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  1. <htmlform>
  2. <head>
  3. <script type="text/javascript">
  4. //Validation and Skip Logic functions
  5. var errorMessage = {};
  6.  
  7. //Handle Error Messages
  8. function fieldErrorMessages(){
  9. //errorMessage is a global variable for error messages
  10. var returnVal=0;
  11. $j.each( errorMessage, function( key, fieldError) {
  12. if(fieldError!=''){
  13. returnVal=1;
  14. }
  15.  
  16. });
  17. return returnVal;
  18. }
  19.  
  20. //Handle required fields
  21. function requiredFields(fields){
  22. arrayElements=fields.split(',');
  23. var returnVal=0;
  24. $j.each( arrayElements, function( key, fieldId) {
  25. var fieldValue=getValue(fieldId+'.value');
  26. if(fieldValue==''){
  27. getField(fieldId+'.error').html('Required').show();
  28. returnVal=1;
  29. }
  30. else{
  31. getField(fieldId+'.error').html('').hide();
  32. }
  33. });
  34. return returnVal;
  35. }
  36.  
  37. //Uncheck checked checkboxes and clear inputs
  38. function clearHtmlElements(sectionId){
  39. //search by ID
  40. $j('#'+sectionId).find("input[type$='checkbox']").each(function() {
  41. $j(this).attr("checked",false);
  42. $j(this).change();
  43.  
  44. });
  45.  
  46. //search by Class
  47. $j('.'+sectionId).find("input[type$='checkbox']").each(function() {
  48. $j(this).attr("checked",false);
  49. $j(this).change();
  50.  
  51. });
  52.  
  53. //clear inputs by ID
  54. $j('#'+sectionId).find("input[type$='text']").each(function() {
  55. var htmlElement=$j(this);
  56. $j(this).val('');
  57. });
  58.  
  59. //clear inputs by class
  60. $j('.'+sectionId).find("input[type$='text']").each(function() {
  61. var htmlElement=$j(this);
  62. $j(this).val('');
  63. });
  64.  
  65. //clear selects by Id
  66. $j('#'+sectionId).find("select").each(function() {
  67. var htmlElement=$j(this);
  68. $j(this).val('');
  69. });
  70.  
  71. //clear selects by class
  72. $j('.'+sectionId).find("select").each(function() {
  73. var htmlElement=$j(this);
  74. $j(this).val('');
  75. });
  76.  
  77. }
  78.  
  79. //receive a div id,span id,tr id or td id and Uncheck any checkboxes and clear inputs
  80. function disableHtmlElements(sectionId,clearData){
  81.  
  82. var sections=sectionId.split(',');
  83. $j.each(sections, function( index,section ) {
  84. //Uncheck any checkboxes and clear inputs
  85. clearHtmlElements(section);
  86.  
  87. //disable inputs and selects by ID
  88. $j('#'+section).find("input").attr("disabled",true);
  89. $j('#'+section).find("select").attr("disabled",true);
  90. $j('#'+section).find("button").attr("disabled",true);
  91.  
  92. //disable inputs and selects by Class
  93. $j('.'+section).find("input").attr("disabled",true);
  94. $j('.'+section).find("select").attr("disabled",true);
  95. $j('.'+section).find("button").attr("disabled",true);
  96. });
  97. }
  98.  
  99. function enableHtmlElements(sectionId){
  100. var sections=sectionId.split(',');
  101. $j.each(sections, function( index,section ) {
  102. //enable by id
  103. $j('#'+section).find("input").attr("disabled",false);
  104. $j('#'+section).find("select").attr("disabled",false);
  105. $j('#'+section).find("button").attr("disabled",false);
  106.  
  107. //enable by class
  108. $j('.'+section).find("input").attr("disabled",false);
  109. $j('.'+section).find("select").attr("disabled",false);
  110. $j('.'+section).find("button").attr("disabled",false);
  111.  
  112.  
  113. });
  114.  
  115. }
  116.  
  117. function hideHtmlField(htmlField,clearData){
  118. if(clearData=='true'){
  119. setValue(htmlField+'.value','');
  120. }
  121. $j(htmlField) .attr("disabled",true);
  122. }
  123.  
  124. //show fields[if multiple fields to be shown, separate by commas]
  125.  
  126. function conditionalFieldDisplay(question,questionResponse,htmlField,clear,action){
  127. var questionValue=getValue(question+'.value');
  128. var fieldType=(typeof questionResponse);
  129. fieldsArray = htmlField.split(',');
  130.  
  131. var allowedResponses=[];
  132. if(fieldType=='number'){
  133.  
  134. }
  135.  
  136. if(fieldType=='string'){
  137. allowedResponses=questionResponse.split(',');
  138.  
  139. }
  140.  
  141. if(allowedResponses.length>0){
  142.  
  143. if($j.inArray(questionValue,allowedResponses)!==-1){
  144. if(action=='show')
  145. enableHtmlElements(htmlField);
  146. if(action=='hide')
  147. disableHtmlElements(htmlField,'false');
  148. }
  149. else{
  150. if(action=='hide')
  151. enableHtmlElements(htmlField);
  152. if(action=='show')
  153. disableHtmlElements(htmlField,'false');
  154. }
  155. }
  156. else{
  157. hideShowField(question,questionResponse,htmlField,clear,action)
  158. }
  159. }
  160.  
  161. function hideShowField(question,questionResponse,fields,clear,action){
  162.  
  163. if((getValue(question+'.value')==questionResponse)||(questionResponse=='showall')){
  164.  
  165. if(action=='show')
  166. enableHtmlElements(fields);
  167.  
  168.  
  169. if(action=='hide')
  170. disableHtmlElements(fields,clear);
  171.  
  172. }
  173. else {
  174.  
  175. if(action=='show')
  176. disableHtmlElements(fields,clear);
  177.  
  178. if(action=='hide')
  179. enableHtmlElements(fields);
  180. }
  181. }
  182.  
  183. function showFieldArray(arrayOfFields){
  184. $j.each(arrayOfFields, function( index,field ) {
  185. $j('#'+field) .attr("disabled",false);
  186. });
  187. }
  188.  
  189. function hideFieldArray(arrayOfFields,clearData){
  190. $j.each(arrayOfFields, function( index,field ) {
  191. if(clearData=='true'){
  192. setValue(field+'.value','');
  193. }
  194. $j('#'+field) .attr("disabled",true);
  195. });
  196. }
  197.  
  198.  
  199. </script>
  200. <!-- 1. A Script to Handle Add/remove side effect/toxicity Drugs -->
  201. <script type="text/javascript">
  202. if(jQuery){
  203. $j(document).ready(function(){
  204. $j('#1-removetoxicityDrug').remove();
  205. $j('#10-addtoxicityDrug').remove();
  206. $j('#1-toggletoxicityDrug').show();
  207.  
  208. });
  209.  
  210. $j(document).ready(function(){
  211. $j('button.addtoxicityDrug').live("click", function(){
  212. var addDrugButtonId = parseFloat(this.id) + 1;
  213. var addDrugId = "#" + addDrugButtonId + "-toggletoxicityDrug";
  214. $j(addDrugId).toggle(true);
  215. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removetoxicityDrug').toggle(false);
  216. return false;});
  217. });
  218.  
  219. $j(document).ready(function(){
  220. $j('button.removetoxicityDrug').live("click", function(){
  221. var removeDrugButtonId = parseFloat(this.id) - 1;
  222. var addDrugId = "#" + parseFloat(this.id) + "-toggletoxicityDrug";
  223. $j(addDrugId).toggle(false);
  224. $j( ':input:not(:button)', addDrugId).val([]);
  225. $j('#' + removeDrugButtonId + '-addtoxicityDrug').toggle(true); $j('#' + removeDrugButtonId + '-removetoxicityDrug').toggle(true);
  226.  
  227. return false;});
  228.  
  229. });
  230. }
  231. </script>
  232.  
  233. <!-- 1. A Script to Handle Add/remove Hospitalization reason -->
  234. <script type="text/javascript">
  235. if(jQuery){
  236. $j(document).ready(function(){
  237. $j('#1-removeHospreason').remove();
  238. $j('#10-addHospreason').remove();
  239. $j('#1-toggleHospreason').show();
  240.  
  241. $j('#11-removeHospreason').remove();
  242. $j('#20-addHospreason').remove();
  243. $j('#11-toggleHospreason').show();
  244.  
  245. $j('#21-removeHospreason').remove();
  246. $j('#30-addHospreason').remove();
  247. $j('#21-toggleHospreason').show();
  248. });
  249.  
  250. $j(document).ready(function(){
  251. $j('button.addHospreason').live("click", function(){
  252. var correctedAddButtonId = parseFloat(this.id) + 1;
  253. var contentAddId = "#" + correctedAddButtonId + "-toggleHospreason";
  254. $j(contentAddId).toggle(true);
  255. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removeHospreason').toggle(false);
  256. return false;});
  257. });
  258.  
  259. $j(document).ready(function(){
  260. $j('button.removeHospreason').live("click", function(){
  261. var correctedRemoveButtonId = parseFloat(this.id) - 1;
  262. var contentAddId = "#" + parseFloat(this.id) + "-toggleHospreason";
  263. $j(contentAddId).toggle(false);
  264. $j( ':input:not(:button)', contentAddId).val([]);
  265. $j('#' + correctedRemoveButtonId + '-addHospreason').toggle(true); $j('#' + correctedRemoveButtonId + '-removeHospreason').toggle(true);
  266.  
  267. return false;});
  268.  
  269. });
  270. }
  271. </script>
  272. <!-- 1. A Script to Handle Add/remove Previous Hospitalisation Diagnosis -->
  273. <script type="text/javascript">
  274. if(jQuery){
  275. $j(document).ready(function(){
  276. $j('#1-removePrevhospdiag').remove();
  277. $j('#10-addPrevhospdiag').remove();
  278. $j('#1-togglePrevhospdiag').show();
  279.  
  280. $j('#11-removePrevhospdiag').remove();
  281. $j('#20-addPrevhospdiag').remove();
  282. $j('#11-togglePrevhospdiag').show();
  283.  
  284. $j('#21-removePrevhospdiag').remove();
  285. $j('#30-addPrevhospdiag').remove();
  286. $j('#21-togglePrevhospdiag').show();
  287. });
  288.  
  289. $j(document).ready(function(){
  290. $j('button.addPrevhospdiag').live("click", function(){
  291. var correctedAddButtonId = parseFloat(this.id) + 1;
  292. var contentAddId = "#" + correctedAddButtonId + "-togglePrevhospdiag";
  293. $j(contentAddId).toggle(true);
  294. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removePrevhospdiag').toggle(false);
  295. return false;});
  296. });
  297.  
  298. $j(document).ready(function(){
  299. $j('button.removePrevhospdiag').live("click", function(){
  300. var correctedRemoveButtonId = parseFloat(this.id) - 1;
  301. var contentAddId = "#" + parseFloat(this.id) + "-togglePrevhospdiag";
  302. $j(contentAddId).toggle(false);
  303. $j( ':input:not(:button)', contentAddId).val([]);
  304. $j('#' + correctedRemoveButtonId + '-addPrevhospdiag').toggle(true); $j('#' + correctedRemoveButtonId + '-removePrevhospdiag').toggle(true);
  305.  
  306. return false;});
  307.  
  308. });
  309. }
  310. </script>
  311. <!-- 2. A Script to Handle Add/remove problem list -->
  312. <script type="text/javascript">
  313. if(jQuery){
  314. $j(document).ready(function(){
  315. $j('#1-removeEntry').remove();
  316. $j('#10-addEntry').remove();
  317. $j('#1-toggleContainer').show();
  318.  
  319. $j('#11-removeEntry').remove();
  320. $j('#20-addEntry').remove();
  321. $j('#11-toggleContainer').show();
  322.  
  323. $j('#21-removeEntry').remove();
  324. $j('#30-addEntry').remove();
  325. $j('#21-toggleContainer').show();
  326. });
  327.  
  328. $j(document).ready(function(){
  329. $j('button.addEntry').live("click", function(){
  330. var correctedAddButtonId = parseFloat(this.id) + 1;
  331. var contentAddId = "#" + correctedAddButtonId + "-toggleContainer";
  332. $j(contentAddId).toggle(true);
  333. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removeEntry').toggle(false);
  334. return false;});
  335. });
  336.  
  337. $j(document).ready(function(){
  338. $j('button.removeEntry').live("click", function(){
  339. var correctedRemoveButtonId = parseFloat(this.id) - 1;
  340. var contentAddId = "#" + parseFloat(this.id) + "-toggleContainer";
  341. $j(contentAddId).toggle(false);
  342. $j( ':input:not(:button)', contentAddId).val([]);
  343. $j('#' + correctedRemoveButtonId + '-addEntry').toggle(true); $j('#' + correctedRemoveButtonId + '-removeEntry').toggle(true);
  344.  
  345. return false;});
  346.  
  347. });
  348. }
  349. </script>
  350.  
  351. <!-- 3. A Script to Handle Add/remove Drugs -->
  352. <script type="text/javascript">
  353. if(jQuery){
  354. $j(document).ready(function(){
  355. $j('#1-removeDrug').remove();
  356. $j('#10-addDrug').remove();
  357. $j('#1-toggleDrug').show();
  358.  
  359. });
  360.  
  361. $j(document).ready(function(){
  362. $j('button.addDrug').live("click", function(){
  363. var addDrugButtonId = parseFloat(this.id) + 1;
  364. var addDrugId = "#" + addDrugButtonId + "-toggleDrug";
  365. $j(addDrugId).toggle(true);
  366. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removeDrug').toggle(false);
  367. return false;});
  368. });
  369.  
  370. $j(document).ready(function(){
  371. $j('button.removeDrug').live("click", function(){
  372. var removeDrugButtonId = parseFloat(this.id) - 1;
  373. var addDrugId = "#" + parseFloat(this.id) + "-toggleDrug";
  374. $j(addDrugId).toggle(false);
  375. $j( ':input:not(:button)', addDrugId).val([]);
  376. $j('#' + removeDrugButtonId + '-addDrug').toggle(true); $j('#' + removeDrugButtonId + '-removeDrug').toggle(true);
  377.  
  378. return false;});
  379.  
  380. });
  381. }
  382. </script>
  383. <!-- 3. A Script to Handle Add/remove Other Drugs -->
  384. <script type="text/javascript">
  385. if(jQuery){
  386. $j(document).ready(function(){
  387. $j('#1-removeOtherDrugs').remove();
  388. $j('#10-addOtherDrugs').remove();
  389. $j('#1-toggleOtherDrugs').show();
  390.  
  391. });
  392.  
  393. $j(document).ready(function(){
  394. $j('button.addOtherDrugs').live("click", function(){
  395. var addOtherDrugsButtonId = parseFloat(this.id) + 1;
  396. var addOtherDrugsId = "#" + addOtherDrugsButtonId + "-toggleOtherDrugs";
  397. $j(addOtherDrugsId).toggle(true);
  398. $j('#' + this.id).toggle(false); $j('#' + parseFloat(this.id) + '-removeOtherDrugs').toggle(false);
  399. return false;});
  400. });
  401.  
