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jerome24

registration xml

jerome24
May 27th, 2024
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  1. <?xml version="1.0" encoding="UTF-8"?>
  2. <xf:xforms xmlns:xf="http://www.w3.org/2002/xforms" xmlns:jr="http://openrosa.org/javarosa" xmlns:xs="http://www.w3.org/2001/XMLSchema" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
  3. <xf:model>
  4. <xf:instance>
  5. <patient name="Patient" id="0" description-template="${/patient/family_name}$ ${/patient/middle_name}$ ${/patient/given_name}$">
  6. <enterer/>
  7. <family_name/>
  8. <middle_name/>
  9. <given_name/>
  10. <birth_date/>
  11.  
  12. <identifier/>
  13.  
  14. <gender/>
  15.  
  16.  
  17.  
  18.  
  19.  
  20.  
  21. <patient_identifier_type_id/>
  22.  
  23.  
  24. <person_attribute5/>
  25.  
  26.  
  27.  
  28.  
  29. <other_identifiers>
  30. <other_identifier/>
  31. <other_identifier_type_id>6</other_identifier_type_id>
  32. <other_identifier_location_id>1</other_identifier_location_id>
  33. </other_identifiers><person_attribute8/>
  34. <person_attribute9/>
  35. <person_attribute10/>
  36. <person_attribute11/>
  37. <person_attribute12/>
  38. <person_attribute13/>
  39. <person_attribute14/>
  40. <person_attribute15/>
  41. <person_attribute16/>
  42. <person_attribute17/>
  43. <person_attribute19/><person_attribute20/><person_attribute21/><person_attribute22/><person_attribute23/><person_attribute24/><person_attribute25/><person_attribute26/><person_attribute27/><person_attribute28/><person_attribute29/><person_attribute31/><person_attribute32/><person_attribute34/><person_attribute36/><person_attribute37/><person_attribute38/>
  44.  
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  60.  
  61.  
  62.  
  63. <person_attribute39/>
  64. <person_attribute40/>
  65. <person_attribute41/>
  66. <person_attribute42/>
  67. <person_attribute43/>
  68. <person_attribute44/>
  69. <person_attribute45/>
  70. <person_attribute46/>
  71. <person_attribute47/>
  72. <person_attribute48/>
  73. <person_attribute49/>
  74. <person_attribute50/>
  75. <person_attribute51/>
  76. <person_attribute52/>
  77. <person_attribute53/>
  78. <person_attribute54/>
  79. <person_attribute55/>
  80. <person_attribute56/>
  81. <person_attribute57/>
  82. <person_attribute58/>
  83. <person_attribute59/>
  84. <person_attribute60/>
  85. <person_attribute61/>
  86.  
  87.  
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  97.  
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  99.  
  100. </patient>
  101. </xf:instance>
  102. <xf:bind id="family_name" nodeset="/patient/family_name" type="xsd:string" required="true()" constraint="length(.) &lt;= 20" message="The length of the field is more than the required, please check"/>
  103. <xf:bind id="middle_name" nodeset="/patient/middle_name" type="xsd:string" constraint="length(.) &lt;= 50" message="The length of the field is more than the required, please check"/>
  104. <xf:bind id="given_name" nodeset="/patient/given_name" type="xsd:string" required="true()" constraint="length(.) &lt;= 20" message="The length of the field is more than the required, please check"/>
  105. <xf:bind id="birth_date" nodeset="/patient/birth_date" type="xsd:date" required="true()"/>
  106.  
  107. <xf:bind id="identifier" nodeset="/patient/identifier" type="xsd:string" required="true()" constraint="length(.) &lt;= 20" message="Data out of range"/>
  108.  
  109. <xf:bind id="gender" nodeset="/patient/gender" type="xsd:string" required="true()"/>
  110.  
  111.  
  112.  
  113.  
  114.  
  115.  
  116. <xf:bind id="patient_identifier_type_id" nodeset="/patient/patient_identifier_type_id" type="xsd:string" required="true()"/>
  117.  
  118.  
  119. <xf:bind id="person_attribute5" nodeset="/patient/person_attribute5" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  120.  
  121.  
  122.  
  123.  
