Created
February 19, 2016 14:29
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ART Card Summary Form
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| <htmlform formName="HMIS 122a HIV Care ART Card - Summary Form" | |
| formDescription="Summary entry form for patients enrolled for ART" | |
| formEncounterType="8d5b27bc-c2cc-11de-8d13-0010c6dffd0f" | |
| formUuid="52653a60-8300-4c13-be4d-4b746da06fee" | |
| formVersion="1.2" | |
| formAddMetadata="yes" | |
| formUILocation="patientDashboard.visitActions" | |
| formOrder="1" | |
| formIcon="icon-medkit" | |
| formShowIf="visit.active && patient.person.dead==false && patient.person.age > 2" | |
| formDisplayStyle="Standard" | |
| formLabel="ART Card - Summary Form"> | |
| <ifMode mode="EDIT" include="false"> | |
| <lookup complexExpression=" | |
| #set( $encounter = 0 ) | |
| #set( $encounter = $fn.latestEncounter('8d5b27bc-c2cc-11de-8d13-0010c6dffd0f')) | |
| #if( $encounter != 0 ) | |
| <script type="text/javascript"> | |
| // check that the HTML form is not being edited via the edit HTML form admin page | |
| jq(document).ready(function () { | |
| if (window.location.href.indexOf('/module/htmlformentry/htmlForm.form?id=3') == -1) { | |
| alert('Redirecting to new location'); | |
| var newUrl =window.location.protocol + "//" + window.location.host + "/"+ OPENMRS_CONTEXT_PATH + "/htmlformentryui/htmlform/enterHtmlFormWithStandardUi.page?patientId=$encounter.patientId&visitId=$encounter.visit.visitId&formUuid=52653a60-8300-4c13-be4d-4b746da06fee&encounterId=$encounter.encounterId&returnUrl=%2F" + OPENMRS_CONTEXT_PATH + "%2Fcoreapps%2Fclinicianfacing%2Fpatient.page%3FpatientId%3D$encounter.patientId"; | |
| document.getElementById('redirectUrl').innerHTML = newUrl; | |
| alert(newUrl); | |
| // location.href = newUrl; | |
| } | |
| }); | |
| </script> | |
| #end"/> | |
| </ifMode> | |
| <script type="text/javascript"> | |
| function enable_disable_fm(selected_option) { | |
| var class_name = jq(selected_option).attr("class"); | |
| var length = class_name.length; | |
| var class_id = parseInt(class_name.substring(length - 1, length)) | |
| var row_id = class_id; | |
| var disable = true; | |
| var row_1 = '[class^="FamilyMember"][class*="Children1"]'; | |
| var row_2 = '[class^="FamilyMember"][class*="Children2"]'; | |
| var row_3 = '[class^="FamilyMember"][class*="Children3"]'; | |
| var row_4 = '[class^="FamilyMember"][class*="Children4"]'; | |
| var row_5 = '[class^="FamilyMember"][class*="Children5"]'; | |
| var xx = row_1; | |
| var selected_value = jq(selected_option).find(":selected").text() | |
| switch (selected_value) { | |
| case "P": | |
| case "Y": | |
| disable = false; | |
| break; | |
| } | |
| switch (row_id) { | |
| case 1: | |
| xx = row_1; | |
| break; | |
| case 2: | |
| xx = row_2; | |
| break; | |
| case 3: | |
| xx = row_3; | |
| break; | |
| case 4: | |
| xx = row_4; | |
| break; | |
| case 5: | |
| xx = row_5; | |
| break; | |
| } | |
| jq(xx).each(function () { | |
| var group = jq(this); | |
| if (class_name.indexOf('Children') == -1) { | |
| group.find("input").attr("disabled", disable); | |
| group.find('select').attr("disabled", disable); | |
| } | |
| else if (class_name.indexOf('GrandChildren') == -1) { | |
| group.find("input").attr("disabled", disable); | |
| } | |
| }); | |
| } | |
| function enable_disable_ei(selected_option) { | |
| var class_name = jq(selected_option).attr("class"); | |
| var length = class_name.length; | |
| var class_id = parseInt(class_name.substring(length - 1, length)) | |
| var row_id = class_id; | |
| var disable = true; | |
| var row_1 = '[class^="ExposedInfant"][class*="Children1"]'; | |
| var row_2 = '[class^="ExposedInfant"][class*="Children2"]'; | |
| var row_3 = '[class^="ExposedInfant"][class*="Children3"]'; | |
| var row_4 = '[class^="ExposedInfant"][class*="Children4"]'; | |
| var row_5 = '[class^="ExposedInfant"][class*="Children5"]'; | |
| var xx = row_1; | |
| var selected_value = jq(selected_option).find(":selected").text() | |
| if (selected_value == "P" && selected_value != "") | |
| disable = false; | |
| switch (row_id) { | |
| case 1: | |
| xx = row_1; | |
| break; | |
| case 2: | |
| xx = row_2; | |
| break; | |
| case 3: | |
| xx = row_3; | |
| break; | |
| case 4: | |
| xx = row_4; | |
| break; | |
| case 5: | |
| xx = row_5; | |
| break; | |
| } | |
| jq(xx).each(function () { | |
| var group = jq(this); | |
| if (class_name.indexOf('Children') == -1) { | |
| group.find("input").attr("disabled", disable); | |
| } | |
| }); | |
| } | |
| function enable_disable_ac(selected_option) { | |
| var class_name = jq(selected_option).attr("class"); | |
| var length = class_name.length; | |
| var class_id = parseInt(class_name.substring(length - 1, length)) | |
| var row_id = class_id; | |
| var disable = true; | |
| var row_1 = '[class^="ArtCare"][class*="Child1"]'; | |
| var row_2 = '[class^="ArtCare"][class*="Child2"]'; | |
| var row_3 = '[class^="ArtCare"][class*="Child3"]'; | |
| var row_4 = '[class^="ArtCare"][class*="Child4"]'; | |
| var row_5 = '[class^="ArtCare"][class*="Child5"]'; | |
| var row_6 = '[class^="ArtCare"][class*="Child6"]'; | |
| var row_7 = '[class^="ArtCare"][class*="Child7"]'; | |
| var row_8 = '[class^="ArtCare"][class*="Child8"]'; | |
| var row_9 = '[class^="ArtCare"][class*="Child9"]'; | |
| var xx = row_1; | |
| var selected_value = jq(selected_option).find(":selected").text() | |
| selected_value = selected_value.trim().toUpperCase(); | |
| if (selected_value.toLowerCase() == "other") | |
| disable = false; | |
| switch (row_id) { | |
| case 1: | |
| xx = row_1; | |
| break; | |
| case 2: | |
| xx = row_2; | |
| break; | |
| case 3: | |
| xx = row_3; | |
| break; | |
| case 4: | |
| xx = row_4; | |
| break; | |
| case 5: | |
| xx = row_5; | |
| break; | |