  402. $j(document).ready(function(){
  403. $j('button.removeOtherDrugs').live("click", function(){
  404. var removeOtherDrugsButtonId = parseFloat(this.id) - 1;
  405. var addOtherDrugsId = "#" + parseFloat(this.id) + "-toggleOtherDrugs";
  406. $j(addOtherDrugsId).toggle(false);
  407. $j( ':input:not(:button)', addOtherDrugsId).val([]);
  408. $j('#' + removeOtherDrugsButtonId + '-addOtherDrugs').toggle(true); $j('#' + removeOtherDrugsButtonId + '-removeOtherDrugs').toggle(true);
  409.  
  410. return false;});
  411.  
  412. });
  413. }
  414. </script>
  415.  
  416. <script type="text/javascript">
  417.  
  418. if(jQuery){
  419. jQuery(document).ready(function(){
  420. if ( $j.browser.msie ) {
  421. $j(":checkbox").click(function(){
  422. $j(this).change();
  423. });
  424. }
  425. $j(".enableDisable").each(function(){
  426. var group = $j(this);
  427. function disableFn(){
  428. group.children("#disabled").fadeTo(250,0.33);
  429. group.children("#disabled").find(":checkbox").attr("checked",false); //uncheck
  430. group.children("#disabled").find("input[type$='text']").val("");
  431. group.children("#disabled").find("input").attr("disabled",true); //disable
  432. }
  433. function enableFn(){
  434. group.children("#disabled").fadeTo(250,1);
  435. group.children("#disabled").find("input").attr("disabled",false);
  436. }
  437. disableFn();
  438. $j(this).children("#trigger").find(":checkbox:first").change(function(){
  439. var checked = $j(this).attr("checked");
  440. if(checked == true){
  441. enableFn();
  442. }else{
  443. disableFn();
  444. }
  445. });
  446. });
  447.  
  448.  
  449. $j(".checkboxGroup").each(function(){
  450. var group = $j(this);
  451. var uncheckAll = function(){
  452. group.find("input[type$='checkbox']").attr("checked",false);
  453. group.find("input[type$='checkbox']").change();
  454. }
  455. var uncheckRadioAndAll = function(){
  456. group.find("#checkboxAll,#checkboxRadio").find("input[type$='checkbox']").attr("checked",false);
  457. group.find("#checkboxAll,#checkboxRadio").find("input[type$='checkbox']").change();
  458. }
  459.  
  460.  
  461. group.find("#checkboxAll").find("input").click(
  462. /* This was tricky... A number of things needed to happen
  463. Basically, This is supposed to treat a group of inputs as if
  464. were all one big checkbox. It is designed so that a checkbox
  465. can be next to an input, and the user clicks the input, the
  466. checkbox checks as well. But, when the user clicks the checkbox,
  467. the browser marks the checkbox as checked. Therefore, when we check
  468. if the checkbox is already checked, it always respondes true...
  469. We needed to have 2 cases: when the clicking action is on the first checkbox
  470. and when the action is on any other. */
  471. function(){
  472. var flip;
  473. var checked = $j(this).siblings(":checkbox:first").attr("checked");
  474. if($j(this).attr("name") == $j(this).parents("#checkboxAll:first").find(":checkbox:first").attr("name")){
  475. checked = $j(this).attr("checked");
  476. flip = checked;
  477. }else{
  478. flip = !checked;
  479. }
  480. if($j(this).attr("type") == "text") if(flip == false) flip = !filp; // this is so the user doesn't go to check the checkbox, then uncheck it when they hit the input.
  481. uncheckAll();
  482. $j(this).parents("#checkboxAll:first").find(":checkbox").attr("checked",flip);
  483. $j(this).parents("#checkboxAll:first").find(":checkbox").change();
  484. }
  485. );
  486.  
  487.  
  488.  
  489. group.find("#checkboxRadio").find("input[type$='checkbox']").click(function(){
  490. uncheckAll();
  491. $j(this).siblings("input[type$='checkbox']").attr("checked",false);
  492. $j(this).attr("checked",true);
  493. $j(this).change();
  494. });
  495.  
  496. group.find("#checkboxCheckbox").click(
  497. function(){
  498. uncheckRadioAndAll();
  499. }
  500. );
  501.  
  502. });
  503. });
  504. }
  505. </script>
  506.  
  507. <script type="text/javascript">
  508. $j(function() {
  509. $j('#hospsincelastvisit').change(function() {
  510. // conditionalFieldDisplay('hospsincelastvisit',true,'hospsincelastvisitDisgnosis','true','show');
  511.  
  512. if(getValue('hospsincelastvisit.value')){
  513. var t=getValue('hospsincelastvisit.value');
  514. if(t=='true'){
  515. enableHtmlElements('hospsincelastvisitDisgnosis');
  516. }
  517. else{
  518. disableHtmlElements('hospsincelastvisitDisgnosis',true);
  519. }
  520. }
  521. });
  522. });
  523.  
  524. //-------------------------------------------------******************
  525.  
  526.  
  527.  
  528. //14f and 23a: If “None” is selected on 14f, then only “None” “Start” may be selected for 23a
  529. $j(function() {
  530. $j('#pcpPlan').change(function() {
  531. // when none is selected
  532. var pcPlan=getValue('pcpPlan.value');
  533.  
  534. if(getValue('pcpprophcurr.value')==1107){
  535. if((pcPlan==1107)||(pcPlan==1256)){
  536. //do nothing
  537. errorMessage['pcpPlan.error1']='';
  538. getField('pcpPlan.error').html('').hide();
  539. }
  540. else{
  541.  
  542. getField('pcpPlan.error').html('Only None or Start may be selected').show();
  543. errorMessage['pcpPlan.error1']='Only None or Start may be selected';
  544. }
  545. }
  546. //14f and 23a: If “Septrin” or “Dapsone” is selected on 14f, then only “Continue,” “Stop,” or “Change Regimen” may be selected for 23a
  547. if((getValue('pcpprophcurr.value')==916)||(getValue('pcpprophcurr.value')==92)){
  548. if((pcPlan==1259)||(pcPlan==1260)||(pcPlan==1257)){
  549. //clear error messages
  550. errorMessage['pcpPlan.error']='';
  551. getField('pcpPlan.error').html('').hide();
  552. }
  553. else{
  554.  
  555. errorMessage['pcpPlan.error']='Only Continue,Stop or Change Regimen may be selected';
  556. getField('pcpPlan.error').html('Only Continue,Stop or Change Regimen may be selected').show();
  557. }
  558. }
  559.  
  560. //23a and 23b: If “None,” “Start,” or “Continue” is selected on 23a, then skip 23b.
  561. conditionalFieldDisplay('pcpPlan','1107,1256,1257','pcpstopreason','true','hide');
  562.  
  563. //23a and 23c: If “Stop” or “Change regimen” is selected on 23a, then skip 23c.
  564. conditionalFieldDisplay('pcpPlan','1260,1259','pcpMed','true','hide');
  565.  
  566. //toxicity
  567. conditionalFieldDisplay('pcpPlan','1260,1259','pcpstopreasonTox,pcpstopreason,pcpstopreasonSpecify','true','show');
  568.  
  569. conditionalFieldDisplay('pcpPlan','1256,1257,1259','pcpMed','true','show');
  570.  
  571. });
  572. });
  573.  
  574.  
  575. //Add other if reason is not toxicity
  576. $j(function() {
  577. $j('#pcpstopreason').change(function() {
  578. conditionalFieldDisplay('pcpstopreason',5622,'pcpstopreasonSpecify','true','show');
  579.  
  580. conditionalFieldDisplay('pcpstopreason',102,'pcpstopreasonTox','true','show');
  581. });
  582. });
  583.  
  584. //14.g and 23d: If “None” is selected on 14g, then only “None” “Start” may be selected for 23d.
  585. $j(function() {
  586. $j('#tbprophPlan').change(function() {
  587. // when none is selected
  588. var tbPlan=getValue('tbprophPlan.value');
  589. if(getValue('tbprophcurr.value')==1107){
  590. if((tbPlan==1107)||(tbPlan==1256)){
  591. //do nothing
  592. errorMessage['tbprophPlan.error1']='';
  593. getField('tbprophPlan.error').html('').hide();
  594. }
  595. else{
  596. errorMessage['tbprophPlan.error1']='Only None or Start may be selected';
  597. getField('tbprophPlan.error').html('Only None or Start may be selected').show();
  598. }
  599.  
  600. if(getValue('tbprophcurr.value')==''){
  601. errorMessage['tbprophPlan.error3']='Current TB Prophylaxis plan not selected';
  602. getField('tbprophPlan.error').html('Current TB Prophylaxis plan not selected').show();
  603. }
  604. }
  605. // 14g and 23d: If “Isoniazid” is selected on 14g, then only “Continue,” “Stop,” or “Change Regimen” may be selected for 23d.
  606. if(getValue('tbprophcurr.value')==656){
  607. if((tbPlan==1259)||(tbPlan==1260)||(tbPlan==1257)){
  608. //do nothing
  609. errorMessage['tbprophPlan.error2']='';
  610. getField('tbprophPlan.error').html('').hide();
  611. }
  612. else{
  613. errorMessage['tbprophPlan.error2']='Only None or Start may be selected';
  614. getField('tbprophPlan.error').html('Only Continue,Stop or Change Regimen may be selected').show();
  615.  
  616.  
  617. }
  618. }
  619.  
  620. //23d and 23e: If “None,” “Start,” “Continue,” or “Change regiment” is selected on 23d, then skip 23e.
  621. conditionalFieldDisplay('tbprophPlan','1107,1256,1257,1259','tbprophstopreason,tbprophstopreasonSpecify','true','hide');
  622.  
  623. //If plan is not STOP, disable this question
  624. //conditionalFieldDisplay('tbprophPlan','1259,1260','tbprophstopreason,tbprophstopreasonSpecify','true','show');
  625. //TB Toxicity
  626. conditionalFieldDisplay('tbprophPlan','1259,1260','tbprophstopreasonTox,tbprophstopreason,tbprophstopreasonSpecify','true','show');
  627.  
  628. });
  629. });
  630.  
  631.  
  632. //14 h: If “None” is selected, then skip 14i and 14j.
  633. $j(function() {
  634. $j('#tbcurr').change(function() {
  635. // when none is selected
  636. conditionalFieldDisplay('tbcurr',1107,'tbcurrmedspickup,tbstartDate,tbcurrOther','true','hide');
  637. // Hide drugs add rule to clear responses in I and j when this concept is blank XXXX
  638. });
  639. });
  640.  
  641. //if TB treatment is Completed then show TB Completed Date
  642. $j(function() {
  643. $j('#tbstopreason').change(function() {
  644. conditionalFieldDisplay('tbstopreason',1267,'tbCompletedDate','true','show');
  645.  
  646. //disable drug entry against completed
  647. conditionalFieldDisplay('tbcurrCompleted',1267,'tbCurrentDrugRows,tbcurrYes,tbcurrOther','true','hide')
  648.  
  649. });
  650. });
  651.  
  652. //Add text box if tbcurrOther is selected
  653. $j(function() {
  654. $j('#tbcurrOther').change(function() {
  655. // conditionalFieldDisplay('tbcurrOther',5622,'w238','true','show');
  656. });
  657. });
  658.  
  659. //For all the drugs, disable the quantities if that specific drug is blank
  660. //TODO find
  661.  
  662. $j(function() {
  663. $j('#cryptPlan').change(function() {
  664. // 14k and 23f: If “None” is selected for 14k, then only “None” or “Start Fluconazole” may be selected for 23f.
  665. var cryTPlan=getValue('cryptPlan.value');
  666.  
  667. if(getValue('cryptocurr.value')==1107){
  668.  
  669. if((cryTPlan==1107)||(cryTPlan==1256)){
  670. //do nothing
  671.  
  672. errorMessage['cryptPlan.error1']='';
  673. getField('cryptPlan.error').html('').hide();
  674. }
  675. else{
  676.  
  677. getField('cryptPlan.error').html('Only None or Start Fluconazole may be selected').show();
  678. errorMessage['cryptPlan.error1']='Only None or Start Fluconazole may be selected';
  679.  
  680. }
  681. }
  682.  
  683. // 14k and 23f: If “Fluconazole 200mg” is selected for 14k, then only “Continue Fluconazole” or “Stop Fluconazole” may be selected for 23f.
  684. if(getValue('cryptocurr.value')==747){
  685. if((cryTPlan==1257)||(cryTPlan==1260)){
  686. //do nothing
  687. errorMessage['cryptPlan.error2']='';
  688. getField('cryptPlan.error').html('').hide();
  689. }
  690. else{
  691.  
  692. getField('cryptPlan.error').html('Only Continue Fluconazole or Stop Fluconazole may be selected').show();
  693. errorMessage['cryptPlan.error2']='Only Continue Fluconazole or Stop Fluconazole may be selected'
  694.  
  695. }
  696. }
  697.  
  698. //toxicity cryptPlan
  699. //NO toxicity option provided
  700. });
  701. });
  702.  
  703. //16a: 16b can only be answered if 16a is answered “YES”. TODO currSideeff=1065 then add ID for b id="currSideEffB"
  704. $j(function() {
  705. $j('#currSideeff').change(function() {
  706. conditionalFieldDisplay('currSideeff',1065,'toxicitySideEffectDrugs','true','show');
  707. conditionalFieldDisplay('currSideeff',1065,'1-addtoxicityDrug','false','show');
  708.  
  709. });
  710. });
  711.  
  712.  
  713. $j(function() {
  714. $j('#arvPlan').change(function() {
  715. //if Note on ARVs Hide arv start reason arv stop reason
  716. //--------------------------
  717. conditionalFieldDisplay('arvPlan',1256,'arvstartreason','false','show');
  718. conditionalFieldDisplay('arvPlan','1260,1849,981,1259,1850,1258','arvstopreason,arvstopreasonTox,arvstopreasonSpecify','false','show');
  719. conditionalFieldDisplay('arvPlan','1107,1257,1260','arvDrugRows','false','hide');
  720. conditionalFieldDisplay('arvPlan',1107,'arveligible,arveligibleSpecify','false','show');
  721.  
  722.  
  723. //,1849,981,1259,1850,1258
  724.  
  725. //-----------------------
  726. });
  727. });
  728. //Reason
  729. $j(function() {
  730. $j('#arvstopreasonTox').change(function() {
  731.  
  732. conditionalFieldDisplay('arvstopreasonTox',5622,'arvstopreasonSpecify','false','show');
  733.  
  734. //-----------------------
  735. });
  736. });
  737.  
  738.  
  739. //24a: If “Start Induction” is selected, then skip 24b.
