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ART Card Summary Form
<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 &amp;&amp; patient.person.dead==false &amp;&amp; patient.person.age &gt; 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( $encounter != 0 )
&lt;script type=&quot;text/javascript&quot;>
// check that the HTML form is not being edited via the edit HTML form admin page
jq(document).ready(function () {
if (window.location.href.indexOf('/module/htmlformentry/htmlForm.form?id=3') == -1) {
alert('Redirecting to new location');
var newUrl =window.location.protocol + &quot;//&quot; + window.location.host + &quot;/&quot;+ OPENMRS_CONTEXT_PATH + &quot;/htmlformentryui/htmlform/enterHtmlFormWithStandardUi.page?patientId=$encounter.patientId&amp;visitId=$encounter.visit.visitId&amp;formUuid=52653a60-8300-4c13-be4d-4b746da06fee&amp;encounterId=$encounter.encounterId&amp;returnUrl=%2F&quot; + OPENMRS_CONTEXT_PATH + &quot;%2Fcoreapps%2Fclinicianfacing%2Fpatient.page%3FpatientId%3D$encounter.patientId&quot;;
document.getElementById('redirectUrl').innerHTML = newUrl;
alert(newUrl);
// location.href = newUrl;
}
});
&lt;/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" &amp;&amp; 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 &gt; 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()) &lt;= 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 &lt;=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>
&lt;6
mths
</th>
<th>
&gt;=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>
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</td>
<td>
<obsgroup groupingConceptId="99086">
<label>
<b>Stop/Lost</b>
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<span class="ARTTreatmentInterruptionEnableDisable2">
<obs conceptId="99132" answerConceptIds="1363,99133"
answerLabels="Stopped, Lost"/>
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<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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