  124. <xf:bind id="other_identifiers" nodeset="/patient/other_identifiers" readonly="true()" visible="false()"/><xf:bind id="person_attribute8" nodeset="/patient/person_attribute8" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  125. <xf:bind id="person_attribute9" nodeset="/patient/person_attribute9" type="xsd:string" relevant="/patient/person_attribute8 = '5622'" action="enable" constraint="length(.) &lt;= 40" message="The length of the field is more than the required, please check" required="true()"/>
  126. <xf:bind id="person_attribute10" nodeset="/patient/person_attribute10" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  127. <xf:bind id="person_attribute11" nodeset="/patient/person_attribute11" type="xsd:string" relevant="/patient/person_attribute10 = '5622'" action="enable" constraint="length(.) &lt;= 40" message="The length of the field is more than the required, please check" required="true()"/>
  128. <xf:bind id="person_attribute12" nodeset="/patient/person_attribute12" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 40" message="" required="true()"/>
  129. <xf:bind id="person_attribute13" nodeset="/patient/person_attribute13" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 40" message="" required="true()"/>
  130. <xf:bind id="person_attribute14" nodeset="/patient/person_attribute14" type="xsd:int" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 10" message="Data out of range" required="true()"/>
  131. <xf:bind id="person_attribute15" nodeset="/patient/person_attribute15" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 50" message="The length of the field is more than the required, please check" required="true()"/>
  132. <xf:bind id="person_attribute16" nodeset="/patient/person_attribute16" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 50" message="The length of the field is more than the required, please check" required="true()"/>
  133. <xf:bind id="person_attribute17" nodeset="/patient/person_attribute17" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  134. <xf:bind id="person_attribute19" nodeset="/patient/person_attribute19" type="xsd:date" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute20" nodeset="/patient/person_attribute20" type="xsd:int" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 10" message="Data out of range" required="true()"/><xf:bind id="person_attribute21" nodeset="/patient/person_attribute21" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute22" nodeset="/patient/person_attribute22" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute23" nodeset="/patient/person_attribute23" type="xsd:string" relevant="/patient/person_attribute22 = '1065'" action="enable" constraint="length(.) &lt;= 50" message="The length of the field is more than the required, please check" required="true()"/><xf:bind id="person_attribute24" nodeset="/patient/person_attribute24" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute25" nodeset="/patient/person_attribute25" type="xsd:string"/><xf:bind id="person_attribute26" nodeset="/patient/person_attribute26" type="xsd:int" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 10" message="The length of the field is more than the required, please check" required="true()"/><xf:bind id="person_attribute27" nodeset="/patient/person_attribute27" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 50" message="The length of the field is more than the required, please check" required="true()"/><xf:bind id="person_attribute28" nodeset="/patient/person_attribute28" type="xsd:int" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 10" message="Data out of range" required="true()"/><xf:bind id="person_attribute29" nodeset="/patient/person_attribute29" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" constraint="length(.) &lt;= 12" message="The length of the field is more than the required, please check" required="true()"/><xf:bind id="person_attribute31" nodeset="/patient/person_attribute31" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute32" nodeset="/patient/person_attribute32" type="xsd:int" relevant="/patient/person_attribute31 = '1065'" action="enable" constraint=". &gt;= 1 and . &lt;= 50" message="Data out of range" required="false()"/><xf:bind id="person_attribute34" nodeset="/patient/person_attribute34" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute36" nodeset="/patient/person_attribute36" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute37" nodeset="/patient/person_attribute37" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/><xf:bind id="person_attribute38" nodeset="/patient/person_attribute38" type="xsd:date" relevant="/patient/person_attribute37 = '161870'" action="enable" constraint=". &lt;= today()" message="Date here is not allowed to be in the future please check" required="true()"/>
  135.  
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  140.  
  141.  
  142.  
  143.  
  144.  
  145.  
  146.  
  147.  
  148.  
  149.  
  150.  
  151.  
  152.  
  153.  
  154. <xf:bind id="person_attribute39" nodeset="/patient/person_attribute39" type="xsd:string" relevant="/patient/person_attribute31 = '1065'" action="enable" required="false()"/>
  155. <xf:bind id="person_attribute40" nodeset="/patient/person_attribute40" type="xsd:string" required="true()"/>
  156. <xf:bind id="person_attribute41" nodeset="/patient/person_attribute41" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 50" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  157. <xf:bind id="person_attribute42" nodeset="/patient/person_attribute42" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 30" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  158. <xf:bind id="person_attribute43" nodeset="/patient/person_attribute43" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 20" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  159. <xf:bind id="person_attribute44" nodeset="/patient/person_attribute44" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 50" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  160. <xf:bind id="person_attribute45" nodeset="/patient/person_attribute45" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 30" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  161. <xf:bind id="person_attribute46" nodeset="/patient/person_attribute46" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 20" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  162. <xf:bind id="person_attribute47" nodeset="/patient/person_attribute47" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 50" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  163. <xf:bind id="person_attribute48" nodeset="/patient/person_attribute48" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 30" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  164. <xf:bind id="person_attribute49" nodeset="/patient/person_attribute49" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 20" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  165. <xf:bind id="person_attribute50" nodeset="/patient/person_attribute50" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 50" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  166. <xf:bind id="person_attribute51" nodeset="/patient/person_attribute51" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 30" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  167. <xf:bind id="person_attribute52" nodeset="/patient/person_attribute52" type="xsd:string" relevant="/patient/person_attribute40 = '1065'" action="enable" constraint="length(.) &lt;= 20" message="The length of the entered value is not correct, please enter correct value." required="false()"/>
  168. <xf:bind id="person_attribute53" nodeset="/patient/person_attribute53" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  169. <xf:bind id="person_attribute54" nodeset="/patient/person_attribute54" type="xsd:boolean" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  170. <xf:bind id="person_attribute55" nodeset="/patient/person_attribute55" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  171. <xf:bind id="person_attribute56" nodeset="/patient/person_attribute56" type="xsd:string" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  172. <xf:bind id="person_attribute57" nodeset="/patient/person_attribute57" type="xsd:boolean" relevant="patient_identifier_type_id = '3'" action="enable" required="true()"/>
  173. <xf:bind id="person_attribute58" nodeset="/patient/person_attribute58" type="xsd:string" relevant="/patient/person_attribute57 = true" action="enable" required="true()"/>
  174. <xf:bind id="person_attribute59" nodeset="/patient/person_attribute59" type="xsd:string" relevant="/patient/person_attribute58 = '162049'" action="enable" required="true()"/>
  175. <xf:bind id="person_attribute60" nodeset="/patient/person_attribute60" type="xsd:string" relevant="/patient/person_attribute37 = '161940'" action="enable" required="true()"/>
  176. <xf:bind id="person_attribute61" nodeset="/patient/person_attribute61" type="xsd:string" relevant="patient_identifier_type_id = '4'" action="enable" required="true()"/>
  177.  