  740. $j(function() {
  741. $j('#tbPlan').change(function() {
  742.  
  743. //24a: If “Start Induction” is selected, then skip 24b.
  744. conditionalFieldDisplay('tbPlan',1256,'tbstopreason,tbstopreasonSpecify','true','hide');
  745. //show start date if on tb treatment
  746. //tbPlan 1259, 1257,1849, 981 tbstartDate tbpickupLocation
  747. conditionalFieldDisplay('tbPlan','1256,1259,1257,1849,981','tbstartDate,tbpickupLocation','true','show');
  748. //24a: If “Change to Continuation,” “Continue Regimen,” “Substitution,” “Re-dose,” or “Stop” is selected, then skip 24a.
  749. //24a: If plan is not stop, change, redoes disable this question.
  750. //conditionalFieldDisplay('tbPlan','1259,1257,1849,981,1260','tbstopreasonTox,tbstopreason,tbstopreasonSpecify','true','show');
  751. conditionalFieldDisplay('tbPlan','981,1260,1259','tbstopreason,tbstopreasonTox,tbstopreasonSpecify','true','show');
  752.  
  753. //tbDrugRows,tbcurrOther
  754. conditionalFieldDisplay('tbPlan','981,1256,1260,1259','tbPlanDrugs,tbcurrOther','false','show');
  755. //"tbPlanDrugs"> tbDrugRows
  756. });
  757. });
  758.  
  759.  
  760. $j(function() {
  761. $j('#tbstopreason').change(function() {
  762. conditionalFieldDisplay('tbstopreason',5622,'tbstopreasonSpecify','true','show');
  763. conditionalFieldDisplay('tbstopreason',102,'tbstopreasonTox','true','show');
  764. });
  765. });
  766.  
  767. $j(function() {
  768. $j('#tbcurrRhze').change(function() {
  769. // disableHtmlElements('tbplanRhzeCustom')
  770. });
  771. });
  772.  
  773. //Hide date if scheduled visit
  774. $j(function() {
  775. $j('#visittype').change(function() {
  776. conditionalFieldDisplay('visittype',1246,'scheduledDate','true','hide');
  777. });
  778. });
  779.  
  780. //Control on TB treatment options
  781. $j(function() {
  782. $j('#tbcurr').change(function() {
  783. if(getValue('tbcurr.value')==1107){
  784. setValue('tbcurrYes.value','');
  785. getField('tbcurrYes.value').change();
  786. // current tb medications
  787. disableHtmlElements('tbCurrentDrugRows,tbcurrOther','false');
  788. }
  789. });
  790. });
  791.  
  792. $j(function() {
  793. $j('#tbcurrYes').change(function() {
  794. if(getValue('tbcurrYes.value')==1065){
  795. setValue('tbcurr.value','');
  796. getField('tbcurr.value').change();
  797. //enable current tb medications
  798. enableHtmlElements('tbCurrentDrugRows,tbcurrOther');
  799. //1065
  800. //tbstartDate tbpickupLocation
  801. //enableHtmlElements('tbDrugsRow1,tbDrugsRow2,tbDrugsRow3');
  802. // conditionalFieldDisplay('tbcurrYes',1065,'tbstartDate,tbpickupLocation','true','show');
  803.  
  804. }
  805. });
  806. });
  807.  
  808. //add span deliveredMsg
  809. $j(function() {
  810. $j('#delivered').change(function() {
  811. if(getValue('delivered.value')){
  812. var t=getValue('delivered.value');
  813. if(t=='true'){
  814. enableHtmlElements('deliveredMsg');
  815. $j('#deliveredMsg').css('background-color','White');
  816. }
  817. else{
  818. disableHtmlElements('deliveredMsg','false');
  819. }
  820. }
  821. });
  822. });
  823.  
  824. $j(function() {
  825. $j('#fp').change(function() {
  826. conditionalFieldDisplay('fp',1065,'fpgroup','false','show');
  827. conditionalFieldDisplay('fp',1066,'notfpreson','true','show');
  828. });
  829. });
  830. //ARVs Logic
  831. $j(function() {
  832. $j('#currmedArvs').change(function() {
  833. fieldsRows="arvstartdatesincelast,currmedtreamentcate,changedrug";
  834. drugRows="arvDrugs1";
  835.  
  836. if(getValue('currmedArvs.value')){
  837. var t=getValue('currmedArvs.value');
  838. if(t=='true'){
  839. enableHtmlElements(fieldsRows);
  840. enableHtmlElements(drugRows);
  841.  
  842. }
  843. else{
  844. disableHtmlElements(fieldsRows,'true');
  845. disableHtmlElements(drugRows,'false');
  846.  
  847.  
  848. }
  849. }
  850. });
  851. });
  852.  
  853. //22 a
  854. //ARVs Logic
  855.  
  856.  
  857. $j(function() {
  858. $j('#arveligible').change(function() {
  859. conditionalFieldDisplay('arveligible',5622,'arveligibleSpecify','false','show');
  860.  
  861. });
  862. });
  863.  
  864. $j(function() {
  865. $j('#tbsympNone').change(function() {
  866. conditionalFieldDisplay('tbsympNone',1107,'tbsymptoms','false','hide');
  867.  
  868. });
  869. });
  870.  
  871.  
  872.  
  873. $j(function() {
  874. $j('#transAmpath').change(function() {
  875. conditionalFieldDisplay('transAmpath',1286,'transferOutLocation','false','show');
  876. conditionalFieldDisplay('transAmpath',1286,'transferout','false','hide');
  877. if(getValue('transAmpath.value')==1286)
  878. setValue('transNonampath.value','');
  879.  
  880. });
  881. });
  882.  
  883. $j(function() {
  884. $j('#transNonampath').change(function() {
  885. conditionalFieldDisplay('transNonampath',1287,'transferOutLocation','false','hide');
  886. conditionalFieldDisplay('transNonampath',1287,'transferout','false','show');
  887. if(getValue('transNonampath.value')==1287)
  888. setValue('transAmpath.value','');
  889.  
  890. });
  891. });
  892.  
  893.  
  894. $j(function() {
  895. $j('#arvadhere').change(function() {
  896. conditionalFieldDisplay('arvadhere',6343,'arvadhereReason','false','hide');
  897.  
  898. });
  899. });
  900. //Other specify for ARV adherence
  901. $j(function() {
  902. $j('#arvadhereOther').change(function() {
  903. conditionalFieldDisplay('arvadhereOther',5622,'arvadhereSpecify','true','show');
  904.  
  905. });
  906. });
  907.  
  908. $j(function() {
  909. $j('#pcpprophadhere').change(function() {
  910. conditionalFieldDisplay('pcpprophadhere',6343,'pcpprophadhereReason','false','hide');
  911.  
  912. });
  913. });
  914.  
  915.  
  916. //Other specify for PCP Proph adherence
  917. $j(function() {
  918. $j('#pcpprophadhereOther').change(function() {
  919. conditionalFieldDisplay('pcpprophadhereOther',5622,'pcpprophadhereSpecify','true','show');
  920.  
  921. });
  922.  
  923. });
  924.  
  925. $j(function() {
  926. $j('#tbprophadhere').change(function() {
  927. conditionalFieldDisplay('tbprophadhere',6343,'tbprophadhereReason','false','hide');
  928.  
  929. });
  930. });
  931.  
  932. //Other specify for TB Proph adherence
  933. $j(function() {
  934. $j('#tbprophadhereOther').change(function() {
  935. conditionalFieldDisplay('tbprophadhereOther',5622,'tbprophadhereSpecify','true','show');
  936.  
  937. });
  938. });
  939.  
  940. $j(function() {
  941. $j('#tbadhere').change(function() {
  942. conditionalFieldDisplay('tbadhere',6343,'tbadhereReason','false','hide');
  943.  
  944. });
  945. });
  946.  
  947. //Other specify for TB adherence
  948. $j(function() {
  949. $j('#tbadhereOther').change(function() {
  950. conditionalFieldDisplay('tbadhereOther',5622,'tbadhereSpecify','true','show');
  951.  
  952. });
  953. });
  954.  
  955. //Tests Ordered
  956. $j(function() {
  957. $j('#testNone').change(function() {
  958. conditionalFieldDisplay('testNone',1107,'testsord','false','hide');
  959.  
  960. });
  961. });
  962.  
  963. //Referrals Ordered
  964. $j(function() {
  965. $j('#refNone').change(function() {
  966. conditionalFieldDisplay('refNone',1107,'reford','false','hide');
  967.  
  968. });
  969. });
  970.  
  971. //RTC
  972. $j(function() {
  973. $j('#rtc').change(function() {
  974. var rtc=getValue('rtc.value');
  975. var encounterDate=getValue('encounterDate.value');
  976. if (encounterDate >rtc ) {
  977. getField('rtc.error').html('RTC should not be before the encounter date').show();
  978. errorMessage['rtc.error']='RTC should not be before the encounter date'
  979. }else{
  980. getField('rtc.error').html('').hide();
  981. errorMessage['rtc.error']='';
  982. }
  983.  
  984. });
  985. });
  986.  
  987. //ARV start date
  988. $j(function() {
  989. $j('#arvstartdatesincelast').change(function() {
  990. var arvstartdatesincelast=getValue('arvstartdatesincelast.value');
  991. var encounterDate=getValue('encounterDate.value');
  992. if (arvstartdatesincelast>encounterDate) {
  993. getField('arvstartdatesincelast.error').html('ARV start date since last visit cannot be greater than the encounter date').show();
  994. errorMessage['arvstartdatesincelast.error']='ARV start date since last visit cannot be greater than the encounter date'
  995. }else{
  996. getField('arvstartdatesincelast.error').html('').hide();
  997. errorMessage['arvstartdatesincelast.error']='';
  998. }
  999.  
  1000. });
  1001. });
  1002.  
  1003.  
  1004. //TB start date
  1005. $j(function() {
  1006. $j('#tbstartDate').change(function() {
  1007. var tbstartDate=getValue('tbstartDate.value');
  1008. var encounterDate=getValue('encounterDate.value');
  1009. if (tbstartDate>encounterDate) {
  1010. getField('tbstartDate.error').html('TB start date since last visit cannot be greater than the encounter date').show();
  1011. errorMessage['tbstartDate.error']='TB start date since last visit cannot be greater than the encounter date'
  1012. }else{
  1013. getField('tbstartDate.error').html('').hide();
  1014. errorMessage['tbstartDate.error']='';
  1015. }
  1016.  
  1017. });
  1018. });
  1019.  
  1020.  
  1021. //TB completed date
  1022. $j(function() {
  1023. $j('#tbCompletedDate').change(function() {
  1024. var tbCompletedDate=getValue('tbCompletedDate.value');
  1025. var encounterDate=getValue('encounterDate.value');
  1026. if (tbCompletedDate>encounterDate) {
  1027. getField('tbCompletedDate.error').html('TB completed date cannot be greater than the encounter date').show();
  1028. errorMessage['tbCompletedDate.error']='TB completed date cannot be greater than the encounter date'
  1029. }else{
  1030. getField('tbCompletedDate.error').html('').hide();
  1031. errorMessage['tbCompletedDate.error']='';
  1032. }
  1033.  
  1034. });
  1035. });
  1036.  
  1037.  
  1038. </script>
  1039.  
  1040. <script type="text/javascript">
  1041. beforeSubmit.push(function() {
  1042. var valRequired = requiredFields('encounterDate,encounterLocation,encounterProvider');
  1043. var valErrors =fieldErrorMessages();
  1044. if ((valRequired ==1) ||(valErrors ==1)){
  1045. return false;
  1046. }
  1047.  
  1048. return true;
  1049. });
  1050. </script>
  1051.  
  1052.  
  1053. </head>
  1054. <macros>
  1055. paperFormId = (Fill this in)
  1056. headerColor =#009d8e
  1057. fontOnHeaderColor = white
  1058. </macros>
  1059.  
  1060. <style type="text/css" media="screen">
  1061.  
  1062. table.standard, table.standard td{
  1063. border: 1px solid black;
  1064. border-collapse: collapse;
  1065. width:100%;
  1066. }
  1067.  
  1068. table.quartercolumn, table.quartercolumn td{
  1069. border: 1px solid black;
  1070. border-collapse: collapse;
  1071. }
  1072.  
  1073. table.quartercolumn td {
  1074. width: 25%;
  1075. }
  1076.  
  1077. table.fivecolumn, table.fivecolumn td{
  1078. border: 1px solid black;
  1079. border-collapse: collapse;
  1080. }
  1081.  
  1082.  
  1083.  
  1084. h4 {
  1085. display: inline;
  1086. font-weight: bold;
  1087. }
  1088.  
  1089.  
  1090. .section {
  1091. border: 1px solid black;
  1092. padding: 2px;
  1093. text-align: left;
  1094. margin-bottom: 1em;
  1095. }
  1096. .sectionHeader {
  1097. background-color: grey;
  1098. color: $fontOnHeaderColor;
  1099. display: block;
  1100. padding: 2px;
  1101. font-weight: bold;
  1102. }
  1103. table.baseline-aligned td {
  1104. vertical-align: baseline;
  1105. }
  1106. </style>
  1107.  
  1108.  
  1109. <span style="float:right">Paper Form ID: $paperFormId</span>
  1110. <h2>AMPATH Adult Return HIV Encounter v6.09 </h2>
  1111. <section headerLabel="Patient demographics">
  1112. <table class="quartercolumn">
  1113.  
  1114. <tr>
  1115. <td colspan="2"><b>1. Name:</b><lookup class="value" expression="patient.personName"/>
  1116. </td>
  1117. <td colspan="2"><b>Encounter/Visit Date:</b><encounterDate allowFutureDates="false"/>
  1118. </td>
  1119. </tr>
  1120. <tr>
  1121. <td colspan="2"><b>2a. AMRS Universal ID:</b><lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('AMRS Universal ID') ) $patId #end "/></td>
  1122. <td colspan="2"><b>b. Unique patient ID (GOK):</b><lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('CCC Number') ) $patId #end "/>
  1123. </td>
  1124. </tr>
  1125. <tr>
  1126. <td colspan="2"><b>c. AMPATH ID:</b> <lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('AMRS Medical Recored Number') ) $patId #end "/>
  1127. </td>
  1128. <td colspan="2"><b>d. TB Registration ID:</b><lookup class="value" expression="personAttributes.get('TB District Registration Number')"/>
  1129. </td>
  1130. </tr>
  1131. <tr>
  1132. <td colspan="4"><h4>3. Indicate patients contact phone number only if is changed since last visit:</h4>
  1133. <lookup class="value" expression="personAttributes.get('Contact Phone Number')"/>
  1134. </td>
  1135. </tr>
  1136. </table>
  1137. </section>
  1138.  
  1139.  
