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<html xmlns="http://www.w3.org/1999/html" xmlns="http://www.w3.org/1999/html" xmlns="http://www.w3.org/1999/html">
<head>
<link href="css/bootstrap.min.css" rel="stylesheet">
<link href="css/muzima.css" rel="stylesheet">
<link href="css/ui-darkness/jquery-ui-1.10.4.custom.min.css" rel="stylesheet">
<script src="js/jquery.min.js"></script>
<script src="js/jquery-ui-1.10.4.custom.min.js"></script>
<script src="js/jquery.validate.min.js"></script>
<script src="js/additional-methods.min.js"></script>
<script src="js/muzima.js"></script>
<title>Costing Form</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data">
</div>
<form id="costing_form" name="costing_form">
<h2 class="text-center">Costing Form</h2>
<div class="section">
<h3>Demographics</h3>
<div class="form-group">
<input class="form-control" id="patient.uuid"
name="patient.uuid" type="hidden" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.medical_record_number">AMRS ID Number:</label>
<input class="form-control" id="patient.medical_record_number"
name="patient.medical_record_number" type="text"
readonly="readonly">
</div>
<div class="form-group">
<label for="patient.family_name">Family Name:</label>
<input class="form-control" id="patient.family_name"
name="patient.family_name" type="text" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.given_name">Given Name:</label>
<input class="form-control" id="patient.given_name"
name="patient.given_name" type="text" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.middle_name">Middle Name:</label>
<input class="form-control" id="patient.middle_name"
name="patient.middle_name" type="text" readonly="readonly">
</div>
<div class="form-group">
<label for="patient.sex">Gender:</label>
<select class="form-control" id="patient.sex" name="patient.sex" readonly="readonly">
<option value="">...</option>
<option value="M">Male</option>
<option value="F">Female</option>
</select>
</div>
<div class="form-group">
<label for="patient.birth_date">Date Of Birth:</label>
<input class="form-control" id="patient.birth_date"
name="patient.birth_date" type="text" readonly="readonly">
</div>
</div>
<div class="section">
<h3>Encounter Details</h3>
<div class="form-group">
<label for="encounter.location_id">Name of Dispensary:<span class="required">*</span></label>
<input class="form-control valid-location-only" id="encounter.location_id" type="text" placeholder="Start typing something..." required="required">
<input class="form-control" name="encounter.location_id" type="hidden">
</div>
<div class="form-group hidden">
<label for="encounter.location_id_select">Encounter Location <span class="required">*</span></label>
<select class="form-control" id="encounter.location_id_select" required="required">
<option>...</option>
<option value="2" data-location="Mosoriot">Mosoriot</option>
<option value="3" data-location="Turbo">Turbo</option>
</select>
</div>
<div class="form-group">
<label for="encounter.provider_id_select">Provider Name <span class="required">*</span></label>
<input class="form-control valid-provider-only" id="encounter.provider_id_select" type="text"
placeholder="Start typing provider name here ...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group hidden">
<select id="select_providers">
<option value="6-7" data-provider = "Josephine Kisato">Josephine Kisato</option>
<option value="9-1" data-provider = "Catherine Chiliswa">Catherine Chiliswa</option>
<option value="4-2" data-provider = "Derek Levembe">Derek Levembe</option>
<option value="15-8" data-provider = "Jackson Rotich">Jackson Rotich</option>
<option value="4-2" data-provider = "Penina Kiptoo">Penina Kiptoo</option>
<option value="8-3" data-provider = "Kennedy Kirwa">Kennedy Kirwa</option>
<option value="7-5" data-provider = "Abraham Saat Kimaru">Abraham Saat Kimaru</option>
<option value="5-9" data-provider = "Keviner Chavera Asigi">Keviner Chavera Asigi</option>
</select>
</div>
<div class="form-group show_provider_id_text">
<label for="encounter.provider_id">Provider's system-id:<span class="required">*</span></label>
<input class="form-control checkDigit" id="encounter.provider_id" name="encounter.provider_id" type="text"
required="required" disabled="disabled">
</div>
<div class="form-group">
<label for="encounter.encounter_datetime">Encounter Date:<span class="required">*</span>
</label>
<input class="form-control datepicker nonFutureDate past-date" id="encounter.encounter_datetime"
name="encounter.encounter_datetime" type="text" readonly="readonly"
required="required">
</div>
<div class="form-group">
<input class="form-control" id="encounter.form_uuid"
name="encounter.form_uuid" type="hidden" required="required">
</div>
</div>
<div class="section">
<h3>SECTION A - DEMOGRAPHICS</h3>
<div class="form-group">
<label for="obs.participant_id">Enter Participant ID:<span class="required">*</span></label>
