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  1. {
  2. "content": [
  3. {
  4. "description": {
  5. "eng": "Please answer the questions below by selecting 'Yes' or 'No'",
  6. "spa": "Responda las siguientes preguntas seleccionando 'S\u00ed' o 'No'"
  7. },
  8. "display": true,
  9. "fields": [
  10. {
  11. "display": true,
  12. "field_type": "instructions_field",
  13. "label": "instructions",
  14. "media": "edit print",
  15. "title": {
  16. "eng": "<b>Symptoms</b>",
  17. "spa": null
  18. }
  19. },
  20. {
  21. "choices": {
  22. "eng": [
  23. "Yes",
  24. "No"
  25. ]
  26. },
  27. "display": true,
  28. "field_type": "binary_field",
  29. "label": "test",
  30. "required": true,
  31. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  32. "title": {
  33. "eng": "1. Cough lasting more than 2-3 weeks in duration?",
  34. "spa": "1. \u00bfLa tos dura m\u00e1s de 2-3 semanas de duraci\u00f3n?"
  35. }
  36. },
  37. {
  38. "choices": {
  39. "eng": [
  40. "Yes",
  41. "No"
  42. ]
  43. },
  44. "display": true,
  45. "field_type": "binary_field",
  46. "label": "",
  47. "required": true,
  48. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  49. "title": {
  50. "eng": "2. Unexplained fever?",
  51. "spa": "2. \u00bfFiebre inexplicable?"
  52. }
  53. },
  54. {
  55. "choices": {
  56. "eng": [
  57. "Yes",
  58. "No"
  59. ]
  60. },
  61. "display": true,
  62. "field_type": "binary_field",
  63. "label": "",
  64. "required": true,
  65. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  66. "title": {
  67. "eng": "3. Night sweats - bedclothes and sheets wet?",
  68. "spa": "3. Sudores nocturnos - ropa de cama y s\u00e1banas mojadas?"
  69. }
  70. },
  71. {
  72. "choices": {
  73. "eng": [
  74. "Yes",
  75. "No"
  76. ]
  77. },
  78. "display": true,
  79. "field_type": "binary_field",
  80. "label": "",
  81. "required": true,
  82. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  83. "title": {
  84. "eng": "4. Hemoptysis - coughing up blood-streaked sputum?",
  85. "spa": "4. Hemoptisis: \u00bftoser esputo manchado de sangre?"
  86. }
  87. },
  88. {
  89. "choices": {
  90. "eng": [
  91. "Yes",
  92. "No"
  93. ]
  94. },
  95. "display": true,
  96. "field_type": "binary_field",
  97. "label": "",
  98. "required": true,
  99. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  100. "title": {
  101. "eng": "5. Shortness of breath / chest pain - presently having symptoms?",
  102. "spa": "5. Dificultad para respirar / dolor en el pecho: \u00bftiene s\u00edntomas actualmente?"
  103. }
  104. },
  105. {
  106. "choices": {
  107. "eng": [
  108. "Yes",
  109. "No"
  110. ]
  111. },
  112. "display": true,
  113. "field_type": "binary_field",
  114. "label": "",
  115. "required": true,
  116. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  117. "title": {
  118. "eng": "6. Weight loss / anorexia - loss of appetite with unexplained weight loss?",
  119. "spa": "6. \u00bfP\u00e9rdida de peso / anorexia - p\u00e9rdida de apetito con p\u00e9rdida de peso inexplicable?"
  120. }
  121. },
  122. {
  123. "choices": {
  124. "eng": [
  125. "Yes",
  126. "No"
  127. ]
  128. },
  129. "display": true,
  130. "field_type": "binary_field",
  131. "label": "",
  132. "required": true,
  133. "scriptOnChange": "var refs = fields({label: 'test',length: 7});binary_validation(refs);",
  134. "title": {
  135. "eng": "7. Fatigue - unexplained tiredness?",
  136. "spa": "7. Fatiga - \u00bfcansancio inexplicable?"
  137. }
  138. },
  139. {
  140. "display": true,
  141. "field_type": "instructions_field",
  142. "label": "instructions:TB",
  143. "media": "edit print",
  144. "title": {
  145. "eng": "<red><b>This patient is displaying symptoms of Tuberculosis\nProvide a mask and tissues to the patient and notify the triage nurse.</b></red>",
  146. "spa": null
  147. }
  148. }
  149. ],
  150. "title": {
  151. "eng": "Tuberculosis Screening for Signs and Symptoms",
  152. "spa": "Detecci\u00f3n de tuberculosis para detectar signos y s\u00edntomas"
  153. }
  154. },
  155. {
  156. "description": {
  157. "eng": "Please answer the questions below by selecting 'Yes' or 'No'",
  158. "spa": "Responda las siguientes preguntas seleccionando 'S\u00ed' o 'No'"
  159. },
  160. "display": true,
  161. "fields": [
  162. {
  163. "display": true,
  164. "field_type": "instructions_field",
  165. "label": "instructions",
  166. "media": "edit print",
  167. "title": {
  168. "eng": "<b>Risk Factors</b>",
  169. "spa": null
  170. }
  171. },
  172. {
  173. "choices": {
  174. "eng": [
  175. "Yes",
  176. "No"
  177. ]
  178. },
  179. "display": true,
  180. "field_type": "binary_field",
  181. "label": "",
  182. "required": true,
  183. "title": {
  184. "eng": "1. History of Tuberculosis?",
  185. "spa": "1. Historia de la tuberculosis?"