  1140. <section headerLabel="Location">
  1141. <table class="quartercolumn">
  1142. <tr>
  1143. <td colspan="2"><h4>4. Facility name (site/satellite clinic required):</h4>
  1144. </td>
  1145. </tr>
  1146. <tr>
  1147. <td colspan="2"><encounterLocation/>
  1148. </td>
  1149. </tr>
  1150. </table>
  1151. </section>
  1152.  
  1153.  
  1154. <section headerLabel="Transfer details">
  1155. <table class="quartercolumn">
  1156. <obsgroup groupingConceptId="7016">
  1157. <tr>
  1158. <td colspan="4"><h4>5. Transfer in from other AMPATH clinic (specify):</h4>
  1159. <obs conceptId="1915" id="transferin" style="location"/>
  1160. </td>
  1161. </tr>
  1162. </obsgroup>
  1163. </table>
  1164. </section>
  1165.  
  1166.  
  1167. <section headerLabel="Visit type:">
  1168. <table class="quartercolumn">
  1169. <tr>
  1170. <td colspan="4"><h4>6a. Visit type:</h4>
  1171. <obs conceptId="1839" id="visittype" answerConceptIds="1246, 1837, 1838" answerLabels="Scheduled visit, Unscheduled Visit Early, Unscheduled Visit Late"/>
  1172. </td>
  1173. </tr>
  1174. <tr>
  1175. <td colspan="4"><h4>b. If unscheduled, actual scheduled date</h4>
  1176. <obs conceptId="7029" id="visitdate" class="scheduledDate" allowFutureDates="true"/>
  1177. </td>
  1178. </tr>
  1179. </table>
  1180. </section>
  1181.  
  1182.  
  1183. <section headerLabel="Civil status">
  1184. <table class="quartercolumn">
  1185. <tr>
  1186. <td colspan="4"><h4>7. Marital Status:</h4>
  1187. <obs conceptId="1054" id="maritalstatus" answerConceptIds="1060,1058,5555, 6290, 1056, 1057, 1059" answerLabels="Cohabiting,Divorced,Married monogamous, Married polygamous,Separated,Single,Widowed"/>
  1188. </td>
  1189. </tr>
  1190. <tr>
  1191. <td colspan="4"><h4>8. Discordant couple:</h4>
  1192. <obs conceptId="6096" id="discouple" answerConceptIds="1065, 1066, 1067" answerLabels="Yes, No, Unknown"/>
  1193. </td>
  1194. </tr>
  1195. <tr>
  1196. <td colspan="4"><h4>9. Patient covered by NHIF:</h4>
  1197. <obs conceptId="6266" id="nhif" answerConceptIds="6815, 1107" answerLabels="Yes, No"/>
  1198. </td>
  1199. </tr>
  1200. </table>
  1201. </section>
  1202.  
  1203.  
  1204. <section headerLabel="PWPs">
  1205. <table class="quartercolumn">
  1206. <tr>
  1207. <td colspan="4"><h4>10. Prevention With Positives (PWPs)</h4>
  1208. </td>
  1209. </tr>
  1210. <tr>
  1211. <td colspan="4"><h4>a. At risk population:</h4>
  1212. <obs conceptId="6578" id="atriskpop" answerConceptIds="8290,1832,6096,105,8291,1107" answerLabels="Client of sex worker,Commercial sex worker,Discordant couple,IV drug use,MSM,Not applicable"/>
  1213. </td>
  1214. </tr>
  1215. <tr>
  1216. <td colspan="4"><h4>b. PWP services:</h4>
  1217. <obs conceptId="8302" id="pwpservices" answerConceptIds="8305,8303,8306,1175,8304" answerLabels="Condom promotion/provision,Couple counseling,Needle exchange,Not applicable,Targeted risk reduction"/>
  1218. </td>
  1219. </tr>
  1220.  
  1221. </table>
  1222.  
  1223. </section>
  1224.  
  1225. <section headerLabel="Past medical/Social history">
  1226. <table class="quartercolumn">
  1227.  
  1228. <obsgroup groupingConceptId="1852">
  1229. <tr>
  1230. <td colspan="3"><h4>11a. Has patient been Hospitalized since last visit:</h4>
  1231. <obs conceptId="976" id="hospsincelastvisit" style="yes_no"/>
  1232. </td>
  1233. </tr>
  1234. <tr>
  1235. <td colspan="4"><h4>b. If yes, reason for hospitalization:</h4>
  1236. <repeat>
  1237. <template>
  1238. <div id="{n}-togglePrevhospdiag" style="display:none;">
  1239. <table>
  1240. <tr>
  1241. <td colspan="1">
  1242. <obs conceptId="1929" id="hospsincelastvisitDisgnosis" answerClasses="{concept}" style="autocomplete"/>
  1243. <button id="{n}-addPrevhospdiag" class="addPrevhospdiag">Add</button>
  1244. <button id="{n}-removePrevhospdiag" class="removePrevhospdiag">Remove</button>
  1245. </td>
  1246.  
  1247.  
  1248. </tr>
  1249. </table>
  1250. </div>
  1251. </template>
  1252. <render n="1" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1253. <render n="2" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1254. <render n="3" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1255. <render n="4" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1256. <render n="5" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1257. <render n="6" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1258. <render n="7" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1259. <render n="8" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1260. <render n="9" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1261. <render n="10" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1262. </repeat>
  1263. </td>
  1264. </tr>
  1265. </obsgroup>
  1266. <includeIf velocityTest="$patient.gender == 'F' ">
  1267. <tr>
  1268. <td colspan="2"><h4>12a. Females: LMP:</h4>
  1269. <obs conceptId="1836" id="lmp" allowFutureDates="false"/>
  1270. </td>
  1271. </tr>
  1272. <tr>
  1273. <td colspan="2"><h4>b. Pregnant (Fill out pMTCT Form):</h4>
  1274. <obs conceptId="8351" id="pregnant" answerConceptIds="1065, 1066" answerLabels="Yes, No"/>
  1275. </td>
  1276. </tr>
  1277. <tr>
  1278. <td colspan="2"><h4>c. Delivered:</h4>
  1279. <obs conceptId="1146" id="delivered" style="yes_no"/><span id="deliveredMsg"><small>If yes, fill out pMTCT form</small></span>
  1280. </td>
  1281. </tr>
  1282. </includeIf>
  1283. <tr>
  1284. <td colspan="1"><h4>d. Family Planning:</h4>
  1285. <obs conceptId="8355" id="fp" answerConceptIds="1065, 1066" answerLabels="Yes, No"/>
  1286. </td>
  1287. </tr>
  1288. <tr>
  1289. <td colspan="4"><h4>e. Method:</h4>
  1290. <span id="fpgroup">
  1291. <obs conceptId="374" id="familyplanning" answerConceptIds="190,6725,6220,5275,5279,8300,780,5622,5277,5276" answerLabels="Condoms,Emergency OCP,Implant,Injectable Hormones,IUD,Lactation Method,OCP,Other,Rhythm Method,Sterilization"/>
  1292. </span>
  1293. </td>
  1294. </tr>
  1295. <tr>
  1296. <td colspan="5"><h4>f. If not on family panning, reason:</h4>
  1297. <obs conceptId="6687" id="notfpreson" answerConceptIds="7062,8299,6685, 5622" answerLabels="Not sexual active,Thinks can't get pregnant, Wants to get pregnant, Other"/>
  1298. </td>
  1299. </tr>
  1300.  
  1301. </table>
  1302.  
  1303. </section>
  1304.  
  1305.  
  1306. <section headerLabel=" Current ARVs">
  1307. <table class="quartercolumn">
  1308.  
  1309. <tr>
  1310. <td><h4>13a. ARVS:</h4>
  1311. <obs conceptId="1192" id="currmedArvs" style="yes_no"/>
  1312. </td>
  1313. </tr>
  1314. <tr>
  1315. <td><h4>b. Has this patient ever had ARV drugs changed for any reason</h4>
  1316. <obs conceptId="1999" id="changedrug" answerConceptIds="1065, 1066" answerLabels="Yes, No"/>
  1317. </td>
  1318. </tr>
  1319. <tr>
  1320. <td><h4>c. If started since last visit record the date</h4><obs id="arvstartdatesincelast" conceptId="1499"/>
  1321. </td>
  1322. </tr>
  1323. <tr >
  1324. <td><h4>d. Treatment Categories</h4><obs conceptId="6744" id="currmedtreamentcate" answerConceptIds="6693,6694,6695" answerLabels="First Regimen,Second Regimen,Third regimen"/>
  1325. </td>
  1326. </tr>
  1327.  
  1328.  
  1329.  
  1330. <obsgroup groupingConceptId="1941">
  1331.  
  1332. <tr class="arvDrugs1">
  1333. <td><b>e.</b><obs conceptId="1088" id="arvcurrNvpzdv3tc" answerConceptId="6467" answerLabel="NVP200/ZDV300/3TC150" style="checkbox"/></td>
  1334. </tr>
  1335. <tr class="arvDrugs1">
  1336. <td><obs conceptId="1088" id="arvcurrTdf3tcefv" answerConceptId="6964" answerLabel="TDF300mg/3TC300mg/EFV600mg" style="checkbox"/></td>
  1337. </tr>
  1338. <tr class="arvDrugs1">
  1339. <td><obs conceptId="1088" id="arvcurr3tctdf" answerConceptId="1400" answerLabel="3TC300mg/TDF300mg" style="checkbox"/></td>
  1340. </tr>
  1341. <tr class="arvDrugs1">
  1342. <td><obs conceptId="1088" id="arvcurr3tcd4t" answerConceptId="6965" answerLabel="3TC150mg/D4T30mg" style="checkbox"/></td>
  1343. </tr>
  1344. <tr class="arvDrugs1">
  1345. <td><obs conceptId="1088" id="arvcurr3tczdv" answerConceptId="630" answerLabel="3TC150mg/ZDV300mg" style="checkbox"/></td>
  1346. </tr>
  1347.  
  1348. <tr class="arvDrugs1">
  1349. <td><obs conceptId="1088" id="arvcurrNvpd4t3tc" answerConceptId="792" answerLabel="NVP200/D4T30/3TC150" style="checkbox"/></td>
  1350. </tr>
  1351. <tr class="arvDrugs1">
  1352. <td> <obs conceptId="1088" id="arvcurrTruvada" answerConceptId="6180" answerLabel="Emtri200mg/TDF300(Truvada)" style="checkbox"/></td>
  1353.  
  1354. </tr>
  1355. <tr class="arvDrugs1">
  1356. <td><obs conceptId="1088" id="arvcurrAluvia" answerConceptId="794" answerLabel="Aluvia(Kaletra)200mg/LPV50mgrit" style="checkbox"/></td>
  1357. </tr>
  1358. <tr class="arvDrugs1">
  1359. <td> <obs conceptId="1088" id="arvcurrAtazanavirit" answerConceptId="6160" answerLabel="Atazanavir300/Ritonavir100" style="checkbox"/>
  1360. </td>
  1361. </tr>
  1362.  
  1363. <tr class="arvDrugs1">
  1364. <td><obs conceptId="1088" id="arvcurrAbacavir" answerConceptId="814" answerLabel="Abacavir300mg" style="checkbox"/></td>
  1365. </tr>
  1366. <tr class="arvDrugs1">
  1367. <td><obs conceptId="1088" id="arvcurrEfavirenz" answerConceptId="633" answerLabel="Efavirenz600mg" style="checkbox"/></td>
  1368. </tr>
  1369. <tr class="arvDrugs1">
  1370. <td><obs conceptId="1088" id="arvcurrLamivudine" answerConceptId="628" answerLabel="Lamivudine150mg" style="checkbox"/></td>
  1371. </tr>
  1372. <tr class="arvDrugs1">
  1373. <td><obs conceptId="1088" id="arvcurrNevirapine" answerConceptId="631" answerLabel="Nevirapine200mg" style="checkbox"/></td>
  1374. </tr>
  1375. <tr class="arvDrugs1">
  1376. <td><obs conceptId="1088" id="arvcurrRaltegravir" answerConceptId="6156" answerLabel="Raltegravir" style="checkbox"/></td>
  1377. </tr>
  1378.  
  1379. <tr class="arvDrugs1">
  1380. <td> <obs conceptId="1088" id="arvcurrOther" answerConceptId="5424" answerLabel="Other" style="checkbox"/></td>
  1381.  
  1382. </tr>
  1383.  
  1384. <tr class="arvDrugs1">
  1385. <td><obs conceptId="1088" id="arvcurrZidovudine" answerConceptId="797" answerLabel="Zidovudine300mg" style="checkbox"/></td>
  1386. </tr>
  1387.  
  1388.  
  1389. </obsgroup>
  1390.  
  1391. </table>
  1392. </section>
  1393.  
  1394.  
  1395.  
  1396.  
  1397. <section headerLabel=" Current prophylaxis and other drugs">
  1398. <table class="quartercolumn">
  1399.  
  1400. <tr>
  1401. <td><h4>14a. PCP Prophylaxis:</h4><obs conceptId="1109" id="pcpprophcurr" answerConceptIds="1107, 916, 92" answerLabels="None, Septrin, Dapsone 100mg"/>
  1402. </td>
  1403. </tr>
  1404. <tr>
  1405. <td><h4>b. TB Prophylaxis</h4><obs conceptId="1110" id="tbprophcurr" answerConceptIds="1107, 656" answerLabels="None, Isoniazid 300mg"/>
  1406. </td>
  1407. </tr>
  1408. <tr>
  1409. <td><h4>c. Cryptococcus Tx:</h4>
  1410.  
  1411. <obs conceptId="1112" id="cryptocurr" answerConceptIds="1107,747" answerLabels="None, Fluconazole 200mg"/>
  1412. </td>
  1413. </tr>
  1414.  
  1415.  
  1416. <tr>
  1417. <obsgroup groupingConceptId="1919">
  1418. <td colspan="5"><h4>d. Other Drugs:</h4>
  1419.  
  1420. <repeat>
  1421. <template>
  1422. <div id="{n}-toggleOtherDrugs" style="display:none;">
  1423. <table>
  1424. <tr>
  1425.  
  1426. <td>
  1427. <obs conceptId="1895" id="OtherDrugs" answerClasses="Drug" style="autocomplete"/>
  1428. <button id="{n}-addOtherDrugs" class="addOtherDrugs">Add</button>
  1429. <button id="{n}-removeOtherDrugs" class="removeOtherDrugs">Remove</button>
  1430.  
  1431. </td>
  1432.  
  1433.  
  1434. </tr>
  1435. </table>
  1436. </div>
  1437. </template>
  1438. <render n="1" concept="Drug"/>
  1439. <render n="2" concept="Drug"/>
  1440. <render n="3" concept="Drug"/>
  1441. <render n="4" concept="Drug"/>
  1442. <render n="5" concept="Drug"/>
  1443. <render n="6" concept="Drug"/>
  1444. <render n="7" concept="Drug"/>
  1445. <render n="8" concept="Drug"/>
  1446. <render n="9" concept="Drug"/>
  1447. <render n="10" concept="Drug"/>
  1448. </repeat>
  1449.  