<input class="form-control" id="obs.participant_id" name="participant_id"
type="number" placeholder="Participant ID" data-concept="9084^PARTICIPANT ID^99DCT" required="required">
</div>
<div class="form-group">
<label for="obs.division_select">
Select Division <span class="required">*</span>
</label>
<select class="form-control" id="obs.division_select" name="obs.division_select"
data-concept="9177^DIVISION^99DCT" required="required">
<option value="">...</option>
<option value="2">Mosoriot</option>
<option value="3">Turbo</option>
</select>
</div>
<div class="form-group show_community_unit_mosoriot_select">
<label for="obs.community_unit_mosoriot_select">Mosoriot units:<span class="required">*</span></label>
<select class="form-control" id="obs.community_unit_mosoriot_select" name="obs.community_unit_mosoriot_select"
data-concept="9085^COMMUNITY UNIT^99DCT">
<option value="">...</option>
<option value="P">Biribiriet</option>
<option value="Q">Chepterit</option>
<option value="R">Itigo</option>
<option value="S">Kokwet</option>
<option value="X">Kosirai</option>
<option value="U">Lelmokwo/Sigot</option>
<option value="V">Mosoriot</option>
<option value="T">Mutwot</option>
<option value="W">Ngechek</option>
</select>
</div>
<div class="form-group show_community_unit_turbo_select">
<label for="obs.community_unit_turbo_select">Turbo units:<span class="required">*</span></label>
<select class="form-control" id="obs.community_unit_turbo_select" name="obs.community_unit_turbo_select"
data-concept="9085^COMMUNITY UNIT^99DCT">
<option value="">...</option>
<option value="A">Chepkemel</option>
<option value="B">Cheplaskei</option>
<option value="C">Chepsaita</option>
<option value="D">Cheramei</option>
<option value="E">Leseru</option>
<option value="F">Murgor hills</option>
<option value="G">Murgusi</option>
<option value="H">Ngenyilel</option>
<option value="I">Osorongai</option>
<option value="J">Sambut</option>
<option value="K">Sokyot</option>
<option value="L">Sosiani</option>
<option value="M">Sugoi</option>
<option value="N">Tuigoin</option>
<option value="O">Turbo/ Kaptebee</option>
</select>
</div>
<div class="form-group show_village">
<label for="obs.village">village:<span class="required">*</span></label>
<input class="form-control" id="obs.village" name="obs.village"
type="text" placeholder="Village" data-concept="9088^VILLAGE^99DCT" required="required">
</div>
<div class="form-group">
<label for="obs.size_of_house_hold"> What is the size of your house hold?<span class="required">*</span></label>
<input class="form-control" id="obs.size_of_house_hold" name="obs.size_of_house_hold"
type="number" placeholder="Size of house hold" data-concept="9087^HOUSEHOLD SIZE^99DCT" required="required">
</div>
<div class="form-group">
<label for="obs.enrollment_strategy">Select Enrollment Strategy:<span class="required">*</span></label>
<select class="form-control" id="obs.enrollment_strategy" name="obs.enrollment_strategy"
data-concept="9176^ENROLLMENT STRATEGY^99DCT" required="required">
<option value="">...</option>
<option value="1">Baraza</option>
<option value="2">Newly identified PHCT</option>
<option value="3">Previously identified PHCT-not linked</option>
<option value="4">Previously identified PHCT-not retained</option>
<option value="5">Health Facility</option>
<option value="6">Identified by CHW</option>
</select>
</div>
<div class="form-group">
<label for="obs.told_having_blood_pressure_in_12_months">
During the past 12 months have you been told by a doctor or other health worker that you have raised blood pressure or hypertension? <span class="required">*</span>
</label>
<select class="form-control" id="obs.told_having_blood_pressure_in_12_months" name="obs.told_having_blood_pressure_in_12_months"
data-concept="9181^TOLD HAVING BLOOD PRESSURE IN 12 MONTHS^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
</div>
<div class="section">
<h3>SECTION B - INPATIENT ADMISSIONS</h3>
<div class="form-group">
<label for="obs.admitted_select">
Have you at any time during the past 12 months been admitted in a hospital for at least one night? <span class="required">*</span>
</label>
<select class="form-control" id="obs.admitted_select" name="obs.admitted_select"
data-concept="6419^ADMITTED TO HOSPITAL^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="admission_in_past_12_months">
<div class="form-group">
<p>How many times were you admitted overnight to a hospital in the past 12 months?<span class="required">*</span> </p>
<input class="form-control" id="no_admission_in_past_12_months" name="obs.no_admission_in_past_12_months"
type="number" placeholder="Number of Admissions" data-concept="5704^NUMBER OF HOSPITALIZATIONS IN PAST YEAR^99DCT" required="required">
</div>
<div class="section cRepeat hospVisits" id="hospVisits" data-name="hospVisits"
data-concept="9194^INPATIENT ADMISSIONS, DETAILED^99DCT">