| case 6: | |
| xx = row_6; | |
| break; | |
| case 7: | |
| xx = row_7; | |
| break; | |
| case 8: | |
| xx = row_8; | |
| break; | |
| case 9: | |
| xx = row_9; | |
| break; | |
| } | |
| jq(xx).each(function () { | |
| var group = jq(this); | |
| if (class_name.indexOf('Child') == -1) { | |
| group.find("input").attr("disabled", disable); | |
| } | |
| }); | |
| } | |
| function enable_disable_ati(selected_option) { | |
| var class_name = jq(selected_option).attr("class"); | |
| var length = class_name.length; | |
| var class_id = parseInt(class_name.substring(length - 1, length)) | |
| var row_id = class_id; | |
| var disable = true; | |
| var row_1 = '[class^="ARTTreatmentInterruption"][class*="Child1"]'; | |
| var row_2 = '[class^="ARTTreatmentInterruption"][class*="Child2"]'; | |
| var row_3 = '[class^="ARTTreatmentInterruption"][class*="Child3"]'; | |
| var row_4 = '[class^="ARTTreatmentInterruption"][class*="Child4"]'; | |
| var row_5 = '[class^="ARTTreatmentInterruption"][class*="Child5"]'; | |
| var row_6 = '[class^="ARTTreatmentInterruption"][class*="Child6"]'; | |
| var xx = row_1; | |
| var selected_value = jq(selected_option).find(":selected").text() | |
| selected_value = selected_value.trim().toUpperCase(); | |
| if (selected_value.toLowerCase() == "stopped" || selected_value.toLowerCase() == "lost") | |
| disable = false; | |
| switch (row_id) { | |
| case 1: | |
| xx = row_1; | |
| break; | |
| case 2: | |
| xx = row_2; | |
| break; | |
| case 3: | |
| xx = row_3; | |
| break; | |
| case 4: | |
| xx = row_4; | |
| break; | |
| case 5: | |
| xx = row_5; | |
| break; | |
| case 6: | |
| xx = row_6; | |
| break; | |
| } | |
| jq(xx).each(function () { | |
| var group = jq(this); | |
| if (class_name.indexOf('Child') == -1) { | |
| group.find("input").attr("disabled", disable); | |
| group.find('select').attr("disabled", disable); | |
| } | |
| }); | |
| } | |
| jq('#w200_0').click(function () { | |
| if (jq('#w200_0').is(':checked')) { | |
| alert("it's checked"); | |
| } | |
| }); | |
| if (jQuery) { | |
| jq(document).ready(function () { | |
| if (jq.browser.msie) { | |
| jq(":checkbox").click(function () { | |
| jq(this).change(); | |
| }); | |
| } | |
| var gender = jq("span.gender").html(); | |
| var age = jq("span.age").html(); | |
| jq('#w196').change(function () { | |
| if (this.value == '90004') { | |
| jq("#w198").prop("checked", false); | |
| jq("#w206").prop("checked", false); | |
| jq("#w214").prop("checked", false); | |
| jq("#w222").prop("checked", false); | |
| jq("input#w198").attr("disabled", true); | |
| jq("input#w206").attr("disabled", true); | |
| jq("input#w214").attr("disabled", true); | |
| jq("input#w222").attr("disabled", true); | |
| } | |
| else if (this.value == '90003') { | |
| jq("input#w198").removeAttr("disabled"); | |
| jq("input#w206").removeAttr("disabled"); | |
| jq("input#w214").removeAttr("disabled"); | |
| jq("input#w222").removeAttr("disabled"); | |
| } | |
| }); | |
| //If Male disable all options that only apply to females | |
| if (gender == "M") { | |
| jq("input#w246").attr("disabled", true); | |
| jq("input#w248").attr("disabled", true); | |
| } | |
| // If above five years disable options that only apply to below 5 year olds | |
| if (age > 5) { | |
| jq("input#w250").attr("disabled", true); | |
| jq("input#w252").attr("disabled", true); | |
| } | |
| jq('input[type=hidden][name=w233][id=w233]').change(function () { | |
| if (new Date(jq("#w233").val()) <= new Date(jq("#w6").val())) { | |
| alert("Enrolled Date is Earlier than the date Comfirmed Positive"); | |
| } | |
| }); | |
| // disable the HIV enrolled date input | |
| jq('#w233-display').attr("disabled", "disabled"); | |
| // When the HIV date confirmed field is selected, then set the minimum value of the HIV enrolled date | |
| jq('#w6-display').change(function () { | |
| // enable the HIV enrolled date picker | |
| jq('#w233-display').removeAttr("disabled", ""); | |
| // clear the HIV enrolled date so that a new one can be selected | |
| jq('#w233-display').val(""); | |
| jq('#w233').val(""); | |
| // set the minimum date using the HIV confirmed date | |
| jq('#w233-display').datepicker("option", "minDate", jq('#w6-display').val()); | |
| }); | |
| // when there is a value in the HIV date confirmed field | |
| if (jq('#w6-display').length > 0) { | |
| // set the minimum date using the HIV confirmed date | |
| jq('#w233-display').datepicker("option", "minDate", jq('#w6-display').val()); | |
| } | |
| // disable the Transfer date input | |
| jq('#w278-display').attr("disabled", "disabled"); | |
| // When the ART start Date field is selected, then set the minimum value of the Transer date | |
| jq('#w286-display').change(function () { | |
| // enable the HIV enrolled date picker | |
| jq('#w278-display').removeAttr("disabled", ""); | |
| // clear the Transfer Date so that a new one can be selected | |
| jq('#w278-display').val(""); | |
| jq('#w233').val(""); | |
| // set the minimum date using the ART start date | |
| jq('#w278-display').datepicker("option", "minDate", jq('#w286-display').val()); | |
| }); | |
| // when there is a value in the Transfer field | |
| if (jq('#w286-display').length > 0) { | |
| // set the minimum date using the ART Start date | |
| jq('#w278-display').datepicker("option", "minDate", jq('#w286-display').val()); | |
| } | |
| jq('[class^="FamilyMemberEnableDisable"]').change(function () { | |
| enable_disable_fm(jq(this)); | |
| }); | |
| jq('[class^="FamilyMemberEnableDisable"]').each(function () { | |
| enable_disable_fm(jq(this)); | |
| }); | |
| jq('[class^="ExposedInfantEnableDisable"]').change(function () { | |
| enable_disable_ei(jq(this)); | |
| }); | |
| jq('[class^="ArtCareEnableDisable"]').change(function () { | |
| enable_disable_ac(jq(this)); | |
| }); | |