  1450. </td>
  1451. </obsgroup>
  1452. </tr>
  1453.  
  1454. </table>
  1455. </section>
  1456.  
  1457. <section headerLabel="Current tuberculosis ">
  1458. <table class="quartercolumn">
  1459. <tr>
  1460. <td><h4>15a. TB treatment</h4><obs conceptId="1111" id="tbcurr" answerConceptId="1107" answerLabel="None"/>
  1461. <obs conceptId="1111" id="tbcurrYes" answerConceptId="1065" answerLabel="On treatment"/><br></br>
  1462. <obs conceptId="1113" id="tbstartDate" labelText="i. Start Date of TB treatment"/>
  1463. </td>
  1464. </tr>
  1465. <tr>
  1466. <td><h4>b. Site of TB meds pick-up</h4><obs conceptId="8068" id="tbcurrmedspickup" answerConceptIds="1286, 5622" answerLabels="This Ampath site, Other"/>
  1467. </td>
  1468. </tr>
  1469.  
  1470.  
  1471.  
  1472. <obsgroup groupingConceptId="6196">
  1473.  
  1474. <tr class="tbCurrentDrugRows">
  1475. <td><b>c.</b>
  1476. <span id="tbcurrRhze"><obs conceptId="1111" answerConceptId="1131" answerLabel="(RHZE)" style="checkbox"/>
  1477. <obs conceptId="1920"/>tabs/day
  1478. </span>
  1479. </td>
  1480. </tr>
  1481. <tr class="tbCurrentDrugRows">
  1482. <td><span id="tbcurrRhz"><obs conceptId="1111" answerConceptId="768" answerLabel="(RHZ)" style="checkbox"/>
  1483. <obs conceptId="1920"/>tabs/day</span>
  1484. </td>
  1485. </tr>
  1486. <tr class="tbCurrentDrugRows">
  1487. <td>
  1488. <span id="tbcurrRhe"><obs conceptId="1111" answerConceptId="2231" answerLabel="(RHE)" style="checkbox"/>
  1489. <obs conceptId="1920"/>tabs/day
  1490. </span>
  1491. </td>
  1492. </tr>
  1493. <tr class="tbCurrentDrugRows">
  1494. <td>
  1495. <span id="tbcurrRh"><obs conceptId="1111" answerConceptId="1194" answerLabel="(RH)" style="checkbox"/>
  1496. <obs conceptId="1920"/>tabs/day
  1497. </span>
  1498. </td>
  1499. </tr>
  1500. <tr class="tbCurrentDrugRows">
  1501. <td>
  1502. <span id="tbcurrEh">
  1503. <obs conceptId="1111" answerConceptId="1108" answerLabel="(EH)" style="checkbox"/>
  1504. <obs conceptId="1899"/>mg
  1505. </span>
  1506. </td>
  1507. </tr>
  1508. <tr class="tbCurrentDrugRows">
  1509. <td><span id="tbcurrEthambutol"><obs conceptId="1111" answerConceptId="745" answerLabel="Ethambutol" style="checkbox"/>
  1510. <obs conceptId="1921"/>mg/day</span>
  1511. </td>
  1512. </tr>
  1513. <tr class="tbCurrentDrugRows">
  1514. <td><span id="tbcurrINH"><obs conceptId="1111" answerConceptId="656" answerLabel="INH" style="checkbox"/>
  1515. <obs conceptId="1921"/>mg/day</span>
  1516. </td>
  1517. </tr>
  1518. <tr class="tbCurrentDrugRows">
  1519. <td><span id="tbcurrMdr"><obs conceptId="1111" answerConceptId="2161" answerLabel="MDR drugs" style="checkbox"/></span>
  1520. </td>
  1521.  
  1522. </tr>
  1523. <tr class="tbCurrentDrugRows">
  1524. <td><span id="tbcurrPyrazinamide"><obs conceptId="1111" answerConceptId="5829" answerLabel="Pyrazinamide" style="checkbox"/>
  1525. <obs conceptId="1899"/>mg</span>
  1526. </td>
  1527. </tr>
  1528. <tr class="tbCurrentDrugRows">
  1529. <td>
  1530. <span id="tbcurrRifabutin"><obs conceptId="1111" answerConceptId="6983" answerLabel="Rifabutin" style="checkbox"/>
  1531. <obs conceptId="1898"/>tabs
  1532. </span>
  1533. </td>
  1534. </tr>
  1535. <tr class="tbCurrentDrugRows">
  1536. <td><span id="tbcurrRifampicin"><obs conceptId="1111" answerConceptId="656" answerLabel="Rifampicin" style="checkbox"/>
  1537. <obs conceptId="1899"/>mg</span>
  1538. </td>
  1539.  
  1540. </tr>
  1541.  
  1542. <tr class="tbCurrentDrugRows">
  1543. <td><span id="tbcurrStreptomycin"><obs conceptId="1111" answerConceptId="438" answerLabel="Streptomycin" style="checkbox"/>
  1544. <obs conceptId="1899"/>mg</span>
  1545. </td>
  1546. </tr>
  1547.  
  1548. <tr>
  1549. <td><obs conceptId="1111" id="tbcurrOther" answerConceptId="5622" answerLabel="Other" style="checkbox"/>
  1550. </td>
  1551. </tr>
  1552.  
  1553. </obsgroup>
  1554.  
  1555. </table>
  1556.  
  1557. </section>
  1558.  
  1559. <section headerLabel="Adherence">
  1560. <table class="quartercolumn">
  1561. <tr>
  1562. <obsgroup groupingConceptId="9210">
  1563. <td> <b>16a.ARVS</b> <obs conceptId="8288" id="arvadhere" answerConceptIds="6343, 6655, 6656" answerLabels="Good, Fair, Poor"/>
  1564. </td>
  1565.  
  1566. <td colspan="4"><h4> Reason:</h4> <span id="arvadhereReason">
  1567. <obs conceptId="1668" id="arvadhereAlcohol" answerConceptId="1445" answerLabel="Alcohol" style= "checkbox"/>
  1568. <obs conceptId="1668" id="arvadhereCost" answerConceptId="6295" answerLabel="Cost" style= "checkbox"/>
  1569. <obs conceptId="1668" id="arvadhereDepression" answerConceptId="207" answerLabel="Depression" style= "checkbox"/>
  1570. <obs conceptId="1668" id="arvadhereFeltwell" answerConceptId="1647" answerLabel="Felt well" style= "checkbox"/>
  1571. <obs conceptId="1668" id="arvadhereForgot" answerConceptId="1648" answerLabel="Forgot" style= "checkbox"/>
  1572. <obs conceptId="1668" id="arvadhereGaveaway" answerConceptId="7064" answerLabel="Gave away" style= "checkbox"/><br/>
  1573. <obs conceptId="1668" id="arvadhereRanout" answerConceptId="6100" answerLabel="Lost/Ran out of pills" style= "checkbox"/>
  1574. <obs conceptId="1668" id="arvadherePillburden" answerConceptId="7065" answerLabel="Pill Burden" style= "checkbox"/>
  1575. <obs conceptId="1668" id="arvadhereSideeffects" answerConceptId="1664" answerLabel="Side Effects" style= "checkbox"/>
  1576. <obs conceptId="1668" id="arvadhereStigma" answerConceptId="1666" answerLabel="Stigma" style= "checkbox"/>
  1577. <obs conceptId="1668" id="arvadhereStockout" answerConceptId="7043" answerLabel="Stock out" style= "checkbox"/>
  1578. <obs conceptId="1668" id="arvadhereTooill" answerConceptId="1548" answerLabel="Too ill" style= "checkbox"/><br/>
  1579. <obs conceptId="1668" id="arvadhereTravproblem" answerConceptId="820" answerLabel="Travel Problems" style= "checkbox"/>
  1580. <obs conceptId="1668" id="arvadhereOther" answerConceptId="5622" answerLabel="Other (specify):" style= "checkbox"/>
  1581. <obs conceptId="1915" id="arvadhereSpecify" style="textbox"/>
  1582. </span>
  1583. </td>
  1584.  
  1585. </obsgroup>
  1586. </tr>
  1587.  
  1588. <tr>
  1589. <obsgroup groupingConceptId="9211">
  1590. <td> <b>b. PCP Prophylaxis</b> <obs conceptId="8289" id="pcpprophadhere" answerConceptIds="6343, 6655, 6656" answerLabels="Good, Fair, Poor"/>
  1591. </td>
  1592. <td colspan="4"><h4> Reason:</h4><span id="pcpprophadhereReason">
  1593. <obs conceptId="1668" id="pcpprophadhereAlcohol" answerConceptId="1445" answerLabel="Alcohol" style= "checkbox"/>
  1594. <obs conceptId="1668" id="pcpprophadhereCost" answerConceptId="6295" answerLabel="Cost" style= "checkbox"/>
  1595. <obs conceptId="1668" id="pcpprophadhereDepression" answerConceptId="207" answerLabel="Depression" style= "checkbox"/>
  1596. <obs conceptId="1668" id="pcpprophadhereFeltwell" answerConceptId="1647" answerLabel="Felt well" style= "checkbox"/>
  1597. <obs conceptId="1668" id="pcpprophadhereForgot" answerConceptId="1648" answerLabel="Forgot" style= "checkbox"/>
  1598. <obs conceptId="1668" id="pcpprophadhereGaveaway" answerConceptId="7064" answerLabel="Gave away" style= "checkbox"/><br/>
  1599. <obs conceptId="1668" id="pcpprophadhereRanout" answerConceptId="6100" answerLabel="Lost/Ran out of pills" style= "checkbox"/>
  1600. <obs conceptId="1668" id="pcpprophadherePillburden" answerConceptId="7065" answerLabel="Pill Burden" style= "checkbox"/>
  1601. <obs conceptId="1668" id="pcpprophadhereSideeffects" answerConceptId="1664" answerLabel="Side Effects" style= "checkbox"/>
  1602. <obs conceptId="1668" id="pcpprophadhereStigma" answerConceptId="1666" answerLabel="Stigma" style= "checkbox"/>
  1603. <obs conceptId="1668" id="pcpprophadhereStockout" answerConceptId="7043" answerLabel="Stock out" style= "checkbox"/>
  1604. <obs conceptId="1668" id="pcpprophadhereTooill" answerConceptId="1548" answerLabel="Too ill" style= "checkbox"/><br/>
  1605. <obs conceptId="1668" id="pcpprophadhereTravproblem" answerConceptId="820" answerLabel="Travel Problems" style= "checkbox"/>
  1606. <obs conceptId="1668" id="pcpprophadhereOther" answerConceptId="5622" answerLabel="Other (specify):" style= "checkbox"/>
  1607. <obs conceptId="1915" id="pcpprophadhereSpecify" style="textbox"/>
  1608. </span></td>
  1609. </obsgroup>
  1610. </tr>
  1611.  
  1612. <tr>
  1613. <obsgroup groupingConceptId="9212">
  1614. <td> <b>c. TB Prophylaxis</b> <obs conceptId="8604" id="tbprophadhere" answerConceptIds="6343, 6655, 6656" answerLabels="Good, Fair, Poor"/>
  1615. </td>
  1616. <td colspan="4"><h4> Reason:</h4><span id="tbprophadhereReason">
  1617. <obs conceptId="1668" id="tbprophadhereAlcohol" answerConceptId="1445" answerLabel="Alcohol" style= "checkbox"/>
  1618. <obs conceptId="1668" id="tbprophadhereCost" answerConceptId="6295" answerLabel="Cost" style= "checkbox"/>
  1619. <obs conceptId="1668" id="tbprophadhereDepression" answerConceptId="207" answerLabel="Depression" style= "checkbox"/>
  1620. <obs conceptId="1668" id="tbprophadhereFeltwell" answerConceptId="1647" answerLabel="Felt well" style= "checkbox"/>
  1621. <obs conceptId="1668" id="tbprophadhereForgot" answerConceptId="1648" answerLabel="Forgot" style= "checkbox"/>
  1622. <obs conceptId="1668" id="tbprophadhereGaveaway" answerConceptId="7064" answerLabel="Gave away" style= "checkbox"/><br/>
  1623. <obs conceptId="1668" id="tbprophadhereRanout" answerConceptId="6100" answerLabel="Lost/Ran out of pills" style= "checkbox"/>
  1624. <obs conceptId="1668" id="tbprophadherePillburden" answerConceptId="7065" answerLabel="Pill Burden" style= "checkbox"/>
  1625. <obs conceptId="1668" id="tbprophadhereSideeffects" answerConceptId="1664" answerLabel="Side Effects" style= "checkbox"/>
  1626. <obs conceptId="1668" id="tbprophadhereStigma" answerConceptId="1666" answerLabel="Stigma" style= "checkbox"/>
  1627. <obs conceptId="1668" id="tbprophadhereStockout" answerConceptId="7043" answerLabel="Stock out" style= "checkbox"/>
  1628. <obs conceptId="1668" id="tbprophadhereTooill" answerConceptId="1548" answerLabel="Too ill" style= "checkbox"/><br/>
  1629. <obs conceptId="1668" id="tbprophadhereTravproblem" answerConceptId="820" answerLabel="Travel Problems" style= "checkbox"/>
  1630. <obs conceptId="1668" id="tbprophadhereOther" answerConceptId="5622" answerLabel="Other (specify):" style= "checkbox"/>
  1631. <obs conceptId="1915" id="tbprophadhereSpecify" style="textbox"/>
  1632. </span></td>
  1633. </obsgroup>
  1634. </tr>
  1635.  
  1636. <tr>
  1637. <obsgroup groupingConceptId="9213">
  1638. <td> <b>d. TB Treatment</b> <obs conceptId="9204" id="tbadhere" answerConceptIds="6343, 6655, 6656" answerLabels="Good, Fair, Poor"/>
  1639. </td>
  1640. <td colspan="4"><h4> Reason:</h4><span id="tbadhereReason">
  1641. <obs conceptId="1668" id="tbadhereAlcohol" answerConceptId="1445" answerLabel="Alcohol" style= "checkbox"/>
  1642. <obs conceptId="1668" id="tbadhereCost" answerConceptId="6295" answerLabel="Cost" style= "checkbox"/>
  1643. <obs conceptId="1668" id="tbadhereDepression" answerConceptId="207" answerLabel="Depression" style= "checkbox"/>
  1644. <obs conceptId="1668" id="tbadhereFeltwell" answerConceptId="1647" answerLabel="Felt well" style= "checkbox"/>
  1645. <obs conceptId="1668" id="tbadhereForgot" answerConceptId="1648" answerLabel="Forgot" style= "checkbox"/>
  1646. <obs conceptId="1668" id="tbadhereGaveaway" answerConceptId="7064" answerLabel="Gave away" style= "checkbox"/><br/>
  1647. <obs conceptId="1668" id="tbadhereRanout" answerConceptId="6100" answerLabel="Lost/Ran out of pills" style= "checkbox"/>
  1648. <obs conceptId="1668" id="tbadherePillburden" answerConceptId="7065" answerLabel="Pill Burden" style= "checkbox"/>
  1649. <obs conceptId="1668" id="tbadhereSideeffects" answerConceptId="1664" answerLabel="Side Effects" style= "checkbox"/>
  1650. <obs conceptId="1668" id="tbadhereStigma" answerConceptId="1666" answerLabel="Stigma" style= "checkbox"/>
  1651. <obs conceptId="1668" id="tbadhereStockout" answerConceptId="7043" answerLabel="Stock out" style= "checkbox"/>
  1652. <obs conceptId="1668" id="tbadhereTooill" answerConceptId="1548" answerLabel="Too ill" style= "checkbox"/><br/>
  1653. <obs conceptId="1668" id="tbadhereTravproblem" answerConceptId="820" answerLabel="Travel Problems" style= "checkbox"/>
  1654. <obs conceptId="1668" id="tbadhereOther" answerConceptId="5622" answerLabel="Other (specify):" style= "checkbox"/>
  1655. <obs conceptId="1915" id="tbadhereSpecify" style="textbox"/>
  1656. </span></td>
  1657. </obsgroup>
  1658. </tr>
  1659.  
