form

<%@ include file="/WEB-INF/template/include.jsp"%>
<%@ include file="/WEB-INF/template/header.jsp"%>

<openmrs:htmlInclude file="${pageContext.request.contextPath}/moduleResources/patientnarratives/css/styles.css"/>

<openmrs:htmlInclude file="${pageContext.request.contextPath}/moduleResources/htmlformentry/htmlFormEntry.js"/>
<openmrs:htmlInclude file="${pageContext.request.contextPath}/moduleResources/htmlformentry/htmlFormEntry.css"/>

<%--<script type="text/javascript" src="${pageContext.request.contextPath}/"></script>--%>
<%--<link href="${pageContext.request.contextPath}/moduleResources/htmlformentry/htmlFormEntry.css" type="text/css" rel="stylesheet" />--%>

<%@ include file="template/localHeader.jsp"%>


<div id="main-wrap">
    <div id="sidebar">
        Left Nav

        <htmlform>
            <!-- Autogenerated example form  (template from 01-Nov-2010 -->
            <macros>
                paperFormId = (Fill this in)
                headerColor =#009d8e
                fontOnHeaderColor = white
            </macros>

            <style>
                .section {
                    border: 1px solid $headerColor;
                    padding: 2px;
                    text-align: left;
                    margin-bottom: 1em;
                }
                .sectionHeader {
                    background-color: $headerColor;
                    color: $fontOnHeaderColor;
                    display: block;
                    padding: 2px;
                    font-weight: bold;
                }
                table.baseline-aligned td {
                    vertical-align: baseline;
                }
            </style>

            <span style="float:right">Paper Form ID: $paperFormId</span>
            <h2>sdf (v)</h2>

            <section headerLabel="1. Encounter Details">
                <table class="baseline-aligned">
                    <tr>
                        <td>Date:</td>
                        <td><encounterDate default="today"/></td>
                    </tr>
                    <tr>
                        <td>Location:</td>
                        <td><encounterLocation/></td>
                    </tr>
                    <tr>
                        <td>Provider:</td>
                        <td><encounterProvider/></td>
                    </tr>
                </table>
            </section>

            <section headerLabel="2. Demographic Information">
                <table class="baseline-aligned">
                    <tr>
                        <td>Name:</td>
                        <td><lookup class="value" expression="patient.personName"/></td>
                    </tr>
                    <tr>
                        <td>Old Identification Number:</td>
                        <td><lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('Old Identification Number') ) $patId #end "/></td>
                    </tr>
                    <tr>
                        <td>OpenMRS Identification Number:</td>
                        <td><lookup class="value" complexExpression="#foreach( $patId in $patientIdentifiers.get('OpenMRS Identification Number') ) $patId #end "/></td>
                    </tr>
                    <tr>
                        <td>Gender:</td>
                        <td><lookup class="value" expression="patient.gender"/></td>
                    </tr>
                    <tr>
                        <td>Birthdate:</td>
                        <td>
                            <lookup class="value" complexExpression="#if( \$patient.birthdateEstimated ) ~#end"/> <lookup class="value" expression="patient.birthdate"/>
                            (Age: <lookup class="value" expression="patient.age"/>)
                        </td>
                    </tr>
                    <tr>
                        <td>Birthplace:</td>
                        <td><lookup class="value" expression="personAttributes.get('Birthplace')"/></td>
                    </tr>
                    <tr>
                        <td>Citizenship:</td>
                        <td><lookup class="value" expression="personAttributes.get('Citizenship')"/></td>
                    </tr>
                    <tr>
                        <td>Civil Status:</td>
                        <td><lookup class="value" expression="personAttributes.get('Civil Status').name.name"/></td>
                    </tr>
                    <tr>
                        <td>Health Center:</td>
                        <td><lookup class="value" expression="personAttributes.get('Health Center')"/></td>
                    </tr>
                    <tr>
                        <td>Health District:</td>
                        <td><lookup class="value" expression="personAttributes.get('Health District')"/></td>
                    </tr>
                    <tr>
                        <td>Mother's Name:</td>
                        <td><lookup class="value" expression="personAttributes.get('Mothers Name')"/></td>
                    </tr>
                    <tr>
                        <td>Race:</td>
                        <td><lookup class="value" expression="personAttributes.get('Race')"/></td>
                    </tr>
                </table>
            </section>

            <submit/>

            <!-- END OF FORM

            Simple examples to copy-and-paste. Full reference at http://wiki.openmrs.org/x/kg8z

            SECTION
                <section headerLabel="\#. Title">
                    Content
                </section>

            NUMERIC OBSERVATION
                <obs conceptId="id-of-numeric-concept" labelText="Label before"/>

            DATE OBSERVATION
                <obs conceptId="id-of-date-concept" labelText="Label before"/>

            CODED OBSERVATION
            (as a dropdown)
                <obs conceptId="id-of-coded-concept" labelText="Label before"/>
            (as radio buttons)
                <obs conceptId="id-of-coded-concept" labelText="Label before" style="radio"/>
            (as an autocomplete)
                <obs conceptId="id-of-coded-concept" labelText="Label before" style="autocomplete" answerClasses="Diagnosis"/>
            (as a checkbox for a specific answer)
                <obs conceptId="id-of-coded-concept" labelText="Label before" answerConceptId="id-of-answer-concept" answerLabel="label for answer"/>
            (as a dropdown with specific choices)
                <obs conceptId="id-of-coded-concept" labelText="Label before" answerConceptIds="concept-id-1,concept-id-2,concept-id-3" answerLabels="Label 1,Label 2, Label 3"/>


            FREE TEXT OBSERVATION
            (as a normal text field)
                <obs conceptId="id-of-text-concept" labelText="Label before"/>
            (as a textarea)
                <obs conceptId="id-of-text-concept" labelText="Label before" rows="4" cols="80"/>
            -->
        </htmlform>


    </div>

    <div id="content-wrap">
        <div id="info-wrap">
            small<br><br><br><br><br>
        </div>
        <div id="info-wrap">
            small<br><br><br>
        </div>
        <div id="info-wrap">
            small<br><br>
        </div>
        <div id="info-wrap">
            small<br>
        </div>
    </div>
</div>

<%@ include file="/WEB-INF/template/footer.jsp"%>