| jq('[class^="ArtCareEnableDisable"]').each(function () { | |
| enable_disable_ac(jq(this)) | |
| }); | |
| jq('[class^="ARTTreatmentInterruptionEnableDisable"]').change(function () { | |
| enable_disable_ati(jq(this)); | |
| }); | |
| jq('[class^="ARTTreatmentInterruptionEnableDisable"]').each(function () { | |
| enable_disable_ati(jq(this)) | |
| }); | |
| jq(".enableDisable").each(function () { | |
| var group = jq(this); | |
| function disableFn() { | |
| group.children("#disabled").fadeTo(250, 1); | |
| group.children("#disabled").find(":checkbox").attr("checked", false); //uncheck | |
| // group.children("#disabled").find("input[type$='text']").val(""); | |
| group.children("#disabled").find("input").attr("disabled", true); //disable | |
| group.children("#disabled").find("select").attr("disabled", true); | |
| } | |
| function enableFn() { | |
| group.children("#disabled").fadeTo(250, 1); | |
| group.children("#disabled").find("input").attr("disabled", false); | |
| group.children("#disabled").find("select").attr("disabled", false); | |
| } | |
| disableFn(); | |
| jq(this).children("#trigger").find(":checkbox:first").change(function () { | |
| var checked = jq(this).attr("checked"); | |
| if (checked == "checked") { | |
| enableFn(); | |
| } else { | |
| disableFn(); | |
| } | |
| }); | |
| }); | |
| jq(".checkboxGroup").each(function () { | |
| var group = jq(this); | |
| var uncheckAll = function () { | |
| group.find("input[type$='checkbox']").attr("checked", false); | |
| group.find("input[type$='checkbox']").change(); | |
| } | |
| var uncheckRadioAndAll = function () { | |
| group.find("#checkboxAll,#checkboxRadio").find("input[type$='checkbox']").attr("checked", false); | |
| group.find("#checkboxAll,#checkboxRadio").find("input[type$='checkbox']").change(); | |
| } | |
| group.find("#checkboxAll").find("input").click( | |
| function () { | |
| var flip; | |
| var checked = jq(this).siblings(":checkbox:first").attr("checked"); | |
| if (jq(this).attr("name") == jq(this).parents("#checkboxAll:first").find(":checkbox:first").attr("name")) { | |
| checked = jq(this).attr("checked"); | |
| flip = checked; | |
| } else { | |
| flip = !checked; | |
| } | |
| if (jq.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. | |
| uncheckAll(); | |
| jq(this).parents("#checkboxAll:first").find(":checkbox").attr("checked", flip); | |
| jq(this).parents("#checkboxAll:first").find(":checkbox").change(); | |
| } | |
| ); | |
| group.find("#checkboxRadio").find("input[type$='checkbox']").click(function () { | |
| uncheckAll(); | |
| jq(this).siblings("input[type$='checkbox']").attr("checked", false); | |
| jq(this).attr("checked", true); | |
| jq(this).change(); | |
| }); | |
| group.find("#checkboxCheckbox").click( | |
| function () { | |
| uncheckRadioAndAll(); | |
| } | |
| ); | |
| }); | |
| }); | |
| } | |
| </script> | |
| <script type="text/javascript"> | |
| function val() { | |
| document.getElementById("fgh").disabled = "true"; | |
| } | |
| </script> | |
| <style type="text/css"> | |
| .error { | |
| color: red; | |
| } | |
| table td { | |
| background: #7BB3D0; | |
| color: #404040; | |
| } | |
| form select, .form select { | |
| min-width: 0px; | |
| } | |
| form input, form select, form textarea, form ul.select, .form input, .form select, .form textarea, .form | |
| ul.select { | |
| background-color: #FBFBFB; | |
| border: 1px solid #404040; | |
| border-radius: 5px; | |
| margin-bottom: 10px; | |
| padding: 10px; | |
| min-width: 50%; | |
| } | |
| .row { | |
| width: 100%; | |
| float: left; | |
| display: inline-flex; | |
| clear: both; | |
| } | |
| .row .row-col2 { | |
| float: left; | |
| width: 50%; | |
| } | |
| table th, table td { | |
| border: 1px solid #BDBDBD; | |
| } | |
| </style> | |
| <!-- Beging of HTML Form --> | |
| <div class="ai-page-frame"> | |
| <div class="headers" style="text-align: center;"> | |
| <h3>HIV ART CARD - Summary Page</h3> | |
| </div> | |
| <section> | |
| <table class="enrollment"> | |
| <tbody> | |
| <tr> | |
| <td> | |
| <label>Clinic Team Leader:</label> | |
| <encounterProvider role="Provider" style="autocomplete"/> | |
| </td> | |
| <td> | |
| <label>Enrolled at:</label> | |
| <encounterLocation default="1"/> | |
| </td> | |
| <td> | |
| <label>HIV Clinic #:</label> | |
| <patient field="identifier" identifierTypeId="e1731641-30ab-102d-86b0-7a5022ba4115" | |
| required="true"/> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <td id="comfirmedDate"> | |
| <label>Date Confirmed HIV +Ve:</label> | |
| <obs conceptId="90267"/> | |
| </td> | |
| <td> | |
| <label>Test type</label> | |
| <obs conceptId="99080" answerConceptIds="99079,99080" | |
| answerLabels="Ab,PCR"/> | |
| </td> | |
| <td> | |
| <label>Where</label> | |
| <obs conceptId="99081" size="20"/> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>Care Entry Point</h3> | |
| <table class="entry-point"> | |
| <tbody> | |
| <tr style="background: #F7F7F7;"> | |
| <obsgroup groupingConceptId="99116"> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90012" answerLabel="eMTCT"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90016" answerLabel="TB"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="99593" answerLabel="YCC"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="99610" answerLabel="SMC"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90019" answerLabel="Outreach"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90013" answerLabel="Out patient"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90015" answerLabel="STI"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90200" answerConceptId="90018" answerLabel="Inpatient"/> | |
| </td> | |
| <td> | |
| <span id="checkboxAll" class="enableDisable"> | |
| <span id="trigger"> | |
| <obs conceptId="90200" answerConceptId="90002" | |
