUS OF CANCER, VULVA LESION^99DCT">
Vulva lesion suspicious for cancer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vulval_exam.condyloma_or_vulvar_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7489^CONDYLOMA OR VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Condyloma or vulvar intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vulval_exam.vulvar_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7488^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Vulvar intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="vulval_exam.vulvar_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7483^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Vulvar intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="vulval_exam.other_non_coded" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="freetext_general_4">Specify</label>
<input class="form-control" id="freetext_general_4" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
</div>
<div class="section">
<div class="section repeat procedures_detailed" id="procedures_detailed"
data-name="procedures_detailed"
data-concept="7480^PROCEDURES DONE THIS VISIT, DETAILED^99DCT">
<div class="form-group">
<label for="procedures_done_this_visit">Procedure done this visit<span class="required">*</span></label>
<select class="form-control" id="procedures_done_this_visit"
name="procedures_done_this_visit"
data-concept="7479^PROCEDURES DONE THIS VISIT^99DCT" required="required">
<option value="">...</option>
<option value="6511^EXCISIONAL OR SURGICAL BIOPSY^99DCT">Biopsies</option>
<option value="7478^ENDOCERVICAL CURETTAGE^99DCT">Endocervical curettage (ECC)</option>
<option value="7466^CRYOTHERAPY^99DCT">Cryotherapy</option>
<option value="7147^LOOP ELECTROSURGICAL EXCISION PROCEDURE^99DCT">
Loop Electrosurgical Excision Procedure (LEEP)
</option>
<option value="9434^Visual Inspection with Acetic Acid(VIA)^99DCT">
Visual Inspection with Acetic Acid(VIA)
</option>
<option class="procedure_done_none" value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group relevant_procedures_done_this_visit_leep">
<label for="anatomic_location_description">Provide Location of specimen</label>
<select class="form-control" id="anatomic_location_description"
name="anatomic_location_description"
data-concept="8268^ANATOMIC LOCATION DESCRIPTION^99DCT">
<option value="">...</option>
<option value="8266^SUPERFICIAL^99DCT">Superficial</option>
<option value="8267^DEEP^99DCT">Deep</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group relevant_procedures_done_this_visit_biopsies">
<label for="clock_face_cervical_biopsy_location">
Provide location where biopsy for specimen was done: __O'clock
</label>
<input class="form-control" id="clock_face_cervical_biopsy_location"
name="clock_face_cervical_biopsy_location" type="number"
data-concept="7481^CLOCK FACE CERVICAL BIOPSY LOCATION ^99DCT">
</div>
<div class="form-group relevant_procedures_done_this_visit_leep">
<label for="number_of_specimen_collected">Number of specimen collected</label>
<input class="form-control" id="number_of_specimen_collected"
name="number_of_specimen_collected" type="number"
data-concept="7481^CLOCK FACE CERVICAL BIOPSY LOCATION ^99DCT">
</div>
<div class="form-group" style="display: none">
<label for="pathological_diagnosis_added_cervix">
Pathological diagnosis for cervical specimen
</label>
<select class="form-control" id="pathological_diagnosis_added_cervix"
name="pathological_diagnosis_added_cervix"
data-concept="8278^PATHOLOGICAL DIAGNOSIS ADDED^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="149^CERVICITIS^99DCT">Cervicitis</option>
<option value="8282^CERVICAL SQUAMOUS METAPLASIA^99DCT">Cervical squamous metaplasia</option>
<option value="7424^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Mild cervical intraepithelial neoplasia (CIN 1)
</option>
<option value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Moderate cervical intraepithelial neoplasia (CIN 2)
</option>
<option value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Severe cervical intraepithelial neoplasia (CIN 3)
</option>
<option value="8275^CERVICAL ADENOCARCINOMA^99DCT">Cervical adenocarcinoma</option>
<option value="7421^SQUAMOUS CELL CARCINOMA, NOT OTHERWISE SPECIFIED ^99DCT">
Cervical squamous cell carcinoma
</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group" style="display: none">
<label for="pathological_diagnosis_added_vagina">
Pathological diagnosis for vaginal specimen
</label>
<select class="form-control" id="pathological_diagnosis_added_vagina"
name="pathological_diagnosis_added_vagina"
data-concept="8278^PATHOLOGICAL DIAGNOSIS ADDED^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="7492^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Mild vaginal intraepithelial neoplasia (VAIN1)
</option>
<option value="7491^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 2 ^99DCT">
Moderate vaginal intraepithelial neoplasia (VAIN 2)
</option>
<option value="7435^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Severe vaginal intraepithelial neoplasia (VAIN 3)
</option>
<option value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Moderate cervical intraepithelial neoplasia (CIN 2)
</option>
<option value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Severe cervical intraepithelial neoplasia (CIN 3)
</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group" style="display: none">
<label for="pathological_diagnosis_added_vulva">
Pathological diagnosis for vulval specimen
</label>
<select class="form-control" id="pathological_diagnosis_added_vulva"
name="pathological_diagnosis_added_vulva"
data-concept="8278^PATHOLOGICAL DIAGNOSIS ADDED^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="7489^CONDYLOMA OR VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Condyloma / Mild vulva intraepithelial neoplasia (VIN1)