  178.  
  179.  
  180.  
  181.  
  182.  
  183.  
  184.  
  185.  
  186.  
  187.  
  188.  
  189.  
  190.  
  191. <xf:bind id="other_identifier" nodeset="/patient/other_identifiers/other_identifier" type="xsd:string" relevant="patient_identifier_type_id = '4'" action="enable" required="true()"/>
  192. <xf:bind id="other_identifier_type_id" nodeset="/patient/other_identifiers/other_identifier_type_id" type="xsd:string" constraint="length(.) &lt;= 20" message="" required="true()"/>
  193. <xf:bind id="other_identifier_location_id" nodeset="/patient/other_identifiers/other_identifier_location_id" type="xsd:string" constraint="length(.) &lt;= 12" message="" locked="true()"/>
  194. </xf:model>
  195. <xf:group id="1">
  196. <xf:label>Page1</xf:label>
  197. <xf:input bind="family_name">
  198. <xf:label>Last Name</xf:label>
  199. <xf:hint>The patient family name</xf:hint>
  200. </xf:input>
  201. <xf:input bind="middle_name">
  202. <xf:label>Middle name</xf:label>
  203. <xf:hint>The patient middle name</xf:hint>
  204. </xf:input>
  205. <xf:input bind="given_name">
  206. <xf:label>First Name</xf:label>
  207. <xf:hint>The patient given name</xf:hint>
  208. </xf:input>
  209. <xf:input bind="birth_date">
  210. <xf:label>Date of birth</xf:label>
  211. <xf:hint>The patient birth date</xf:hint>
  212. </xf:input>
  213.  
  214. <xf:input bind="identifier">
  215. <xf:label>NACP number</xf:label>
  216. <xf:hint>The patient identifier</xf:hint>
  217. </xf:input>
  218.  
  219. <xf:select1 bind="gender">
  220. <xf:label>Gender</xf:label>
  221. <xf:hint>The patient's sex</xf:hint>
  222. <xf:item id="M">
  223. <xf:label>Male</xf:label>
  224. <xf:value>M</xf:value>
  225. </xf:item>
  226. <xf:item id="F">
  227. <xf:label>Female</xf:label>
  228. <xf:value>F</xf:value>
  229. </xf:item>
  230. </xf:select1>
  231.  
  232.  
  233.  
  234.  
  235.  
  236.  
  237. <xf:select1 bind="patient_identifier_type_id">
  238. <xf:label>Identifier Type</xf:label>
  239. <xf:hint>The patient's identifier type</xf:hint>
  240. <xf:item id="3">
  241. <xf:label>NACPNO</xf:label>
  242. <xf:value>3</xf:value>
  243. </xf:item><xf:item id="4">
  244. <xf:label>HEINO</xf:label>
  245. <xf:value>4</xf:value>
  246. </xf:item>
  247.  
  248.  
  249.  
  250.  
  251.  
  252. </xf:select1>
  253.  
  254.  