  186. }
  187. },
  188. {
  189. "choices": {
  190. "eng": [
  191. "Yes",
  192. "No"
  193. ]
  194. },
  195. "display": true,
  196. "field_type": "binary_field",
  197. "label": "",
  198. "required": true,
  199. "title": {
  200. "eng": "2. Exposure to positive patient?",
  201. "spa": "2. \u00bfFiebre inexplicable?"
  202. }
  203. },
  204. {
  205. "choices": {
  206. "eng": [
  207. "Yes",
  208. "No"
  209. ]
  210. },
  211. "display": true,
  212. "field_type": "binary_field",
  213. "label": "",
  214. "required": true,
  215. "title": {
  216. "eng": "3. Positive TB skin test or chest X-ray?",
  217. "spa": "3. \u00bfPrueba cut\u00e1nea positiva de TB o radiograf\u00eda de t\u00f3rax?"
  218. }
  219. },
  220. {
  221. "choices": {
  222. "eng": [
  223. "Yes",
  224. "No"
  225. ]
  226. },
  227. "display": true,
  228. "field_type": "binary_field",
  229. "label": "",
  230. "required": true,
  231. "title": {
  232. "eng": "4. Previously on TB medications?",
  233. "spa": "4. Anteriormente en medicamentos para la tuberculosis?"
  234. }
  235. },
  236. {
  237. "choices": {
  238. "eng": [
  239. "Yes",
  240. "No"
  241. ]
  242. },
  243. "display": true,
  244. "field_type": "binary_field",
  245. "label": "",
  246. "required": true,
  247. "title": {
  248. "eng": "5. Pneumonia or upper respiratory infections more than 2 times within the last year (HIV positive)?",
  249. "spa": "5. \u00bfNeumon\u00eda o infecciones respiratorias superiores m\u00e1s de 2 veces en el \u00faltimo a\u00f1o (VIH positivo)?"
  250. }
  251. },
  252. {
  253. "choices": {
  254. "eng": [
  255. "Yes",
  256. "No"
  257. ]
  258. },
  259. "display": true,
  260. "field_type": "binary_field",
  261. "label": "",
  262. "required": true,
  263. "title": {
  264. "eng": "6. Healthcare worker?",
  265. "spa": "6. \u00bfTrabajador de la salud?"
  266. }
  267. },
  268. {
  269. "choices": {
  270. "eng": [
  271. "Yes",
  272. "No"
  273. ]
  274. },
  275. "display": true,
  276. "field_type": "binary_field",
  277. "label": "",
  278. "required": true,
  279. "title": {
  280. "eng": "7. Lived in a group type setting (Nursing home, prison, community shelter)?",
  281. "spa": "7. \u00bfVivi\u00f3 en un entorno de tipo grupal (asilo de ancianos, prisi\u00f3n, refugio comunitario)?"
  282. }
  283. },
  284. {
  285. "choices": {
  286. "eng": [
  287. "Yes",
  288. "No"
  289. ]
  290. },
  291. "display": true,
  292. "field_type": "binary_field",
  293. "label": "",
  294. "required": true,
  295. "scriptOnChange": "var refs = fields({label: 'test',length: 8});binary_validation(refs);",
  296. "title": {
  297. "eng": "8. Immigrant or traveled outside of the United States?",
  298. "spa": "8. \u00bfInmigrante o viajado fuera de los Estados Unidos?"
  299. }
  300. },
  301. {
  302. "display": true,
  303. "field_type": "instructions_field",
  304. "label": "instructions",
  305. "media": "print",
  306. "title": {
  307. "eng": "<red><b>This patient is at high risk for Tuberculosis\nPlace on airborne precautions</b></red>",
  308. "spa": null
  309. }
  310. }
  311. ],
  312. "title": {
  313. "eng": "Tuberculosis Screening for Signs and Symptoms",
  314. "spa": "Detecci\u00f3n de tuberculosis para detectar signos y s\u00edntomas"
  315. }
  316. }
  317. ],
  318. "form_author": "{practice.legal_name}",
  319. "form_title": "CWH - TB Screening Signs and Symptoms",
  320. "label": "cwh-tbScreenSignsSymptoms",
  321. "languages": [
  322. "eng",
  323. "spa"
  324. ],
  325. "revision": 1,
  326. "script": "function binary_validation(refs) {var tmp = 0;for (var i = 0; i < refs.length; i++) {var f = refs[i];if (f.value == 0) {tmp++;} else {}}if (tmp > 0) {field({label: 'instructions:TB'}).display = true;} else {field({label: 'instructions:TB'}).display = false;}}",
  327. "title": {
  328. "eng": "CWH - TB Screening Signs and Symptoms"
  329. },
  330. "version": 3
  331. }
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