| answerLabel="Other specify"/> | |
| </span> | |
| <span id="disabled"> | |
| <obs size="10" conceptId="99115" labelText=""/> | |
| </span> | |
| </span> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>Treatment Supporter</h3> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <td colspan="2"> | |
| <label>Medicine picked by:</label> | |
| <obs size="15" conceptId="99142"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| <label>District</label> | |
| <obs conceptId="99138" size="12"/> | |
| </td> | |
| <td> | |
| <label>Division/SubCounty</label> | |
| <obs conceptId="99139" size="12"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| <label>Parish</label> | |
| <obs conceptId="99140" size="12"/> | |
| </td> | |
| <td> | |
| <label>Village</label> | |
| <obs conceptId="99141" size="12"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| <label>Telephone (whose)</label> | |
| <obs conceptId="90278" size="12"/> | |
| </td> | |
| <td> | |
| <label>Home Care provided by:</label> | |
| <obs conceptId="99124" size="20" labelText=""/> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>Family members and Partners</h3> | |
| <table border="0" style="background-color: #EEE"> | |
| <tbody> | |
| <tr> | |
| <td style="color: #404040; padding: 15px;"> | |
| <b>Name</b> | |
| </td> | |
| <td style="color: #404040; padding: 15px;"> | |
| <b>Age</b> | |
| <br/> | |
| (if <=2yrs, write in mths) | |
| </td> | |
| <td style="color: #404040; padding: 15px;"> | |
| <b>HIV | |
| P/N/U | |
| </b> | |
| </td> | |
| <td style="color: #404040; padding: 15px;"> | |
| <b>HIV | |
| Care Y/N | |
| </b> | |
| </td> | |
| <td style="color: #404040; padding: 15px;">Unique | |
| <b>No</b> | |
| </td> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99075"> | |
| <td> | |
| <obs conceptId="99073" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99074"/> | |
| <obs conceptId="99725" answerConceptIds="1074,99726" | |
| answerLabels="Yrs,Mths"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisable1"> | |
| <obs conceptId="90253" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableChildren1"> | |
| <obs conceptId="90270" answerConceptIds="90003,90004" | |
| answerLabels="Y,N" onchange="return val()"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableGrandChildren1"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99075"> | |
| <td> | |
| <obs conceptId="99073" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99074"/> | |
| <obs conceptId="99725" answerConceptIds="1074,99726" | |
| answerLabels="Yrs,Mths"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisable2"> | |
| <obs conceptId="90253" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableChildren2"> | |
| <obs conceptId="90270" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableGrandChildren2"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99075"> | |
| <td> | |
| <obs conceptId="99073" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99074"/> | |
| <obs conceptId="99725" answerConceptIds="1074,99726" | |
| answerLabels="Yrs,Mths"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisable3"> | |
| <obs conceptId="90253" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableChildren3"> | |
| <obs conceptId="90270" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableGrandChildren3"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99075"> | |
| <td> | |
| <obs conceptId="99073" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99074"/> | |
| <obs conceptId="99725" answerConceptIds="1074,99726" | |
| answerLabels="Yrs,Mths"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisable4"> | |
| <obs conceptId="90253" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableChildren4"> | |
| <obs conceptId="90270" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableGrandChildren4"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99075"> | |
| <td> | |
| <obs conceptId="99073" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99074"/> | |
| <obs conceptId="99725" answerConceptIds="1074,99726" | |
| answerLabels="Yrs,Mths"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisable5"> | |
| <obs conceptId="90253" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableChildren5"> | |
| <obs conceptId="90270" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td class="FamilyMemberEnableDisableGrandChildren5"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section class="exposed-infant"> | |
| <h3>Exposed Infant Follow-up</h3> | |
| <table border="0" style="background-color: #EEE"> | |
| <thead> | |
| <tr> | |
| <th rowspan="2"> | |
| Name | |
| </th> | |
| <th rowspan="2"> | |
| DOB | |
| </th> | |
| <th colspan="2"> | |
| Infant | |
| feeding | |
| </th> | |
| <th rowspan="2"> | |
| CTX | |
| started at 2 mths | |
| </th> | |
| <th rowspan="2"> | |
| Date | |
| of 1st PCR/Result | |
| </th> | |
| <th rowspan="2"> | |
| Final | |
| status | |
| </th> | |
| <th rowspan="2"> | |
| If | |
| Confirm + Unique ID | |
| </th> | |
| </tr> | |
| <tr> | |
| <th> | |
| <6 | |
| mths | |
| </th> | |
| <th> | |
| >=6 | |
| mths | |
| </th> | |
| </tr> | |
| </thead> | |
| <tr> | |
| <obsgroup groupingConceptId="99078"> | |
| <td> | |
| <obs conceptId="99077" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90261"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99607" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99608" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99076" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99606" size="5"/> | |
| <obs conceptId="99153" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisable1"> | |
| <obs conceptId="99121" answerConceptIds="90166,90167,99122,99112,90001" | |
| answerLabels="P,N,N/BF,Dead,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisableChildren1"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99078"> | |