</option>
<option value="7488^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Moderate vulva intraepithelial neoplasia (VIN 2)
</option>
<option value="7483^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Severe vulva intraepithelial neoplasia (VIN 3)
</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="form-group">
<label for="ccsp_plan">Management Plan<span class="required">*</span></label>
<select class="form-control" id="ccsp_plan" name="ccsp_plan"
data-concept="7500^GYNECOLOGIC ONCOLOGY PLAN^99DCT" required="required">
<option value="">...</option>
<option value="9178^VIA FOLLOW-UP IN THREE MONTHS^99DCT">VIA 3 months follow up</option>
<option value="7498^ROUTINE VIA IN 6-MONTHS^99DCT">VIA 6 months follow up</option>
<option value="7496^ROUTINE VIA IN 1-YEAR^99DCT">Routine VIA in 1-year</option>
<option value="7497^ROUTINE VIA IN 3-YEARS^99DCT">Routine VIA in 3-years</option>
<option value="7383^REFERRAL FOR COLPOSCOPY^99DCT">Referral for Colposcopy</option>
<option value="7499^REFERRAL TO GYNAE-ONCOLOGY^99DCT">Referral to Gynae-Oncology</option>
<option value="7466^CRYOTHERAPY^99DCT">Referral for Cryotherapy</option>
<option value="1496^CLINICIAN^99DCT">Referral to Clinician</option>
<option value="6102^DISCHARGED FROM CLINIC^99DCT">Discharged from Clinic</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group">
<h5><strong>Directive family planning counseling performed</strong></h5>
<fieldset name="6681^FAMILY PLANNING COUNSELING PERFORMED^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="ccsp_directive_fp" type="radio"
data-concept="6681^FAMILY PLANNING COUNSELING PERFORMED^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="ccsp_directive_fp" type="radio"
data-concept="6681^FAMILY PLANNING COUNSELING PERFORMED^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
</fieldset>
</div>
</div>
<div class="section" data-concept="9175^FAMILY PLANNING REFILL PROVIDED, DETAILED^99DCT">
<h4>Family planning refills dispensed</h4>
<fieldset name="7495^FAMILY PLANNING REFILL PROVIDED^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.condoms" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="190^CONDOMS^99DCT">
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.female_sterilization" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5276^FEMALE STERILIZATION^99DCT">
Sterilization / Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.intrauterine_device" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5275^INTRAUTERINE DEVICE^99DCT">
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.diaphragm" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5278^DIAPHRAGM^99DCT">
Diaphragm / Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.family_planning_via_oral_contraceptive_pills" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="780^ORAL CONTRACEPTION^99DCT">
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.natural_family_planning" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5277^NATURAL FAMILY PLANNING^99DCT">
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.injectable_contraceptives" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5279^INJECTABLE CONTRACEPTIVES^99DCT">
Injectable hormonesa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.contraceptive_implant" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="6220^CONTRACEPTIVE IMPLANT^99DCT">
Implant / Patching
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.none" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="ccsp_refill_dispense.other_non_coded" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="freetext_general_6">Specify</label>
<input class="form-control" id="freetext_general_6" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
</div>
<div class="section" data-concept="9176^FAMILY PLANNING METHOD CHOSEN, DETAILED^99DCT">
<h4>New family planning method initiated</h4>
<fieldset name="7240^FAMILY PLANNING METHOD CHOSEN^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.condoms" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="190^CONDOMS^99DCT">
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.female_sterilization" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5276^FEMALE STERILIZATION^99DCT">
Sterilization / Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.intrauterine_device" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5275^INTRAUTERINE DEVICE^99DCT">
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.diaphragm" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5278^DIAPHRAGM^99DCT">
Diaphragm / Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.family_planning_via_oral_contraceptive_pills" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="780^ORAL CONTRACEPTION^99DCT">
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.natural_family_planning" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5277^NATURAL FAMILY PLANNING^99DCT">
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.injectable_contraceptives" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5279^INJECTABLE CONTRACEPTIVES^99DCT">
Injectable hormonesa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.contraceptive_implant" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="6220^CONTRACEPTIVE IMPLANT^99DCT">
Implant / Patching
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_new_method.none" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="ccsp_new_method.other_non_coded" type="checkbox"
data-concept="7240^FAMILY PLANNING METHOD CHOSEN^99DCT"
value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="freetext_general_5">Specify</label>
<input class="form-control" id="freetext_general_5" name="freetext_general" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT">
</div>
</fieldset>
</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 = "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>