<div class="alert alert-info" id="countVisits">Inpatient Admission 1</div>
<p>
<div class="form-group">
<label for="obs.admission_injury_select">
Was the admission the result of an accident or injury? <span class="required">*</span>
</label>
<select class="form-control" id="obs.admission_injury_select" name="obs.admission_injury_select"
data-concept="9089^ADMISSION DUE TO INJURY^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group admission_disease_select">
<label for="obs.admission_disease_select">
Was the admission the result of any specific disease e.g malaria, typhoid, hypertension etc? <span class="required">*</span>
</label>
<select class="form-control obs.admission_disease_select" name="obs.admission_disease_select"
data-concept="9090^ADMISSION DUE TO DISEASE^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="admission_disease_input">
<div class="form-group">
<label>
What was/were the reason(s)/disease(s). <span class="required">*</span>
</label>
<div class="sub-section concept-set" data-concept="9192^REASON FOR ADMISSION, DETAILED^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_hypertension" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="903^HYPERTENSION^99DCT">
Hypertension
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_diabetes" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="175^DIABETES MELLITUS^99DCT">
Diabetes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_malaria" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="123^MALARIA^99DCT">
Malaria
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_typhoid" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="141^TYPHOID FEVER^99DCT">
Typhoid
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_others" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="5622^OTHER NON-CODED^99DCT">
Others
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_dk" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="1624^DO NOT KNOW^99DCT">
Don't Know
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="admission_disease disease_selection disease_selection_rf" type="checkbox"
data-concept="9191^REASON FOR ADMISSION^99DCT" value="1958^REFUSAL^99DCT">
Refused/No Answer
</label>
</div>
<div class="repeat sub-section other_disease_selection" id="other_disease_selection" data-name="diseases">
<div class="form-group">
<label>
Specify other reason/disease: <span class="required">*</span>
</label>
<input class="form-control obs.other_admission_disease"
name="obs.other_admission_disease" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT"
required="required">
</div>
</div>
</div>
</div>
</div>
<div class="form-group">
<label>Did you pay for this admission using any of the following sources: Please select all that apply</label>
<div class="sub-section">
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" id="obs.source_of_payment_nhif" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="1">
NHIF
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.source_of_payment_private" class="sources_of_payment" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="2">
Private Medical Insurance
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" id="obs.source_of_payment_pocket" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT"
value="3">
Out of pocket
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" id="obs.source_of_payment_loan" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="4">
Loan from Chama
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" id="obs.source_of_payment_waiver" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="5">
Waiver
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" id="obs.source_of_payment_donations" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="6">
Donations
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="7">
Others
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment obs.source_of_payment_dk" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="-77">
Don't Know
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="sources_of_payment obs.source_of_payment_rf" type="checkbox"
data-concept="9092^SOURCE OF PAYMENT^99DCT" value="-99">
Refused
</label>
</div>
</div>
</div>
<div class="form-group cRepeatWithUniqueElementAttrs">
<label for="obs.medical_bill">How much was the total bill for the admission?<span class="required">*</span></label>
<div class="sub-section form-group">
<input class="form-control obs.medical_bill" type="number" data-concept="9093^MEDICAL BILL^99DCT" required="required">
<input class="form-control hiddenInput medical_bill_DK_RF" type="text">
<fieldset name="obs.medical_bill_DR">
<input class="obs.medical_bill_DK" id="obs.medical_bill_DK" type="radio" value="-77"
data-concept="9093^MEDICAL BILL^99DCT">
<label for="obs.medical_bill_DK">Don't Know</label>
<input class="obs.medical_bill_RF" id="obs.medical_bill_RF" type="radio" value="-99"