| <td> | |
| <obs conceptId="99077" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90261"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99607" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99608" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99076" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99606" size="5"/> | |
| <obs conceptId="99153" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisable2"> | |
| <obs conceptId="99121" answerConceptIds="90166,90167,99122,99112,90001" | |
| answerLabels="P,N,N/BF,Dead,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisableChildren2"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99078"> | |
| <td> | |
| <obs conceptId="99077" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90261"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99607" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99608" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99076" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99606" size="5"/> | |
| <obs conceptId="99153" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisable3"> | |
| <obs conceptId="99121" answerConceptIds="90166,90167,99122,99112,90001" | |
| answerLabels="P,N,N/BF,Dead,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisableChildren3"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99078"> | |
| <td> | |
| <obs conceptId="99077" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90261"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99607" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99608" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99076" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99606" size="5"/> | |
| <obs conceptId="99153" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisable4"> | |
| <obs conceptId="99121" answerConceptIds="90166,90167,99122,99112,90001" | |
| answerLabels="P,N,N/BF,Dead,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisableChildren4"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99078"> | |
| <td> | |
| <obs conceptId="99077" size="10"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90261"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99607" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99608" labelText="" answerConceptIds="5526,99089,6046" | |
| answerLabels="EBF,RF,MF"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99076" answerConceptIds="90003,90004" | |
| answerLabels="Y,N"/> | |
| </td> | |
| <td> | |
| <obs conceptId="99606" size="5"/> | |
| <obs conceptId="99153" answerConceptIds="90166,90167,90001" | |
| answerLabels="P,N,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisable5"> | |
| <obs conceptId="99121" answerConceptIds="90166,90167,99122,99112,90001" | |
| answerLabels="P,N,N/BF,Dead,U"/> | |
| </td> | |
| <td class="ExposedInfantEnableDisableChildren5"> | |
| <obs conceptId="90263" size="10"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>Prior ART</h3> | |
| <table border="0" id="art-history" style="background-color: #EEE"> | |
| <tbody> | |
| <tr style="background: beige;"> | |
| <td> | |
| <b>Prior ART</b> | |
| </td> | |
| <td colspan="3"> | |
| <obs conceptId="99055" answerConceptIds="90003,90004" | |
| answerLabels="Yes,None"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| </td> | |
| <td> | |
| <b>Date</b> | |
| </td> | |
| <td> | |
| <b>Where</b> | |
| </td> | |
| <td> | |
| <b>Drug</b> | |
| </td> | |
| </tr> | |
| <tr class="checkboxGroup hideShowPriorOptions enableDisable"> | |
| <obsgroup groupingConceptId="99066"> | |
| <td id="trigger"> | |
| <obs conceptId="99056" answerConceptId="90003" answerLabel="PEP:" | |
| id="hideShowPriorOptions"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="second" conceptId="99154" labelText=""/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="third" conceptId="99057"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="fourth" conceptId="99130" | |
| answerConceptIds="630,99276,99275,99277,99278,99279,99006,99016,99046,99280,99281,90002" | |
| answerLabels="AZT-3TC, AZT-FTC, TDF-3TC, TDF-FTC, d4T-3TC, d4T-FTC,AZT-3TC-EFV,D4T-3TC-EFV,AZT-3TC-LPV/r,AZT-3TC-NFV,d4T-3TC-LPV/r, Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr class="hideShowPriorOptions enableDisable"> | |
| <obsgroup groupingConceptId="99598"> | |
| <td id="trigger"> | |
| <obs conceptId="99594" answerConceptId="90003" answerLabel="Hep-B:"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="second" conceptId="99595" labelText=""/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="third" conceptId="99596"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="fourth" conceptId="99597" | |
| answerConceptIds="630,99276,99275,99277,99278,99279,99006,99016,99046,99280,99281,90002" | |
| answerLabels="AZT-3TC, AZT-FTC, TDF-3TC, TDF-FTC, d4T-3TC, d4T-FTC,AZT-3TC-EFV,D4T-3TC-EFV,AZT-3TC-LPV/r,AZT-3TC-NFV,d4T-3TC-LPV/r, Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <excludeIf velocityTest="$patient.gender =='M' "> | |
| <tr class="hideShowPriorOptions enableDisable"> | |
| <obsgroup groupingConceptId="99067"> | |
| <td id="trigger"> | |
| <obs conceptId="90012" answerConceptId="90003" | |
| answerLabel="PMTCT Only:"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="second" conceptId="99155" labelText=""/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="third" conceptId="99058"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="fourth" conceptId="99131" | |
| answerConceptIds="631,97,628,630,99005,99006,99039,99040,99041,99042,90002" | |
| answerLabels="NVP, AZT,3TC, AZT-3TC, AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP, TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </excludeIf> | |
| <tr class="hideShowPriorOptions enableDisable"> | |