  1660.  
  1661.  
  1662.  
  1663.  
  1664. <tr>
  1665. <td colspan="5"><h4>17a. Side effects/toxicity: Any side effects attributable to any drug that the patient is currently taking:</h4><obs conceptId="6836" id="currSideeff" answerConceptIds="1065, 1066" answerLabels="Yes, No"/><br/>
  1666.  
  1667. </td>
  1668. </tr>
  1669.  
  1670. <tr>
  1671. <td colspan="5"><h4>b. If yes, drug(s):</h4>
  1672.  
  1673. <repeat>
  1674. <template>
  1675. <div id="{n}-toggletoxicityDrug" style="display:none;">
  1676. <table>
  1677. <tr>
  1678. <td>
  1679.  
  1680. <obs conceptId="6838" id="toxicitySideEffectDrugs" answerClasses="Drug" style="autocomplete" labelText="Side effect Drug:"/>
  1681. <button id="{n}-addtoxicityDrug" class="addtoxicityDrug">Add</button>
  1682. <button id="{n}-removetoxicityDrug" class="removetoxicityDrug">Remove</button>
  1683.  
  1684. </td>
  1685.  
  1686.  
  1687. </tr>
  1688. </table>
  1689. </div>
  1690. </template>
  1691. <render n="1" concept="Drug"/>
  1692. <render n="2" concept="Drug"/>
  1693. <render n="3" concept="Drug"/>
  1694. <render n="4" concept="Drug"/>
  1695. <render n="5" concept="Drug"/>
  1696. <render n="6" concept="Drug"/>
  1697. <render n="7" concept="Drug"/>
  1698. <render n="8" concept="Drug"/>
  1699. <render n="9" concept="Drug"/>
  1700. <render n="10" concept="Drug"/>
  1701. </repeat>
  1702.  
  1703. </td>
  1704. </tr>
  1705. </table>
  1706. </section>
  1707.  
  1708. <section headerLabel="Vital signs">
  1709. <table class="quartercolumn">
  1710. <tr><td colspan="5"><b>18.</b><obs conceptId="5085" labelText="BP:"/>/<obs conceptId="5086"/><obs conceptId="5087" labelText="Pulse"/><obs conceptId="5088" labelText="Temp:"/><obs conceptId="5089" labelText="Weight:"/><obs conceptId="5090" labelText="Height:"/><obs conceptId="5092" labelText="SaO2:"/><obs conceptId="1342" labelText="BMI:"/><br/>
  1711.  
  1712. <button id="missingvitals" value="" name="button">Missing vital results, submit anyway</button>
  1713. </td>
  1714.  
  1715. </tr>
  1716. </table>
  1717. </section>
  1718.  
  1719. <section headerLabel="Interval complaints">
  1720. <table class="quartercolumn">
  1721.  
  1722. <tr><td colspan="5"><h4>19. Does the patient have any interval complaints:</h4><obs conceptId="1154" style="yes_no"/></td>
  1723. </tr>
  1724. </table>
  1725. </section>
  1726. <section headerLabel="TB Screening questions">
  1727. <table class="standard">
  1728. <tr >
  1729. <td class="checkboxGroup"><h4>20a. TB Symptoms:</h4>
  1730. <span id="checkboxAll">
  1731. <obs conceptId="6174" id="tbsympNone" answerConceptId="1107" answerLabel="None"/></span>
  1732. <span id="checkboxCheckbox">
  1733. <obs conceptId="6174" answerConceptId="5960" id="tbsympBreathlessness" answerLabel="Breathlessness" style="checkbox" />
  1734. <obs conceptId="6174" answerConceptId="136" id="tbsympChestpain" answerLabel="Chest pain" style="checkbox"/>
  1735. <obs conceptId="6174" answerConceptId="6171" id="tbsympCough" answerLabel="Cough = 2 weeks" style="checkbox"/>
  1736. <obs conceptId="6174" answerConceptId="8065" id="tbsympFever" answerLabel="Fever for = 2 weeks" style="checkbox"/>
  1737. <obs conceptId="6174" answerConceptId="8067" id="tbsympExposure" answerLabel=" New exposure to household contact with TB " style="checkbox"/><br/>
  1738. <obs conceptId="6174" answerConceptId="832" id="tbsympWeightloss" answerLabel="Noticeable Weight loss" style="checkbox"/>
  1739. <br/>
  1740. <obs conceptId="6174" answerConceptId="8061" id="tbsympNightsweats" answerLabel="Night sweats = 2 weeks" style="checkbox"/>
  1741. <obs conceptId="6174" labelText="Swelling of:" answerConceptId="6019" id="tbsympswellingAbdomen" answerLabel="Abdomen" style="checkbox"/>
  1742. <obs conceptId="6174" answerConceptId="8060" id="tbsympswellingArmpit" answerLabel="Armpit" style="checkbox"/>
  1743. <obs conceptId="6174" answerConceptId="8066" id="tbsympswellingGroin" answerLabel="Groin" style="checkbox"/>
  1744. <obs conceptId="6174" answerConceptId="5312" id="tbsympswellingJoints" answerLabel="Joints" style="checkbox"/>
  1745. <obs conceptId="6174" id="tbsympswellingNeck" answerConceptId="8059" answerLabel="Neck" style="checkbox"/>
  1746.  
  1747. </span>
  1748. </td>
  1749. </tr>
  1750. <tr>
  1751. <td><h4>b. TB Status:</h4>
  1752. <obs conceptId="8292" answerConceptIds="6921,1107, 6176, 6971" answerLabels="Not assessed,No signs, On TB treatment, Suspect"/>
  1753. </td>
  1754. </tr>
  1755. </table>
  1756.  
  1757. </section>
  1758.  
  1759.  
  1760.  
  1761. <section headerLabel="WHO staging">
  1762. <table class="quartercolumn">
  1763.  
  1764. <tr><td colspan="1"><h4>21. WHO stage:</h4><obs conceptId="5356" answerConceptIds="1204, 1205, 1206, 1207" answerLabels="1, 2, 3, 4"/>
  1765. </td>
  1766. <td colspan="3"><h4>Criteria:</h4><obs conceptId="6048" type="text" value=""/></td>
  1767. <td colspan="1"><h4>New stage:</h4><obs conceptId="1248" style="yes_no"/></td>
  1768. </tr>
  1769.  
  1770. </table>
  1771. </section>
  1772.  
  1773. <section headerLabel="Test results: (Please record date sample was drawn, rather than date test was run)">
  1774. <table class="quartercolumn">
  1775.  
  1776. <tr>
  1777. <td>22.<h5>Test</h5></td>
  1778. <td colspan="3"><h5>Result</h5></td>
  1779. </tr>
  1780. <tr>
  1781. <td>Platelets/mm3</td>
  1782. <td colspan="3"><obs conceptId="729" id="testresultPlatelets" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1783. </tr>
  1784. <tr>
  1785. <td>WBC/mm3</td>
  1786. <td colspan="3"><obs conceptId="678" id="testresultWbc" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1787. </tr>
  1788. <tr>
  1789. <td>Hgb g/dL</td>
  1790. <td colspan="3"><obs conceptId="21" id="testresultHgb" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1791. </tr>
  1792. <tr>
  1793. <td>MCV</td>
  1794. <td colspan="3"><obs conceptId="851" id="testresultMcv" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1795. </tr>
  1796. <tr>
  1797. <td>ALC/ mm3</td>
  1798. <td colspan="3"><obs conceptId="952" id="testresultAlc" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1799. </tr>
  1800. <tr>
  1801. <td>CD4</td>
  1802. <td colspan="3"><obs conceptId="5497" id="testresultCd4" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1803. </tr>
  1804. <tr>
  1805. <td>CD4%</td>
  1806. <td colspan="3"><obs conceptId="730" id="testresultCd4%" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1807. </tr>
  1808. <tr>
  1809. <td>Viral Load</td>
  1810. <td colspan="3"><obs conceptId="856" id="testresultViral" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1811.  
  1812.  
  1813. </tr>
  1814. <tr>
  1815. <td>Creatinine mmol/L</td>
  1816. <td colspan="3"><obs conceptId="790" id="testresultCreatinine" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1817. </tr>
  1818. <tr>
  1819. <td>SGPT(ALT)</td>
  1820. <td colspan="3"><obs conceptId="654" id="testresultSgpt" showDate="true" allowFutureDates="false" dateLabel="Date"/></td>
  1821.  
  1822. </tr>
  1823.  
  1824. <tr>
  1825. <td>VDRL</td>
  1826. <td colspan="3"><obs conceptId="299" id="testresultVdrl" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="703,664,1138,1304" answerLabels="Positive,Negative,Indeterminate,Poor sample quality"/></td>
  1827. </tr>
  1828.  
  1829.  
  1830. <tr>
  1831. <td>Sputum Gene xpert MTB</td>
  1832. <td colspan="3"><obs conceptId="8070" id="testresultXpert" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="703,664,1138,1304" answerLabels="Positive,Negative,Indeterminate,Poor sample quality"/></td>
  1833. </tr>
  1834.  
  1835.  
  1836. <tr>
  1837. <td>Sputum Gene xpert RIF</td>
  1838. <td colspan="3"><obs conceptId="8071" id="testresultXpert" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="703,664,1138,1304" answerLabels="Positive,Negative,Indeterminate,Poor sample quality"/></td>
  1839. </tr>
  1840.  
  1841. <tr>
  1842. <td>Sputum AFB Smear</td>
  1843. <td><obs conceptId="307" id="testresultAfb" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="2301,2302,2303,703,664,1138,1304" answerLabels="1+,2+,3+,Positive,Negative,Indeterminate,Poor sample quality"/></td>
  1844. </tr>
  1845.  
  1846. <tr>
  1847. <td>Sputum Culture</td>
  1848. <td colspan="3"><obs conceptId="2311" id="testresultCulture" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="703,664,1304, 8242,8243" answerLabels="Positive,Negative,Poor sample quality,Mycobacterium tuberculosis,NonTuberculosis mycobacteria"/></td>
  1849. </tr>
  1850.  
  1851.  
  1852. <tr>
  1853. <td colspan="1"><h5>CXR</h5></td>
  1854. <td colspan="3"><h5>Code:</h5><obs conceptId="012" id="testresultCXR" showDate="true" allowFutureDates="false" dateLabel="Date" answerConceptIds="5158,6052,6050,6049,1137,1115,1136,5622" answerLabels="Cardiomegaly,Cavitary,Diffuse abn/non-miliary,Infiltrate,Milliary,Normal,PI Effusion,Other"/></td>
  1855. </tr>
  1856. </table>
  1857. </section>
  1858.  
  1859. <section headerLabel="Problem list">
  1860. <table class="quartercolumn">
  1861.  
  1862. <obsgroup groupingConceptId="1284">
  1863. <tr><td colspan="4">
  1864. <repeat>
  1865. <template>
  1866. <div id="{n}-toggleContainer" style="display:none;">
  1867. <table>
  1868. <tr>
  1869. <td colspan="1">
  1870. <obs conceptId="6042" answerClasses="{concept}" style="autocomplete" labelText="23a. Problem Added:"/>
  1871. <button id="{n}-addEntry" class="addEntry">Add</button>
  1872. <button id="{n}-removeEntry" class="removeEntry">Remove</button>
  1873. </td>
  1874.  
  1875.  
  1876. </tr>
  1877. </table>
  1878. </div>
  1879. </template>
  1880. <render n="1" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1881. <render n="2" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1882. <render n="3" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1883. <render n="4" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1884. <render n="5" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1885. <render n="6" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1886. <render n="7" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1887. <render n="8" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1888. <render n="9" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1889. <render n="10" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1890. </repeat>
  1891. </td>
  1892.  
  1893.  
  1894. <td colspan="4">
  1895. <repeat>
  1896. <template>
  1897. <div id="{n}-toggleContainer" style="display:none;">
  1898. <table>
  1899. <tr>
  1900. <td><obs conceptId="2034" answerClasses="{concept}" style="autocomplete" labelText="b. Problem Ongoing"/>
  1901. <button id="{n}-addEntry" class="addEntry">Add</button>
  1902. <button id="{n}-removeEntry" class="removeEntry">Remove</button>
  1903. </td>
  1904. </tr>
  1905. </table>
  1906. </div>
  1907. </template>
  1908.  
  1909. <render n="11" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1910. <render n="12" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1911. <render n="13" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1912. <render n="14" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1913. <render n="15" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1914. <render n="16" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1915. <render n="17" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1916. <render n="18" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1917. <render n="19" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1918. <render n="20" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1919. </repeat>
  1920. </td>
  1921.  
  1922.  
  1923.  
  1924. <td colspan="4">
  1925. <repeat>
  1926. <template>
  1927. <div id="{n}-toggleContainer" style="display:none;">
  1928. <table>
  1929. <tr>
  1930. <td><obs conceptId="6097" answerClasses="{concept}" style="autocomplete" labelText="c. Problem Resolved"/>
  1931. <button id="{n}-addEntry" class="addEntry">Add</button>
  1932. <button id="{n}-removeEntry" class="removeEntry">Remove</button>
  1933. </td>
  1934. </tr>
  1935. </table>
  1936. </div>
  1937. </template>
  1938.  
  1939. <render n="21" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1940. <render n="22" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1941. <render n="23" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1942. <render n="24" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1943. <render n="25" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1944. <render n="26" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1945. <render n="27" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1946. <render n="28" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1947. <render n="29" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1948. <render n="30" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  1949. </repeat>
  1950. </td></tr>
  1951. </obsgroup>
  1952.  
  1953. </table>
  1954. </section>
  1955.  
  1956.  