  255. <xf:select1 bind="person_attribute5">
  256. <xf:label>Civil Status</xf:label>
  257. <xf:hint>Marriage status of this person</xf:hint>
  258. <xf:item concept_id="1056" id="1056">
  259. <xf:label>SEPARATED</xf:label>
  260. <xf:value>1056</xf:value>
  261. </xf:item>
  262. <xf:item concept_id="1057" id="1057">
  263. <xf:label>NEVER MARRIED</xf:label>
  264. <xf:value>1057</xf:value>
  265. </xf:item>
  266. <xf:item concept_id="1058" id="1058">
  267. <xf:label>DIVORCED</xf:label>
  268. <xf:value>1058</xf:value>
  269. </xf:item>
  270. <xf:item concept_id="1059" id="1059">
  271. <xf:label>WIDOWED</xf:label>
  272. <xf:value>1059</xf:value>
  273. </xf:item>
  274. <xf:item concept_id="1060" id="1060">
  275. <xf:label>LIVING WITH PARTNER</xf:label>
  276. <xf:value>1060</xf:value>
  277. </xf:item>
  278. <xf:item concept_id="5555" id="5555">
  279. <xf:label>MARRIED</xf:label>
  280. <xf:value>5555</xf:value>
  281. </xf:item>
  282. <xf:item concept_id="5622" id="5622">
  283. <xf:label>OTHER NON-CODED</xf:label>
  284. <xf:value>5622</xf:value>
  285. </xf:item>
  286. </xf:select1>
  287.  
  288.  
  289.  
  290.  
  291. <xf:group id="other_identifiers">
  292. <xf:label>Other dentifiers</xf:label>
  293. <xf:repeat bind="other_identifiers">
  294. <xf:input bind="other_identifier">
  295. <xf:label>Identifier</xf:label>
  296. <xf:hint>The patient's other identifier value</xf:hint>
  297. </xf:input>
  298. <xf:select1 bind="other_identifier_type_id">
  299. <xf:label>Identifier Type</xf:label>
  300. <xf:hint>The patient's other identifier type</xf:hint>
  301.  
  302.  
  303.  
  304.  
  305.  
  306. <xf:item id="6">
  307. <xf:label>PAEDS_Number</xf:label>
  308. <xf:value>6</xf:value>
  309. </xf:item>
  310. </xf:select1>
  311. <xf:select1 bind="other_identifier_location_id">
  312. <xf:label>Identifier Location</xf:label>
  313. <xf:hint>The patient's other identifier location</xf:hint>
  314. <xf:item id="1">
  315. <xf:label>Unknown Location [1]</xf:label>
  316. <xf:value>1</xf:value>
  317. </xf:item>
  318. </xf:select1>
  319. </xf:repeat>
  320. </xf:group><xf:select1 bind="person_attribute8">
  321. <xf:label>District</xf:label>
  322. <xf:hint>this is the residence of the patient (district)</xf:hint>
  323. <xf:item concept_id="161002" id="161002">
  324. <xf:label>KILOMBERO</xf:label>
  325. <xf:value>161002</xf:value>
  326. </xf:item>
  327. <xf:item concept_id="161003" id="161003">
  328. <xf:label>KILOSA</xf:label>
  329. <xf:value>161003</xf:value>
  330. </xf:item>
  331. <xf:item concept_id="161004" id="161004">
  332. <xf:label>ULANGA</xf:label>
  333. <xf:value>161004</xf:value>
  334. </xf:item>
  335. <xf:item concept_id="5622" id="5622">
  336. <xf:label>OTHER NON-CODED</xf:label>
  337. <xf:value>5622</xf:value>
  338. </xf:item>
  339. </xf:select1>
  340. <xf:input bind="person_attribute9">
  341. <xf:label>Other distict(please specify)</xf:label>
  342. <xf:hint>other unspecified district</xf:hint>
  343. </xf:input>
  344. <xf:select1 bind="person_attribute10">
  345. <xf:label>Ward</xf:label>
  346. <xf:hint>residence of the patient(ward)</xf:hint>
  347. <xf:item concept_id="161005" id="161005">
  348. <xf:label>IDETE</xf:label>
  349. <xf:value>161005</xf:value>
  350. </xf:item>
  351. <xf:item concept_id="161006" id="161006">
  352. <xf:label>IFAKARA</xf:label>
  353. <xf:value>161006</xf:value>
  354. </xf:item>
  355. <xf:item concept_id="161007" id="161007">
  356. <xf:label>KIBAONI</xf:label>
  357. <xf:value>161007</xf:value>
  358. </xf:item>
  359. <xf:item concept_id="161008" id="161008">
  360. <xf:label>KIBEREGE</xf:label>
  361. <xf:value>161008</xf:value>
  362. </xf:item>
  363. <xf:item concept_id="161009" id="161009">
  364. <xf:label>KIDATU</xf:label>
  365. <xf:value>161009</xf:value>
  366. </xf:item>
  367. <xf:item concept_id="161010" id="161010">