| <obsgroup groupingConceptId="99068"> | |
| <td id="trigger"> | |
| <obs conceptId="99059" answerConceptId="90003" | |
| answerLabel="Earlier ARV not transfer:"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="second" conceptId="99156" labelText=""/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="third" conceptId="99129"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs id="fourth" conceptId="99129" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99007,99008,99044,99043,99282,99283,99046,99017,99018,99019,99045,99284,99285,99286,90002" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-ddI(250)-LPV/r,ABC-ddI(400)-LPV/r,TDF-3TC-LPV/r,TDF-FTC-LPV/r,ZDV-ddI(250)-LPV/r,ZDV-ddI(400)-LPV/r,ZDV-3TC-LPV/r,ABC-ddI-LPV/r,ABC-ddI-NFV,ABC-ddI-SQV/r,ZDV-ddI-LPV/r,ZDV-ABC-LPV/r,ABC-ddI-ATV/r,ZDV-3TC-ATV/r,Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>HIV Care</h3> | |
| <table border="0" id="hiv-care" style="background-color: #EEE"> | |
| <tbody> | |
| <tr> | |
| <td> | |
| <b>HIV enrolled:</b> | |
| </td> | |
| <td> | |
| <p> | |
| <b>Date</b> | |
| </p> | |
| <encounterDate id="hivEnrolledDate"/> | |
| </td> | |
| <td class="checkboxGroup"> | |
| <span class="enableDisable"> | |
| <p id="trigger"> | |
| <obs conceptId="99110" answerConceptId="90003" id="trigger" | |
| answerLabel="HIV care"/> | |
| </p> | |
| <p id="disabled"> | |
| <b>Transfer in from</b> | |
| <obs conceptId="99109" labelText=""/> | |
| </p> | |
| </span> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| <b>Eligible for ART:</b> | |
| </td> | |
| <td> | |
| <p> | |
| <b>Date</b> | |
| </p> | |
| <obs conceptId="90297"/> | |
| </td> | |
| <td> | |
| <b>Clinical Stage:</b> | |
| <p> | |
| <obs conceptId="99083" answerConceptIds="1204,1205,1206,1207" | |
| answerLabels="1, 2, 3, 4"/> | |
| </p> | |
| <p> | |
| <obs conceptId="99082" labelText="Cd4:"/> | |
| </p> | |
| <p> | |
| <obs conceptId="99600" style="checkbox" labelText="TB"/> | |
| </p> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td> | |
| <b>Eligible and Ready:</b> | |
| </td> | |
| <td> | |
| <p> | |
| <b>Date</b> | |
| </p> | |
| <obs conceptId="90299"/> | |
| </td> | |
| <td> | |
| <p> | |
| <obs conceptId="99123" style="checkbox" | |
| labelText="Presumptive HIV Diagnosis of severe HIV infection in infants"/> | |
| </p> | |
| <excludeIf velocityTest="$patient.age > 9 "> | |
| <p> | |
| <obs conceptId="99149" style="checkbox" labelText="PCR-Infant"/> | |
| </p> | |
| </excludeIf> | |
| <excludeIf velocityTest="$patient.gender =='M' "> | |
| <p> | |
| <obs conceptId="99601" style="checkbox" labelText="Breast feeding"/> | |
| </p> | |
| <p> | |
| <obs conceptId="99602" style="checkbox" labelText="Pregnancy"/> | |
| </p> | |
| </excludeIf> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <div class="row"> | |
| <div class="row-col2"> | |
| <section> | |
| <h3>Drug allergies</h3> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <td> | |
| <obsgroup groupingConceptId="90230"> | |
| <label>1</label> | |
| <obs conceptId="142" size="30"/> | |
| <br/> | |
| <label>2</label> | |
| <obs conceptId="142" size="30"/> | |
| <br/> | |
| <label>3</label> | |
| <obs conceptId="142" size="30"/> | |
| <br/> | |
| <label>4</label> | |
| <obs conceptId="142" size="30"/> | |
| <br/> | |
| <label>5</label> | |
| <obs conceptId="142" size="30"/> | |
| </obsgroup> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| </div> | |
| <div class="row-col2"> | |
| <section> | |
| <h3>Relevant medical conditions</h3> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <td> | |
| <obsgroup groupingConceptId="99104"> | |
| <label>1</label> | |
| <obs conceptId="99111" size="30"/> | |
| <br/> | |
| <label>2</label> | |
| <obs conceptId="99111" size="30"/> | |
| <br/> | |
| <label>3</label> | |
| <obs conceptId="99111" size="30"/> | |
| <br/> | |
| <label>4</label> | |
| <obs conceptId="99111" size="30"/> | |
| <br/> | |
| <label>5</label> | |
| <obs conceptId="99111" size="30"/> | |
| </obsgroup> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| </div> | |
| </div> | |
| </section> | |
| <section> | |
| <h3>ART Care</h3> | |
| <table border="0" id="art-care" | |
| style="padding: 10px; margin: 5px; border: solid 1px #D2D2D2;"> | |
| <tbody> | |
| <tr> | |
| <td colspan="4" style="background-color: #377F9C; color: white;"> | |
| Start ART - 1st Line | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">Date started:</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="99161"/> | |
| </td> | |
| <td style="color: #333;" class="ArtCareEnableDisable2">1st line Regiment: | |
| <obs conceptId="99061" | |
| answerConceptIds="99005,99006,99015,99016,99039,99040,99041,99042,99884,99885,99143" | |
| answerLabels="AZT-3TC-NVP, AZT-3TC-EFV, D4T-3TC-NVP, D4T-3TC-EFV, TDF-3TC-NVP, TDF-3TC-EFV, TDF-FTC-NVP, TDF-FTC-EFV,ABC-3TC-NVP,ABC-3TC-EFV,OTHER" | |
| labelText=""/> | |
| </td> | |
| <td class="ArtCareEnableDisableChild2"> | |
| <obs conceptId="99268"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">Weight (Wt):</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="99069"/> | |
| </td> | |
| <td style="color: #333;">CI.Stage:</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="99070" answerConceptIds="1204,1205,1206,1207" | |
| answerLabels="1,2,3,4" style="dropdown"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">CD4:</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="99071"/> | |
| </td> | |
| <td style="color: #333;">Preg:</td> | |
| <td style="color: #333;"> | |
| <excludeIf velocityTest="$patient.gender ='M' "> | |
| <obs conceptId="99072" answerConceptIds="90003,90004" | |
| answerLabels="Y, N"/> | |
| </excludeIf> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">Lactating:</td> | |
| <td style="color: #333;"> | |
| <excludeIf velocityTest="$patient.gender ='M' "> | |