  1957. <section headerLabel="ARV plan">
  1958. <table class="quartercolumn">
  1959. <tr>
  1960. <td colspan="5"><b>24a. ARV Plan:</b><obs conceptId="1255" id="arvPlan" answerConceptIds=" 981, 1259, 1258, 1257, 1849, 1107, 1256, 1850, 1260" answerLabels=" Change dose, Change regimen, Change formulation, Continue regimen, Drug substitution, Not on ARVS, Restart, Start ARVs, Stop all"/>
  1961. </td>
  1962. </tr>
  1963. <tr>
  1964. <td colspan="5"><h4>b.Reason to Start ARVs</h4>
  1965. <obs conceptId="1251" id="arvstartreason" answerConceptIds="9215, 6096, 1206, 1207" answerLabels="CD4 less than 500, Discordant couple, WHO stage 3, WHO stage 4"/>
  1966. </td>
  1967. </tr>
  1968. <tr>
  1969. <td colspan="5"><h4>c.Reason for stopping/change/substitution/interruption</h4>
  1970. <obsgroup groupingConceptId="1924">
  1971. <obs conceptId="1252" id="arvstopreason" answerConceptIds="1434,843,7043,58,6419,8296,5240,1930,6295,8308,44,7061,1504,5622,102,8297" answerLabels="Adherence concerns,Clinical treatment failure,Drug out of stock,Due to new TB,Illness/hospitalization,Immunologic failure,Lost to follow-up,New drug available,Patient lacks finances,Planned Rx interruption,Pregnancy,Risk of pregnancy,Other patient décisions,Other,Toxicity,Virologic failure"/>
  1972. <h5>If toxicity, please provide cause</h5><obs conceptId="1879" id="arvstopreasonTox" answerConceptIds="151,7862,7863,3,1443,207,175,16,877,7771,5949,620,8607,29,7687,1486,867,1478,215,1877,1874,1446,7866,7867,121,5978,6636,1887,5622,1875,821,512,1885,1886,6033,7873,7865,5960,1876,1878,2030,7864,839,5980,5226" answerLabels="Abdominal pain,Akathisia,Akinesia,Anemia,Anxiety,Depression,Diabetes Mellitus,Diarrhea,Dizziness,Extrapyramidal side effects,Fatigue,Headache,Hepatotoxicity,Hepatitis,Hyperactive,Hypotension,Insomnia,IRIS,Jaundice,Kidney stone,Lacti acidosis,Lipodystrophy,Mania,Metabolic side effects,Myalgia,Nausea,Neuropathy,Optic neuritis,Other,Pancreatitis,Peripheral neuropathy,Rash,Renal failure,Renal insufficiency,Renal disease,Sedation,Sexual dysfunction,Shortness of breath,Sleep disturbance,Stroke,Stevens-Johnson syndrome,Tardive dyskinesia,Thrombocytopenia,Vomiting,Weakness"/>
  1973. <obs conceptId="1915" id="arvstopreasonSpecify" labelText="Other Specify:"/>
  1974. </obsgroup>
  1975. </td>
  1976. </tr>
  1977. <tr>
  1978. <td colspan="5"><h4>d. Eligible for ARVs but not started:</h4>
  1979. <obsgroup groupingConceptId="2046">
  1980. <obs conceptId="1505" id="arveligible" answerConceptIds="1434,5487,5622,1504" answerLabels="Adherence Concerns,On TB Treatment, Other,Patient Refused"/>
  1981. <obs conceptId="1915" id="arveligibleSpecify" labelText="Specify:"/>
  1982. </obsgroup>
  1983. </td>
  1984. </tr>
  1985. <tr>
  1986. <td colspan="5"><h4>e.If patient on ARVS, choose regimen below:</h4></td>
  1987. </tr>
  1988. <tr class="arvDrugRows">
  1989. <td><obs conceptId="1250" id="arvplan3tcTdf" answerConceptId="1400" answerLabel="3TC300mg/TDF300mg" style="checkbox"/></td>
  1990. </tr>
  1991. <tr class="arvDrugRows">
  1992. <td><obs conceptId="1250" id="arvplan3tcD4t" answerConceptId="6965" answerLabel="3TC150mg/D4T30mg" style="checkbox"/></td>
  1993. </tr>
  1994. <tr class="arvDrugRows">
  1995. <td><obs conceptId="1250" id="arvplan3tcZdv" answerConceptId="630" answerLabel="3TC150mg/ZDV300mg" style="checkbox"/></td>
  1996. </tr>
  1997. <tr class="arvDrugRows">
  1998. <td><obs conceptId="1250" id="arvplanNvpZdv3tc" answerConceptId="6467" answerLabel="NVP200mg/ZDV300mg/3TC150mg" style="checkbox"/></td>
  1999. </tr>
  2000. <tr class="arvDrugRows">
  2001. <td><obs conceptId="1250" id="arvplanNvpD4t3tc" answerConceptId="792" answerLabel="NVP200/D4T30/3TC150" style="checkbox"/></td>
  2002. </tr>
  2003. <tr class="arvDrugRows">
  2004. <td><obs conceptId="1250" id="arvplanTdf3tcEfv" answerConceptId="6964" answerLabel="TDF300mg/3TC300mg/EFV600mg" style="checkbox"/></td>
  2005. </tr>
  2006. <tr class="arvDrugRows">
  2007. <td><obs conceptId="1250" id="arvplanAluvia" answerConceptId="794" answerLabel="Aluvia(Kaletra)200mgLPV" style="checkbox"/></td>
  2008. </tr>
  2009. <tr class="arvDrugRows">
  2010. <td colspan="2"><obs conceptId="1250" id="arvplanAtazRit" answerConceptId="6160" answerLabel="Atazanavir300/Ritonavir100" style="checkbox"/></td>
  2011. </tr>
  2012. <tr class="arvDrugRows">
  2013. <td colspan="2"><obs conceptId="1250" id="arvplanTruvada" answerConceptId="6180" answerLabel="Truvada(Emtri200mg/TDF300)" style="checkbox"/></td>
  2014. </tr>
  2015. <tr class="arvDrugRows">
  2016. <td><obs conceptId="1250" id="arvplanAbacavir" answerConceptId="814" answerLabel="Abacavir300mg" style="checkbox"/></td>
  2017. </tr>
  2018. <tr class="arvDrugRows">
  2019. <td><obs conceptId="1250" id="arvplanEfavirenz" answerConceptId="633" answerLabel="Efavirenz600mg" style="checkbox"/></td>
  2020. </tr>
  2021. <tr class="arvDrugRows">
  2022. <td><obs conceptId="1250" id="arvplanLamivudine" answerConceptId="628" answerLabel="Lamivudine150mg" style="checkbox"/></td>
  2023. </tr>
  2024. <tr class="arvDrugRows">
  2025. <td><obs conceptId="1250" id="arvplanNevirapine" answerConceptId="631" answerLabel="Nevirapine200mg" style="checkbox"/></td>
  2026. </tr>
  2027. <tr class="arvDrugRows">
  2028. <td colspan="2"><obs conceptId="1250" id="arvplanRaltergravir" answerConceptId="6156" answerLabel="Raltergravir400mg" style="checkbox"/></td>
  2029. </tr>
  2030. <tr class="arvDrugRows">
  2031. <td colspan="2"><obs conceptId="1250" id="arvplanOther" answerConceptId="5424" answerLabel="Other:" style="checkbox"/></td>
  2032. </tr>
  2033. <tr class="arvDrugRows">
  2034. <td><obs conceptId="1250" id="arvplanZidovudine" answerConceptId="797" answerLabel="Zidovudine 300mg" style="checkbox"/></td>
  2035. </tr>
  2036.  
  2037. </table>
  2038. </section>
  2039.  
  2040. <section headerLabel="Prophylaxis plan">
  2041. <table class="quartercolumn">
  2042. <tr>
  2043. <td colspan="5"><h4>25a. PCP Prophylaxis Plan:</h4>
  2044. <obs conceptId="1261" id="pcpPlan" answerConceptIds=" 1259, 1257,1107,1256, 1260" answerLabels="Change Regimen,Continue,None, Start, Stop"/>
  2045. </td>
  2046. </tr>
  2047. <tr>
  2048. <td colspan="5"><h4>b.If Change/Stop, reason:</h4>
  2049. <obsgroup groupingConceptId="1925">
  2050. <obs conceptId="1262" id="pcpstopreason" answerConceptIds="102,5622" answerLabels="Toxicity, Other"/>
  2051. <h5>If toxicity, please provide cause:</h5><obs conceptId="1879" id="pcpstopreasonTox" answerConceptIds="151,7862,7863,3,1443,207,175,16,877,7771,5949,620,8607,29,7687,1486,867,1478,215,1877,1874,1446,7866,7867,121,5978,6636,1887,5622,1875,821,512,1885,1886,6033,7873,7865,5960,1876,1878,2030,7864,839,5980,5226" answerLabels="Abdominal pain,Akathisia,Akinesia,Anemia,Anxiety,Depression,Diabetes Mellitus,Diarrhea,Dizziness,Extrapyramidal side effects,Fatigue,Headache,Hepatotoxicity,Hepatitis,Hyperactive,Hypotension,Insomnia,IRIS,Jaundice,Kidney stone,Lacti acidosis,Lipodystrophy,Mania,Metabolic side effects,Myalgia,Nausea,Neuropathy,Optic neuritis,Other,Pancreatitis,Peripheral neuropathy,Rash,Renal failure,Renal insufficiency,Renal disease,Sedation,Sexual dysfunction,Shortness of breath,Sleep disturbance,Stroke,Stevens-Johnson syndrome,Tardive dyskinesia,Thrombocytopenia,Vomiting,Weakness"/>
  2052. <obs conceptId="1915" id="pcpstopreasonSpecify" labelText="Other Specify"/>
  2053. </obsgroup>
  2054. </td>
  2055. </tr>
  2056.  
  2057. <tr>
  2058. <td colspan="5"><h4>c. If Start/Cont/Change, regimen:</h4>
  2059. <obs conceptId="1263" id="pcpMed" answerConceptIds="92,916" answerLabels="Dapsone,Septrin"/>
  2060. </td>
  2061. </tr>
  2062.  
  2063. <tr>
  2064. <td colspan="5"><h4>d.TB Prophylaxis Plan:</h4>
  2065. <obs conceptId="1265" id="tbprophPlan" answerConceptIds=" 1259,1257,1107,1256,1260" answerLabels=" Change Regimen, Continue,None, Start, Stop"/>
  2066. </td>
  2067. </tr>
  2068.  
  2069. <tr>
  2070. <td colspan="5"><h4>e.If Stoping, reason:</h4>
  2071. <obsgroup groupingConceptId="1926">
  2072. <obs conceptId="1266" id="tbprophstopreason" answerConceptIds="58,1267,5622,102" answerLabels=" Active TB,Completed, Other, Toxicity"/>
  2073. <h5>If toxicity, please provide cause:</h5><obs conceptId="1879" id="tbprophstopreasonTox" answerConceptIds="151,7862,7863,3,1443,207,175,16,877,7771,5949,620,8607,29,7687,1486,867,1478,215,1877,1874,1446,7866,7867,121,5978,6636,1887,5622,1875,821,512,1885,1886,6033,7873,7865,5960,1876,1878,2030,7864,839,5980,5226" answerLabels="Abdominal pain,Akathisia,Akinesia,Anemia,Anxiety,Depression,Diabetes Mellitus,Diarrhea,Dizziness,Extrapyramidal side effects,Fatigue,Headache,Hepatotoxicity,Hepatitis,Hyperactive,Hypotension,Insomnia,IRIS,Jaundice,Kidney stone,Lacti acidosis,Lipodystrophy,Mania,Metabolic side effects,Myalgia,Nausea,Neuropathy,Optic neuritis,Other,Pancreatitis,Peripheral neuropathy,Rash,Renal failure,Renal insufficiency,Renal disease,Sedation,Sexual dysfunction,Shortness of breath,Sleep disturbance,Stroke,Stevens-Johnson syndrome,Tardive dyskinesia,Thrombocytopenia,Vomiting,Weakness"/>
  2074. <obs conceptId="1915" id="tbprophstopreasonSpecify" labelText="Other Specify"/>
  2075. </obsgroup>
  2076. </td>
  2077. </tr>
  2078.  
  2079. <tr>
  2080. <td colspan="5"><h4>f.Crypto Prophylaxis Plan:</h4>
  2081. <obs conceptId="1277" id="cryptPlan" answerConceptIds=" 1257,1107,1256, 1260" answerLabels=" Continue Fluconazole,None, Start Fluconazole, Stop Fluconazole"/>
  2082. </td>
  2083. </tr>
  2084. </table>
  2085. </section>
  2086.  
  2087. <section headerLabel="TB Treatment plan">
  2088. <table class="quartercolumn">
  2089. <tr>
  2090. <td colspan="5"><h4>26a. Plan</h4>
  2091. <obs conceptId="1268" id="tbPlan" answerConceptIds=" 1259, 1257, 981, 1256,1849,1260" answerLabels=" Change to Continuation, Continue Regimen, Re-dose, Start Induction, Substitution, Stop"/>
  2092. </td>
  2093. </tr>
  2094.  
  2095. <tr>
  2096. <td colspan="5"><h4>b. If plan is to stop/change/re-dose, reason: </h4>
  2097. <obsgroup groupingConceptId="1927">
  2098. <obs conceptId="1268" id="tbstopreason" answerConceptIds="1267,5622,102" answerLabels="Completed, Other,Toxicity"/>
  2099. <h5>If toxicity, please provide cause:</h5><obs conceptId="1879" id="tbstopreasonTox" answerConceptIds="151,7862,7863,3,1443,207,175,16,877,7771,5949,620,8607,29,7687,1486,867,1478,215,1877,1874,1446,7866,7867,121,5978,6636,1887,5622,1875,821,512,1885,1886,6033,7873,7865,5960,1876,1878,2030,7864,839,5980,5226" answerLabels="Abdominal pain,Akathisia,Akinesia,Anemia,Anxiety,Depression,Diabetes Mellitus,Diarrhea,Dizziness,Extrapyramidal side effects,Fatigue,Headache,Hepatotoxicity,Hepatitis,Hyperactive,Hypotension,Insomnia,IRIS,Jaundice,Kidney stone,Lacti acidosis,Lipodystrophy,Mania,Metabolic side effects,Myalgia,Nausea,Neuropathy,Optic neuritis,Other,Pancreatitis,Peripheral neuropathy,Rash,Renal failure,Renal insufficiency,Renal disease,Sedation,Sexual dysfunction,Shortness of breath,Sleep disturbance,Stroke,Stevens-Johnson syndrome,Tardive dyskinesia,Thrombocytopenia,Vomiting,Weakness"/>
  2100. <obs conceptId="1915" id="tbstopreasonSpecify" labelText="Other Specify"/>
  2101. </obsgroup>
  2102. </td>
  2103. </tr>
  2104.  