  368. <xf:label>LUMEMO</xf:label>
  369. <xf:value>161010</xf:value>
  370. </xf:item>
  371. <xf:item concept_id="161011" id="161011">
  372. <xf:label>LUPIRO</xf:label>
  373. <xf:value>161011</xf:value>
  374. </xf:item>
  375. <xf:item concept_id="161012" id="161012">
  376. <xf:label>MANG'ULA</xf:label>
  377. <xf:value>161012</xf:value>
  378. </xf:item>
  379. <xf:item concept_id="161014" id="161014">
  380. <xf:label>MLIMBA</xf:label>
  381. <xf:value>161014</xf:value>
  382. </xf:item>
  383. <xf:item concept_id="161015" id="161015">
  384. <xf:label>MNGETA</xf:label>
  385. <xf:value>161015</xf:value>
  386. </xf:item>
  387. <xf:item concept_id="5622" id="5622">
  388. <xf:label>OTHER NON-CODED</xf:label>
  389. <xf:value>5622</xf:value>
  390. </xf:item>
  391. </xf:select1>
  392. <xf:input bind="person_attribute11">
  393. <xf:label>Other ward(please specify)</xf:label>
  394. <xf:hint>Other ward unspecified</xf:hint>
  395. </xf:input>
  396. <xf:input bind="person_attribute12">
  397. <xf:label>Village</xf:label>
  398. <xf:hint>residence of this patient(village)</xf:hint>
  399. </xf:input>
  400. <xf:input bind="person_attribute13">
  401. <xf:label>Street</xf:label>
  402. <xf:hint>residence of this patient(Street)</xf:hint>
  403. </xf:input>
  404. <xf:input bind="person_attribute14">
  405. <xf:label>Telephone number</xf:label>
  406. <xf:hint>telephone number of the patient</xf:hint>
  407. </xf:input>
  408. <xf:input bind="person_attribute15">
  409. <xf:label>10CELL_LEADER</xf:label>
  410. <xf:hint>10 cell leader name</xf:hint>
  411. </xf:input>
  412. <xf:input bind="person_attribute16">
  413. <xf:label>HEADD_HOUSEHOLD</xf:label>
  414. <xf:hint>Head household of the patient</xf:hint>
  415. </xf:input>
  416. <xf:select1 bind="person_attribute17">
  417. <xf:label>EDUCATION</xf:label>
  418. <xf:hint>highest education level of the patient</xf:hint>
  419. <xf:item concept_id="1107" id="1107">
  420. <xf:label>NONE</xf:label>
  421. <xf:value>1107</xf:value>
  422. </xf:item>
  423. <xf:item concept_id="1713" id="1713">
  424. <xf:label>PRIMARY SCHOOL EDUCATION</xf:label>
  425. <xf:value>1713</xf:value>
  426. </xf:item>
  427. <xf:item concept_id="1714" id="1714">
  428. <xf:label>SECONDARY SCHOOL EDUCATION</xf:label>
  429. <xf:value>1714</xf:value>
  430. </xf:item>
  431. <xf:item concept_id="159785" id="159785">
  432. <xf:label>college/university/polytechnic</xf:label>
  433. <xf:value>159785</xf:value>
  434. </xf:item>
  435. <xf:item concept_id="5622" id="5622">
  436. <xf:label>OTHER NON-CODED</xf:label>
  437. <xf:value>5622</xf:value>
  438. </xf:item>
  439. </xf:select1>
  440. <xf:input bind="person_attribute19">
  441. <xf:label>DATE_FIRST_POS</xf:label>
  442. <xf:hint>Date of first positive HIV test</xf:hint>
  443. </xf:input><xf:input bind="person_attribute20">
  444. <xf:label>VCT_NO</xf:label>
  445. <xf:hint>VCT number</xf:hint>
  446. </xf:input><xf:select1 bind="person_attribute21">
  447. <xf:label>HIVTYPE</xf:label>
  448. <xf:hint>HIV type</xf:hint>
  449. <xf:item concept_id="161017" id="161017">
  450. <xf:label>HIV type I</xf:label>
  451. <xf:value>161017</xf:value>
  452. </xf:item>
  453. <xf:item concept_id="161018" id="161018">
  454. <xf:label>HIV type II</xf:label>
  455. <xf:value>161018</xf:value>
  456. </xf:item>
  457. <xf:item concept_id="161019" id="161019">
  458. <xf:label>Both</xf:label>
  459. <xf:value>161019</xf:value>
  460. </xf:item>
  461. <xf:item concept_id="1067" id="1067">
  462. <xf:label>UNKNOWN</xf:label>
  463. <xf:value>1067</xf:value>
  464. </xf:item>
  465. </xf:select1><xf:select1 bind="person_attribute22">
  466. <xf:label>COMM_SUPPORT</xf:label>
  467. <xf:hint>community support</xf:hint>
  468. <xf:item concept_id="1065" id="1065">
  469. <xf:label>YES</xf:label>
  470. <xf:value>1065</xf:value>
  471. </xf:item>
  472. <xf:item concept_id="1066" id="1066">