| <obs conceptId="99603" answerConceptIds="90003,90004" | |
| answerLabels="Y, N"/> | |
| </excludeIf> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| <table border="0" id="art-care"> | |
| <tbody> | |
| <tr> | |
| <td colspan="4" style="background-color: #377F9C; color: white;"> | |
| ART Transfer | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">Date transfered:</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="99160"/> | |
| </td> | |
| <td style="color: #333;">Transfered from:</td> | |
| <td style="color: #333;"> | |
| <obs conceptId="90206" size="10"/> | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #333;">ARVs:</td> | |
| <td style="color: #333;" class="ArtCareEnableDisable1"> | |
| <small> | |
| <obs conceptId="99064" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99007,99008,99044,99043,99282,99283,99046,99017,99018,99019,99045,99284,99285,99286,99046,90002" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-ddI(250)-LPV/r,ABC-ddI(400)-LPV/r,TDF-3TC-LPV/r,TDF-FTC-LPV/r,ZDV-ddI(250)-LPV/r,ZDV-ddI(400)-LPV/r,ZDV-3TC-LPV/r,ABC-ddI-LPV/r,ABC-ddI-NFV,ABC-ddI-SQV/r,ZDV-ddI-LPV/r,ZDV-ABC-LPV/r,ABC-ddI-ATV/r,AZT-3TC-ATV/r,AZT-3TC-LPV/r,Other"/> | |
| </small> | |
| </td> | |
| <td style="color: #333;">Others ARVs:</td> | |
| <td style="color: #333;" class="ArtCareEnableDisableChild1"> | |
| <obs conceptId="99269" size="12" labelText="Specify:"/> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| <table border="0" id="art-care"> | |
| <tbody> | |
| <tr> | |
| <td colspan="4" style="background-color: #377F9C; color: white;"> | |
| Substitution with 1st line | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Date</b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Regimen</b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Other | |
| Regimen | |
| </b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Reason</b> | |
| </td> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99062"> | |
| <td class="ArtCareEnableDisable3"> | |
| <obs conceptId="99163"/> | |
| </td> | |
| <td class="ArtCareEnableDisable3"> | |
| <obs conceptId="90315" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99884,99885,99143" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-3TC-NVP,ABC-3TC-EFV,Other"/> | |
| </td> | |
| <td class="ArtCareEnableDisableChild3"> | |
| <obs size="10" conceptId="99146" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90246" answerConceptIds="90040,90043,90044,90045,90002" | |
| answerLabels="1.Toxi,2.NewTB,3.NewDrug,4.Drug Stock,5.Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99062"> | |
| <td class="ArtCareEnableDisable4"> | |
| <obs conceptId="99163"/> | |
| </td> | |
| <td class="ArtCareEnableDisable4"> | |
| <obs conceptId="90315" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99884,99885,99143" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-3TC-NVP,ABC-3TC-EFV,Other"/> | |
| </td> | |
| <td class="ArtCareEnableDisableChild4"> | |
| <obs size="10" conceptId="99146" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90246" answerConceptIds="90040,90043,90044,90045,90002" | |
| answerLabels="1.Toxi,2.NewTB,3.NewDrug,4.Drug Stock,5.Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99062"> | |
| <td class="ArtCareEnableDisable5"> | |
| <obs conceptId="99163"/> | |
| </td> | |
| <td class="ArtCareEnableDisable5"> | |
| <obs conceptId="90315" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99884,99885,99143" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-3TC-NVP,ABC-3TC-EFV,Other"/> | |
| </td> | |
| <td class="ArtCareEnableDisableChild4"> | |
| <obs size="10" conceptId="99146" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90246" answerConceptIds="90040,90043,90044,90045,90002" | |
| answerLabels="1.Toxi,2.NewTB,3.NewDrug,4.Drug Stock,5.Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99062"> | |
| <td class="ArtCareEnableDisable6"> | |
| <obs conceptId="99163"/> | |
| </td> | |
| <td class="ArtCareEnableDisable6"> | |
| <obs conceptId="90315" | |
| answerConceptIds="99015,99016,99005,99006,99039,99040,99041,99042,99884,99885,99143" | |
| answerLabels="d4T-3TC-NVP,d4T-3TC-EFV,AZT-3TC-NVP,AZT-3TC-EFV,TDF-3TC-NVP,TDF-3TC-EFV,TDF-FTC-NVP,TDF-FTC-EFV,ABC-3TC-NVP,ABC-3TC-EFV,Other"/> | |
| </td> | |
| <td class="ArtCareEnableDisableChild6"> | |
| <obs size="10" conceptId="99146" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90246" answerConceptIds="90040,90043,90044,90045,90002" | |
| answerLabels="1.Toxi,2.NewTB,3.NewDrug,4.Drug Stock,5.Other"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| <table border="0" id="art-care"> | |
| <tbody> | |
| <tr> | |
| <td colspan="4" style="background-color: #377F9C; color: white;"> | |
| Switch to 2nd-line (or substitute within | |
| 2nd- line) | |
| </td> | |
| </tr> | |
| <tr> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Date</b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Regimen</b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Other | |
| Regimen | |
| </b> | |
| </td> | |
| <td style="color: #404040; background-color: #F3F3F3"> | |
| <b>Reason</b> | |
| </td> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99063"> | |
| <td class="ArtCareEnableDisable7"> | |
| <obs conceptId="99164"/> | |
| </td> | |
| <td class="ArtCareEnableDisable7"> | |
| <small> | |
| <obs conceptId="90315" | |
| answerConceptIds="99007,99008,99044,99043,99282,99283,99046,99017,99018,99019,99045,99284,99285,99286,99046,99046,99887,99888,99144" | |
| answerLabels="ABC-ddI(250)-LPV/r,ABC-ddI(400)-LPV/r,TDF-3TC-LPV/r,TDF-FTC-LPV/r,ZDV-ddI(250)-LPV/r,ZDV-ddI(400)-LPV/r,ZDV-3TC-LPV/r,ABC-ddI-LPV/r,ABC-ddI-NFV,ABC-ddI-SQV/r,ZDV-ddI-LPV/r,ZDV-ABC-LPV/r,ABC-ddI-ATV/r,AZT-3TC-ATV/r,AZT-3TC-LPV/r,TDF-3TC-ATV/r,ABC-3TC-ATV/r,Other"/> | |
| </small> | |
| </td> | |
| <td class="ArtCareEnableDisableChild7"> | |