  2105.  
  2106.  
  2107. <tr>
  2108. <td>
  2109. <obsgroup groupingConceptId="1926">
  2110. <h4>If completed, date:</h4><obs conceptId="2041" id="tbCompletedDate"/>
  2111. </obsgroup>
  2112. </td>
  2113. </tr>
  2114.  
  2115.  
  2116. <tr>
  2117. <td colspan="5"><h4>c. If re/starting, reason: </h4>
  2118. <obs conceptId="6981" answerConceptIds="6978,6979,2161,6977,6980" answerLabels=" Defaulted, Failure, MDR TB regimen,New treatment, Relapse/re-infection"/>
  2119. </td>
  2120. </tr>
  2121.  
  2122. <tr>
  2123. <td colspan="5"><h4>d. If on treatment: start date</h4>
  2124. <obs conceptId="1113" id="tbstartDate"/>
  2125. </td>
  2126. </tr>
  2127. <tr>
  2128. <td><h4>e. Site of TB meds pick-up</h4>
  2129. <obsgroup groupingConceptId="8069">
  2130. <obs conceptId="8068" id="tbpickupLocation" answerConceptIds="1286,5622" answerLabels="Ampath,Other"/>
  2131. </obsgroup>
  2132. </td>
  2133. </tr>
  2134.  
  2135. <obsgroup groupingConceptId="1825">
  2136.  
  2137. <tr class="tbPlanDrugs">
  2138. <td><b>f.</b>
  2139. <obs conceptId="1270" id="tbplanRhze" answerConceptId="1131" answerLabel="(RHZE)" style="checkbox"/>
  2140. <obs conceptId="1920"/>tabs/day
  2141. </td>
  2142. </tr>
  2143. <tr class="tbPlanDrugs">
  2144. <td>
  2145. <obs conceptId="1270" id="tbplanRhz" answerConceptId="768" answerLabel="(RHZ)" style="checkbox"/>
  2146. <obs conceptId="1920"/>tabs/day
  2147. </td>
  2148. </tr>
  2149. <tr class="tbPlanDrugs">
  2150. <td>
  2151. <obs conceptId="1270" id="tbplanRhe" answerConceptId="2231" answerLabel="(RHE)" style="checkbox"/>
  2152. <obs conceptId="1920"/>tabs/day
  2153. </td>
  2154. </tr>
  2155. <tr class="tbPlanDrugs">
  2156. <td>
  2157. <obs conceptId="1270" id="tbplanRh" answerConceptId="1194" answerLabel="(RH)" style="checkbox"/>
  2158. <obs conceptId="1920"/>tabs/day
  2159. </td>
  2160. </tr>
  2161. <tr class="tbPlanDrugs">
  2162. <td>
  2163. <obs conceptId="1270" id="tbplanEh" answerConceptId="1108" answerLabel="(EH)" style="checkbox"/>
  2164. <obs conceptId="1899"/>mg
  2165. </td>
  2166. </tr>
  2167. <tr class="tbPlanDrugs">
  2168. <td>
  2169. <obs conceptId="1270" id="tbplanEthambutol" answerConceptId="745" answerLabel="Ethambutol" style="checkbox"/>
  2170. <obs conceptId="1921"/>mg/day
  2171. </td>
  2172. </tr>
  2173. <tr class="tbPlanDrugs">
  2174. <td>
  2175. <obs conceptId="1270" id="tbplanInh" answerConceptId="656" answerLabel="INH" style="checkbox"/>
  2176. <obs conceptId="1921"/>mg/day
  2177. </td>
  2178. </tr>
  2179. <tr class="tbPlanDrugs">
  2180. <td>
  2181. <obs conceptId="1270" id="tbplanMdr" answerConceptId="2161" answerLabel="MDR drugs" style="checkbox"/>
  2182. </td>
  2183. </tr>
  2184. <tr class="tbPlanDrugs">
  2185. <td>
  2186. <obs conceptId="1270" id="tbplanPyrazinamide" answerConceptId="5829" answerLabel="Pyrazinamide" style="checkbox"/>
  2187. <obs conceptId="1899"/>mg
  2188. </td>
  2189. </tr>
  2190. <tr class="tbPlanDrugs">
  2191. <td>
  2192. <obs conceptId="1270" id="tbplanRifabutin" answerConceptId="6983" answerLabel="Rifabutin" style="checkbox"/>
  2193. <obs conceptId="1898"/>tabs
  2194. </td>
  2195. </tr>
  2196. <tr class="tbPlanDrugs">
  2197. <td>
  2198. <obs conceptId="1270" id="tbplanRifampicin" answerConceptId="656" answerLabel="Rifampicin" style="checkbox"/>
  2199. <obs conceptId="1899"/>mg
  2200. </td>
  2201. </tr>
  2202.  
  2203. <tr class="tbPlanDrugs">
  2204. <td>
  2205. <obs conceptId="1270" id="tbplanStreptomycin" answerConceptId="438" answerLabel="Streptomycin" style="checkbox"/>
  2206. <obs conceptId="1899"/>mg
  2207. </td>
  2208. </tr>
  2209.  
  2210. <tr class="tbPlanDrugs">
  2211. <td>
  2212. <obs conceptId="1270" id="tbplanOther" answerConceptId="5622" answerLabel="Other" style="checkbox"/>
  2213. </td>
  2214. </tr>
  2215. </obsgroup>
  2216. </table>
  2217. </section>
  2218.  
  2219. <section headerLabel="Additional drugs">
  2220. <table class="quartercolumn">
  2221. <obsgroup groupingConceptId="1901">
  2222. <tr><td colspan="5"><h4>27. Add drugs:</h4>
  2223. <repeat>
  2224. <template>
  2225. <div id="{n}-toggleDrug" style="display:none;">
  2226. <table>
  2227. <tr>
  2228. <td>
  2229. <obs conceptId="1895" answerClasses="Drug" style="autocomplete" labelText="Drug:"/>
  2230. <button id="{n}-addDrug" class="addDrug">Add</button>
  2231. <button id="{n}-removeDrug" class="removeDrug">Remove</button>
  2232. </td>
  2233.  
  2234.  
  2235. </tr>
  2236. </table>
  2237. </div>
  2238. </template>
  2239. <render n="1" concept="Drug"/>
  2240. <render n="2" concept="Drug"/>
  2241. <render n="3" concept="Drug"/>
  2242. <render n="4" concept="Drug"/>
  2243. <render n="5" concept="Drug"/>
  2244. <render n="6" concept="Drug"/>
  2245. <render n="7" concept="Drug"/>
  2246. <render n="8" concept="Drug"/>
  2247. <render n="9" concept="Drug"/>
  2248. <render n="10" concept="Drug"/>
  2249. </repeat>
  2250. </td></tr>
  2251. </obsgroup>
  2252. </table>
  2253. </section>
  2254.  
  2255. <section headerLabel="Test ordered">
  2256. <table class="quartercolumn">
  2257. <obsgroup groupingConceptId="8191">
  2258. <tr>
  2259. <td colspan="4"><h4>28. Tests:</h4><span id="testsordered">
  2260. <obs conceptId="1271" id="testNone" answerConceptId="1107" answerLabel="None" style="checkbox"/>
  2261. </span>
  2262. <span id="testsord">
  2263. <obs conceptId="1271" id="testCbc" answerConceptId="1019" answerLabel="CBC" style="checkbox"/>
  2264. <obs conceptId="1271" id="testCd4" answerConceptId="657" answerLabel="CD4" style="checkbox"/>
  2265. <obs conceptId="1271" id="testCxr" answerConceptId="12" answerLabel="CXR" style="checkbox"/>
  2266. <obs conceptId="1271" id="testElisa" answerConceptId="1042" answerLabel="Elisa" style="checkbox"/>
  2267. <obs conceptId="1271" id="testXpert" answerConceptId="8070" answerLabel="Gene Xpert" style="checkbox"/>
  2268. <obs conceptId="1271" id="testHgb" answerConceptId="21" answerLabel="Hgb" style="checkbox"/>
  2269. <obs conceptId="1271" id="testSgpt" answerConceptId="654" answerLabel="SGPT" style="checkbox"/>
  2270. <obs conceptId="1271" id="testAfb" answerConceptId="307" answerLabel="Sputum AFB" style="checkbox"/>
  2271. <obs conceptId="1271" id="testCulture" answerConceptId="2311" answerLabel="TB Culture" style="checkbox"/>
  2272. <obs conceptId="1271" id="testViral" answerConceptId="856" answerLabel="Viral Load" style="checkbox"/>
  2273. <obs conceptId="1271" id="testOther" answerConceptId="5622" answerLabel="Other" style="checkbox"/>
  2274. <obs conceptId="1915" id="testSpecify" answerLabel="Specify"/>
  2275. </span></td>
  2276. </tr>
  2277. </obsgroup>
  2278. <tr>
  2279. <td colspan="4"><h4>29. Notes</h4></td>
  2280. </tr>
  2281.  
  2282. </table>
  2283.  
  2284. </section>
  2285.  
  2286. <section headerLabel="Referrals ordered">
  2287. <table class="quartercolumn">
  2288. <tr>
  2289. <td><h4>30a. What referrals were made to the patient </h4><span id="refordered">
  2290. <obs conceptId="1272" id="refNone" answerConceptId="1107" answerLabel="None" style= "checkbox"/>
  2291. </span>
  2292. <span id="reford">
  2293. <obs conceptId="1272" id="refAlcohol" answerConceptId="1288" answerLabel="Alcohol counselling/support groups" style= "checkbox"/>
  2294. <obs conceptId="1272" id="refAdherence" answerConceptId="5488" answerLabel="Adherence counselling" style= "checkbox"/>
  2295. <obs conceptId="1272" id="refCardiology" answerConceptId="8074" answerLabel="Cardiology" style= "checkbox"/>
  2296. <obs conceptId="1272" id="refDiabetes" answerConceptId="7341" answerLabel="Diabetes" style= "checkbox"/>
  2297. <obs conceptId="1272" id="refDisclosure" answerConceptId="1167" answerLabel="Disclosure counselling" style= "checkbox"/><br/>
  2298. <obs conceptId="1272" id="refFp" answerConceptId="5483" answerLabel="Family Planning services" style= "checkbox"/>
  2299. <obs conceptId="1272" id="refOncology" answerConceptId="8053" answerLabel="Oncology" style= "checkbox"/>
  2300. <obs conceptId="1272" id="refMental" answerConceptId="5489" answerLabel="Mental Health Services" style= "checkbox"/>
  2301. <obs conceptId="1272" id="refNutrition" answerConceptId="5484" answerLabel="Nutritional support" style= "checkbox"/>
  2302. <obs conceptId="1272" id="refPsycho" answerConceptId="1581" answerLabel="Psychosocial support" style= "checkbox"/><br/>
  2303. <obs conceptId="1272" id="refPmtct" answerConceptId="1776" answerLabel="pMTCT" style= "checkbox"/>
  2304. <obs conceptId="1272" id="refSocial" answerConceptId="1580" answerLabel="Social work services" style= "checkbox"/>
  2305. <obs conceptId="1272" id="refTbdot" answerConceptId="5487" answerLabel="TB/DOT Program" style= "checkbox"/>
  2306. <obs conceptId="1272" id="refOther" answerConceptId="5622" answerLabel="Other (specify):" style= "checkbox"/>
  2307. <obs conceptId="1915" id="refSpecify" style="textbox"/>
  2308. </span></td>
  2309. </tr>
  2310. <tr>
  2311. <td><h4>b.If referred for hospitalization, choose location: </h4>
  2312. <obs conceptId="1273" id="hospitalization" answerConceptIds="1275,1274,5622" answerLabels="Local Health Centre/Hospital,MTRH,Other"/>
  2313. </td>
  2314. </tr>
  2315. <tr><td colspan="4">
  2316. <obsgroup groupingConceptId="1852">
  2317. <repeat>
  2318. <template>
  2319. <div id="{n}-toggleHospreason" style="display:none;">
  2320. <table>
  2321. <tr>
  2322. <td colspan="2"><b>b.Reason for Hospitalisation:</b>
  2323. <obs conceptId="1929" answerClasses="{concept}" style="autocomplete" />
  2324. <button id="{n}-addHospreason" class="addHospreason">Add</button>
  2325. <button id="{n}-removeHospreason" class="removeHospreason">Remove</button>
  2326. </td>
  2327. </tr>
  2328. </table>
  2329. </div>
  2330. </template>
  2331. <render n="1" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2332. <render n="2" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2333. <render n="3" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2334. <render n="4" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2335. <render n="5" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2336. <render n="6" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2337. <render n="7" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2338. <render n="8" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2339. <render n="9" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2340. <render n="10" concept="Diagnosis,Symptom,Symptom/Finding,Finding"/>
  2341. </repeat>
  2342. </obsgroup>
  2343. </td>
  2344. </tr>
  2345.  
  2346. <obsgroup groupingConceptId="2035">
  2347. <tr>
  2348. <td>
  2349. <h4>31.Transfer care to other centre: </h4><br/>
  2350. <obs conceptId="1285" id="transAmpath" answerConceptId="1286" answerLabel="AMPATH" style= "checkbox"/>
  2351.  
  2352. <obs id="transferOutLocation" conceptId="1915" style="location"/>
  2353.  
  2354. <obs conceptId="1285" id="transNonampath" answerConceptId="1287" answerLabel="Non-Ampath" style= "checkbox"/>
  2355. <obs conceptId="1915" id="transferout" style="text"/>
  2356. </td>
  2357. </tr>
  2358. </obsgroup>
  2359. </table>
  2360. </section>
  2361.  
  2362. <section headerLabel="Next appointment">
  2363. <table>
  2364. <tr>
  2365. <td><h4>32. Return to clinic:</h4><br/>
  2366. <obs conceptId="1893" id="wks" labelText="weeks" style="textbox"/>
  2367. <obs conceptId="1894" id="mths" labelText="Months" style="textbox"/>
  2368. </td>
  2369. </tr>
  2370. <tr>
  2371.  
  2372. <td><obs conceptId="5096" id="rtc" labelText="Return to clinic date:" style="date" allowFutureDates="true"/></td>
  2373. </tr>
  2374. </table>
  2375. </section>
  2376. <section headerLabel="Provider">
  2377. <table border="1" width="100%">
  2378. <tr>
  2379. <td> Nurse </td>
  2380. <td> p# </td>
  2381. <td> Medical Officer </td>
  2382. <td> p# </td>
  2383. </tr>
  2384. <tr>
  2385. <td> Clinical Officer </td>
  2386. <td><encounterProvider id="encounterProvider" /></td>
  2387. <td> Consultant Physician </td>
  2388. <td> p# </td>
  2389. </tr>
  2390. </table>
  2391.  
  2392. </section>
  2393.  
  2394. <submit/>
  2395.  
  2396. </htmlform>
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