  473. <xf:label>NO</xf:label>
  474. <xf:value>1066</xf:value>
  475. </xf:item>
  476. </xf:select1><xf:input bind="person_attribute23">
  477. <xf:label>SUPPORT_GROUP</xf:label>
  478. <xf:hint>support group</xf:hint>
  479. </xf:input><xf:select bind="person_attribute24">
  480. <xf:label>PAT_REF</xf:label>
  481. <xf:hint>patient referral source</xf:hint>
  482. <xf:item concept_id="160542" id="160542">
  483. <xf:label>Outpatient department</xf:label>
  484. <xf:value>160542</xf:value>
  485. </xf:item>
  486. <xf:item concept_id="161020" id="161020">
  487. <xf:label>PLHIV group</xf:label>
  488. <xf:value>161020</xf:value>
  489. </xf:item>
  490. <xf:item concept_id="160546" id="160546">
  491. <xf:label>Sexually transmitted infection program/clinic</xf:label>
  492. <xf:value>160546</xf:value>
  493. </xf:item>
  494. <xf:item concept_id="161039" id="161039">
  495. <xf:label>HBC</xf:label>
  496. <xf:value>161039</xf:value>
  497. </xf:item><xf:item concept_id="161021" id="161021">
  498. <xf:label>RCH/PMTCT/EID</xf:label>
  499. <xf:value>161021</xf:value>
  500. </xf:item><xf:item concept_id="5485" id="5485">
  501. <xf:label>Inpatient</xf:label>
  502. <xf:value>5485</xf:value>
  503. </xf:item><xf:item concept_id="5487" id="5487">
  504. <xf:label>Tuberculosis Treatment or DOT Program</xf:label>
  505. <xf:value>5487</xf:value>
  506. </xf:item><xf:item concept_id="5622" id="5622">
  507. <xf:label>OTHER NON-CODED</xf:label>
  508. <xf:value>5622</xf:value>
  509. </xf:item>
  510.  
  511.  
  512.  
  513.  
  514.  
  515.  
  516. </xf:select><xf:input bind="person_attribute25">
  517. <xf:label>OTHER_PATREF</xf:label>
  518. <xf:hint>Other source of referral not specified</xf:hint>
  519. </xf:input><xf:input bind="person_attribute26">
  520. <xf:label>TELNO_HH</xf:label>
  521. <xf:hint>telephone number of head household of the patient</xf:hint>
  522. </xf:input><xf:input bind="person_attribute27">
  523. <xf:label>TXT_SUPPORTER</xf:label>
  524. <xf:hint>Name of treatment support of this patient</xf:hint>
  525. </xf:input><xf:input bind="person_attribute28">
  526. <xf:label>TELNO_TXTSUPP</xf:label>
  527. <xf:hint>telephone number of treatment supporter of this patient</xf:hint>
  528. </xf:input><xf:input bind="person_attribute29">
  529. <xf:label>DSS_NO</xf:label>
  530. <xf:hint>DSS number</xf:hint>
  531. </xf:input><xf:select1 bind="person_attribute31">
  532. <xf:label>CHILDREN</xf:label>
  533. <xf:hint>This patient has children?</xf:hint>
  534. <xf:item concept_id="1065" id="1065">
  535. <xf:label>YES</xf:label>
  536. <xf:value>1065</xf:value>
  537. </xf:item>
  538. <xf:item concept_id="1066" id="1066">
  539. <xf:label>NO</xf:label>
  540. <xf:value>1066</xf:value>
  541. </xf:item>
  542. </xf:select1><xf:input bind="person_attribute32">
  543. <xf:label>NO_CHILD</xf:label>
  544. <xf:hint>number of children</xf:hint>
  545. </xf:input><xf:select1 bind="person_attribute34">
  546. <xf:label>OCCUPATION</xf:label>
  547. <xf:hint>Occupation of this patient</xf:hint>
  548. <xf:item concept_id="1538" id="1538">
  549. <xf:label>FARMER</xf:label>
  550. <xf:value>1538</xf:value>
  551. </xf:item>
  552. <xf:item concept_id="159465" id="159465">
  553. <xf:label>Student</xf:label>
  554. <xf:value>159465</xf:value>
  555. </xf:item>
  556. <xf:item concept_id="161457" id="161457">
  557. <xf:label>Employee-private</xf:label>
  558. <xf:value>161457</xf:value>
  559. </xf:item>
  560. <xf:item concept_id="161013" id="161013">
  561. <xf:label>Employee-government</xf:label>
  562. <xf:value>161013</xf:value>
  563. </xf:item>
  564. <xf:item concept_id="161016" id="161016">
  565. <xf:label>self-employed</xf:label>
  566. <xf:value>161016</xf:value>
  567. </xf:item>
  568. <xf:item concept_id="123801" id="123801">
  569. <xf:label>Unemployed</xf:label>
  570. <xf:value>123801</xf:value>
  571. </xf:item>