| <obs size="10" conceptId="99147" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90247" answerConceptIds="90046,90047,99889" | |
| answerLabels="6.Clinical, 7.Immuno, 8. Virological"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99063"> | |
| <td class="ArtCareEnableDisable8"> | |
| <obs conceptId="99164"/> | |
| </td> | |
| <td class="ArtCareEnableDisable8"> | |
| <small> | |
| <obs conceptId="90315" | |
| answerConceptIds="99007,99008,99044,99043,99282,99283,99046,99017,99018,99019,99045,99284,99285,99286,99046,99046,99887,99888,99144" | |
| answerLabels="ABC-ddI(250)-LPV/r,ABC-ddI(400)-LPV/r,TDF-3TC-LPV/r,TDF-FTC-LPV/r,ZDV-ddI(250)-LPV/r,ZDV-ddI(400)-LPV/r,ZDV-3TC-LPV/r,ABC-ddI-LPV/r,ABC-ddI-NFV,ABC-ddI-SQV/r,ZDV-ddI-LPV/r,ZDV-ABC-LPV/r,ABC-ddI-ATV/r,AZT-3TC-ATV/r,AZT-3TC-LPV/r,TDF-3TC-ATV/r,ABC-3TC-ATV/r,Other"/> | |
| </small> | |
| </td> | |
| <td class="ArtCareEnableDisableChild8"> | |
| <obs size="10" conceptId="99147" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90247" answerConceptIds="90046,90047,99889" | |
| answerLabels="6.Clinical, 7.Immuno, 8. Virological"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr> | |
| <obsgroup groupingConceptId="99063"> | |
| <td class="ArtCareEnableDisable9"> | |
| <obs conceptId="99164"/> | |
| </td> | |
| <td class="ArtCareEnableDisable9"> | |
| <small> | |
| <obs conceptId="90315" | |
| answerConceptIds="99007,99008,99044,99043,99282,99283,99046,99017,99018,99019,99045,99284,99285,99286,99046,99046,99887,99888,99144" | |
| answerLabels="ABC-ddI(250)-LPV/r,ABC-ddI(400)-LPV/r,TDF-3TC-LPV/r,TDF-FTC-LPV/r,ZDV-ddI(250)-LPV/r,ZDV-ddI(400)-LPV/r,ZDV-3TC-LPV/r,ABC-ddI-LPV/r,ABC-ddI-NFV,ABC-ddI-SQV/r,ZDV-ddI-LPV/r,ZDV-ABC-LPV/r,ABC-ddI-ATV/r,AZT-3TC-ATV/r,AZT-3TC-LPV/r,TDF-3TC-ATV/r,ABC-3TC-ATV/r,Other"/> | |
| </small> | |
| </td> | |
| <td class="ArtCareEnableDisableChild9"> | |
| <obs size="10" conceptId="99147" labelText="Specify"/> | |
| </td> | |
| <td> | |
| <obs conceptId="90247" answerConceptIds="90046,90047,99889" | |
| answerLabels="6.Clinical, 7.Immuno, 8. Virological"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>ART treatment interruptions -- STOP or MISSED drug pick up</h3> | |
| <table> | |
| <tbody> | |
| <tr> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable1"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels="Stopped,Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild1"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable2"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels="Stopped, Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild2"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable3"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels="Stopped, Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild3"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable4"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels=" Stopped, Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild4"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable5"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels=" Stopped, Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild5"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| <td> | |
| <obsgroup groupingConceptId="99086"> | |
| <label> | |
| <b>Stop/Lost</b> | |
| </label> | |
| <span class="ARTTreatmentInterruptionEnableDisable6"> | |
| <obs conceptId="99132" answerConceptIds="1363,99133" | |
| answerLabels="Stopped, Lost"/> | |
| </span> | |
| <span class="ARTTreatmentInterruptionEnableDisableChild6"> | |
| <br/> | |
| <br/> | |
| <b>Date</b> | |
| <br/> | |
| <obs conceptId="99084"/> | |
| <br/> | |
| <br/> | |
| <b>Reason</b> | |
| <br/> | |
| <obs conceptId="1252" labelText="" | |
| answerConceptIds="90040,90046,90158,90050,90045,90051,90052,90066,99289,90002" | |
| answerLabels="1.Toxi,2.Tx Failure,3.Adhe, 4.Ill, 5.Stock, 6.Finan, 7. Px Decn, 8.Tx intpn, 9.Ex HIV, 10.Other,"/> | |
| <br/> | |
| <br/> | |
| <b>Restart Date</b> | |
| <br/> | |
| <obs conceptId="99085"/> | |
| </span> | |
| </obsgroup> | |
| </td> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| <section> | |
| <h3>Patient Status</h3> | |
| <table border="0" id="art-care" | |
| style="padding: 10px; margin: 5px; border: solid 1px #D2D2D2;"> | |
| <tbody> | |
| <tr> | |
| <td style="color: #404040; background-color: #F3F3F3">Status</td> | |
| <td style="color: #404040; background-color: #F3F3F3">Date</td> | |
| <td style="color: #404040; background-color: #F3F3F3">Location</td> | |
| </tr> | |
| <tr class="enableDisable"> | |
| <obsgroup groupingConceptId="99166"> | |
| <td id="trigger"> | |
| <obs conceptId="90306" answerConceptId="90003" | |
| answerLabel="Transfer out:"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs conceptId="99165"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs conceptId="90211" labelText="Where"/> | |
| </td> | |
| </obsgroup> | |
| </tr> | |
| <tr class="enableDisable"> | |
| <obsgroup groupingConceptId="99167"> | |
| <td id="trigger"> | |
| <obs conceptId="5240" answerConceptId="90003" | |
| answerLabel="Lost to follow-up (drop):"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs conceptId="90209"/> | |
| </td> | |
| <td></td> | |
| </obsgroup> | |
| </tr> | |
| <tr class="enableDisable"> | |
| <obsgroup groupingConceptId="99168"> | |
| <td id="trigger"> | |
| <obs conceptId="99112" answerConceptId="90003" | |
| answerLabel="Dead:"/> | |
| </td> | |
| <td id="disabled"> | |
| <obs conceptId="90272"/> | |
| </td> | |
| <td></td> | |
| </obsgroup> | |
| </tr> | |
| </tbody> | |
| </table> | |
| </section> | |
| </div> | |
| <section> | |
| <submit/> | |
| </section> | |
| <div id="redirectUrl"> | |
| xxx | |
| </div> | |
| <!-- End of HTML Form --> | |
| </htmlform> |
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