  572. <xf:item concept_id="160295" id="160295">
  573. <xf:label>Housewife</xf:label>
  574. <xf:value>160295</xf:value>
  575. </xf:item>
  576. <xf:item concept_id="159461" id="159461">
  577. <xf:label>Retired</xf:label>
  578. <xf:value>159461</xf:value>
  579. </xf:item>
  580. <xf:item concept_id="5622" id="5622">
  581. <xf:label>OTHER NON-CODED</xf:label>
  582. <xf:value>5622</xf:value>
  583. </xf:item>
  584. </xf:select1><xf:select bind="person_attribute36">
  585. <xf:label>TRANSFER_IN</xf:label>
  586. <xf:hint>Transfer in(select all that apply)</xf:hint>
  587. <xf:item concept_id="1175" id="1175">
  588. <xf:label>NOT APPLICABLE</xf:label>
  589. <xf:value>1175</xf:value>
  590. </xf:item>
  591. <xf:item concept_id="161049" id="161049">
  592. <xf:label>with records(referral and CTC 1 forms)</xf:label>
  593. <xf:value>161049</xf:value>
  594. </xf:item>
  595. <xf:item concept_id="161050" id="161050">
  596. <xf:label>No records available</xf:label>
  597. <xf:value>161050</xf:value>
  598. </xf:item>
  599. <xf:item concept_id="161051" id="161051">
  600. <xf:label>In care</xf:label>
  601. <xf:value>161051</xf:value>
  602. </xf:item>
  603. <xf:item concept_id="161052" id="161052">
  604. <xf:label>On ART</xf:label>
  605. <xf:value>161052</xf:value>
  606. </xf:item>
  607. </xf:select><xf:select1 bind="person_attribute37">
  608. <xf:label>CONSENT</xf:label>
  609. <xf:hint>informed consent patient signed</xf:hint>
  610. <xf:item concept_id="161054" id="161054">
  611. <xf:label>No, the patient refused</xf:label>
  612. <xf:value>161054</xf:value>
  613. </xf:item><xf:item concept_id="161870" id="161870">
  614. <xf:label>Yes, given today</xf:label>
  615. <xf:value>161870</xf:value>
  616. </xf:item><xf:item concept_id="161939" id="161939">
  617. <xf:label>No, Patient too sick to be asked</xf:label>
  618. <xf:value>161939</xf:value>
  619. </xf:item><xf:item concept_id="161940" id="161940">
  620. <xf:label>Not signed for other reason</xf:label>
  621. <xf:value>161940</xf:value>
  622. </xf:item>
  623.  
  624.  
  625.  
  626.  
  627.  
  628.  
  629. </xf:select1><xf:input bind="person_attribute38">
  630. <xf:label>DATE_CONSENT</xf:label>
  631. <xf:hint>Date of informed consent</xf:hint>
  632. </xf:input>
  633.  
  634.  
  635.  
  636.  
  637.  
  638.  
  639.  
  640.  
  641.  
  642.  
  643.  
  644.  
  645.  
  646.  
  647.  
  648.  
  649.  
  650.  
  651.  
  652. <xf:select1 bind="person_attribute39">
  653. <xf:label>CHILDREN_LESS16</xf:label>
  654. <xf:hint>Any children who are &lt;16 years of age</xf:hint>
  655. <xf:item concept_id="1066" id="1066">
  656. <xf:label>NO</xf:label>
  657. <xf:value>1066</xf:value>
  658. </xf:item>
  659. <xf:item concept_id="1065" id="1065">
  660. <xf:label>YES</xf:label>
  661. <xf:value>1065</xf:value>
  662. </xf:item>
  663. </xf:select1>
  664. <xf:select1 bind="person_attribute40">
  665. <xf:label>FAMILY_CDCI</xf:label>
  666. <xf:hint>Any family members attending CDCI?</xf:hint>
  667. <xf:item concept_id="1066" id="1066">
  668. <xf:label>NO</xf:label>
  669. <xf:value>1066</xf:value>
  670. </xf:item>
  671. <xf:item concept_id="1065" id="1065">
  672. <xf:label>YES</xf:label>
  673. <xf:value>1065</xf:value>
  674. </xf:item>
  675. <xf:item concept_id="1067" id="1067">
  676. <xf:label>UNKNOWN</xf:label>
  677. <xf:value>1067</xf:value>
  678. </xf:item>
  679. </xf:select1>
  680. <xf:input bind="person_attribute41">
  681. <xf:label>FAMILY_NAME1</xf:label>
  682. <xf:hint>Name of 1st family member</xf:hint>
  683. </xf:input>
  684. <xf:input bind="person_attribute42">
  685. <xf:label>FAMILY_RELATION1</xf:label>
  686. <xf:hint>Relationship of 1st family member</xf:hint>
  687. </xf:input>
  688. <xf:input bind="person_attribute43">
  689. <xf:label>FAMILY_NACP1</xf:label>
  690. <xf:hint>NACPNO for 1st family member</xf:hint>
  691. </xf:input>
  692. <xf:input bind="person_attribute44">
  693. <xf:label>FAMILY_NAME2</xf:label>
  694. <xf:hint>Name of 2nd family member</xf:hint>
  695. </xf:input>
  696. <xf:input bind="person_attribute45">
  697. <xf:label>FAMILY_RELATION2</xf:label>
  698. <xf:hint>Relationship of 2ND family member</xf:hint>
  699. </xf:input>
  700. <xf:input bind="person_attribute46">
  701. <xf:label>FAMILY_NACP2</xf:label>
  702. <xf:hint>NACPNO for 2ND family member</xf:hint>
  703. </xf:input>
  704. <xf:input bind="person_attribute47">
  705. <xf:label>FAMILY_NAME3</xf:label>
  706. <xf:hint>Name of 3RD family member</xf:hint>
  707. </xf:input>
  708. <xf:input bind="person_attribute48">
  709. <xf:label>FAMILY_RELATION3</xf:label>
  710. <xf:hint>Relationship of 3RD family member</xf:hint>
  711. </xf:input>
  712. <xf:input bind="person_attribute49">
  713. <xf:label>FAMILY_NACP3</xf:label>
  714. <xf:hint>NACPNO for 3RD family member</xf:hint>
  715. </xf:input>
  716. <xf:input bind="person_attribute50">
  717. <xf:label>FAMILY_NAME4</xf:label>
  718. <xf:hint>Name of 4TH family member</xf:hint>
  719. </xf:input>
  720. <xf:input bind="person_attribute51">
  721. <xf:label>FAMILY_RELATION4</xf:label>
  722. <xf:hint>Relationship of 4TH family member</xf:hint>
  723. </xf:input>
  724. <xf:input bind="person_attribute52">
  725. <xf:label>FAMILY_NACP4</xf:label>
  726. <xf:hint>NACPNO for 4TH family member</xf:hint>
  727. </xf:input>
  728. <xf:input bind="person_attribute53">
  729. <xf:label>NICK_NAME</xf:label>
  730. <xf:hint>A well known name of a client</xf:hint>
  731. </xf:input>
  732. <xf:input bind="person_attribute54">
  733. <xf:label>Birth Date Estimated</xf:label>
  734. <xf:hint>Is the patient birth date estimated?</xf:hint>
  735. </xf:input>
  736. <xf:input bind="person_attribute55">
  737. <xf:label>TB_NO</xf:label>
  738. <xf:hint>Unique identification number of tb patient</xf:hint>
  739. </xf:input>
  740. <xf:input bind="person_attribute56">
  741. <xf:label>CBHS_NO</xf:label>
  742. <xf:hint>CBHS number</xf:hint>
  743. </xf:input>
  744. <xf:input bind="person_attribute57">
  745. <xf:label>HEALTH_INSURANCE</xf:label>
  746. <xf:hint>Do you have health insurance?</xf:hint>
  747. </xf:input>
  748. <xf:select1 bind="person_attribute58">
  749. <xf:label>HEALTH_INSURANCE_TYPE</xf:label>
  750. <xf:hint>Type of health insurance scheme</xf:hint>
  751. <xf:item concept_id="162044" id="162044">
  752. <xf:label>NHIF</xf:label>
  753. <xf:value>162044</xf:value>
  754. </xf:item>
  755. <xf:item concept_id="162045" id="162045">
  756. <xf:label>SHIB_NSSF</xf:label>
  757. <xf:value>162045</xf:value>
  758. </xf:item>
  759. <xf:item concept_id="162046" id="162046">
  760. <xf:label>CHF</xf:label>
  761. <xf:value>162046</xf:value>
  762. </xf:item>
  763. <xf:item concept_id="162047" id="162047">
  764. <xf:label>TIKA</xf:label>
  765. <xf:value>162047</xf:value>
  766. </xf:item>
  767. <xf:item concept_id="162048" id="162048">
  768. <xf:label>AAR</xf:label>
  769. <xf:value>162048</xf:value>
  770. </xf:item>
  771. <xf:item concept_id="162049" id="162049">
  772. <xf:label>OTHER_HEALTH_INSURANCE</xf:label>
  773. <xf:value>162049</xf:value>
  774. </xf:item>
  775. </xf:select1>
  776. <xf:input bind="person_attribute59">
  777. <xf:label>OTHER_HEALTH_INSURANCE_SPECIFY</xf:label>
  778. <xf:hint>Other health insurance specify</xf:hint>
  779. </xf:input>
  780. <xf:input bind="person_attribute60">
  781. <xf:label>CONSENT_OTHER</xf:label>
  782. <xf:hint>Other reasons for not signing consent form</xf:hint>
  783. </xf:input>
  784. <xf:input bind="person_attribute61">
  785. <xf:label>MOTHER_NACPNO</xf:label>
  786. </xf:input>
  787.  
  788.  
  789.  
  790.  
  791.  
  792.  
  793.  
  794.  
  795.  
  796.  
  797.  
  798.  
  799.  
  800.  
  801. </xf:group>
  802. </xf:xforms>
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