data-concept="9093^MEDICAL BILL^99DCT">
<label for="obs.medical_bill_RF">Refused</label><br>
</fieldset>
</div>
</div>
<div class="form-group">
<label for="obs.medical_bill_self_paid">How much did you pay using your own money including money
from loans that you will need to pay back?<span class="required">*</span></label>
<div class="sub-section form-group cRepeatWithUniqueElementAttrs">
<input class="form-control obs.medical_bill_self_paid" type="number"
data-concept="9094^MEDICAL BILL PAID BY OWN MONEY^99DCT" required="required">
<input class="form-control hiddenInput medical_bill_self_paid_DK_RF" type="text">
<fieldset name="obs.medical_bill_self_paid_DR">
<input class="obs.medical_bill_self_paid_DK" id="obs.medical_bill_self_paid_DK"
type="radio" value="-77"
data-concept="9094^MEDICAL BILL PAID BY OWN MONEY^99DCT">
<label for="obs.medical_bill_self_paid_DK">Don't Know</label>
<input class="obs.medical_bill_self_paid_RF" id="obs.medical_bill_self_paid_RF"
type="radio" value="-99"
data-concept="9094^MEDICAL BILL PAID BY OWN MONEY^99DCT">
<label for="obs.medical_bill_self_paid_RF">Refused</label><br>
</fieldset>
</div>
</div>
</div>
<div class="alert alert-info">During your last hospital admission</div>
<div class="form-group means_to_hosp">
<label for="obs.means_to_hosp">
What means of transport did you use to get to the hospital? <span class="required">*</span>
</label>
<div class="sub-section">
<div class="form-group">
<label class="font-normal">
<input id="obs.means_to_hosp_walking" class="means_to_hosp" type="checkbox"
data-concept="9095^MEANS OF TRANSPORT TO HOSPITAL^99DCT" value="6415^WALKING^99DCT">
On foot
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.means_to_hosp_bodaboda" class="means_to_hosp" type="checkbox"
data-concept="9095^MEANS OF TRANSPORT TO HOSPITAL^99DCT" value="6580^BODA-BODA^99DCT">
Boda Boda
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.means_to_hosp_matatu" class="means_to_hosp" type="checkbox"
data-concept="9095^MEANS OF TRANSPORT TO HOSPITAL^99DCT" value="6416^MATATU^99DCT">
Matatu
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.means_to_hosp_refusal" class="means_to_hosp" type="checkbox"
data-concept="9095^MEANS OF TRANSPORT TO HOSPITAL^99DCT" value="1958^REFUSAL^99DCT">
Refused
</label>
</div>
</div>
</div>
<label for="obs.time_to_hospital_hours">
How much time did it take to reach the hospital?
</label>
<div class="sub-section">
<div class="form-group">
<p></p>
<label class="font-normal">Hours</label>
<select class="form-control" name="obs.time_to_hospital_hours" id="obs.time_to_hospital_hours">
<option value="">...</option>
<option value="0">0</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
</div>
<div class="form-group">
<label for="obs.time_to_hospital_mins"> </label>
<label class="font-normal">Minutes</label>
<select class="form-control" name="obs.time_to_hospital_mins" id="obs.time_to_hospital_mins">
<option value="">...</option>
<option value="0">0</option>
<option value="5">5</option>
<option value="10">10</option>
<option value="15">15</option>
<option value="20">20</option>
<option value="25">25</option>
<option value="30">30</option>
<option value="35">35</option>
<option value="40">40</option>
<option value="45">45</option>
<option value="50">50</option>
<option value="55">55</option>
</select>
</div>
<div class="form-group">
<label for="obs.transport_cost_to_hospital">Time to Hospital in minutes: <span class="required">*</span></label>
<input class="form-control" name="obs.time_to_hosp" id="obs.time_to_hosp" type="text"
data-concept="9133^NUMBER OF MINUTES TO REACH HOSPITAL^99DCT" disabled>
<input class="form-control hiddenInput" id="time_to_hosp_DK_RF" type="text" disabled>
</div>
<div class="form-group" id="time_to_hospitalDR" data-name="time_to_hospitalDR">
<fieldset name="obs.time_to_hospitalDR">
<input id="time_to_hospital_DK" type="radio" data-concept="9133^NUMBER OF MINUTES TO REACH HOSPITAL^99DCT"
name="time_to_hospitalDR" value="-77">
<label for="time_to_hospital_DK">Don't Know</label>
<input id="time_to_hospital_RF" type="radio" data-concept="9133^NUMBER OF MINUTES TO REACH HOSPITAL^99DCT"
name="time_to_hospitalDR" value="-99">
<label for="time_to_hospital_RF">Refused</label><br>
</fieldset>
</div>
</div>
<div class="form-group">
<label for="obs.transport_cost_to_hospital">How much was the transport cost?</label>
<div class="sub-section form-group">
<input class="form-control" id="obs.transport_cost_to_hospital" name="obs.transport_cost_to_hospital"
type="number" data-concept="9220^INPATIENT TRANSPORTION COST^99DCT">
<input class="form-control hiddenInput" id="transport_cost_to_hospital_DK_RF" type="text">
<fieldset name="obs.transport_cost_to_hospital_DR">
<input id="obs.transport_cost_to_hospital_DK" type="radio" name="obs.transport_cost_to_hospital_DR" value="-77"
data-concept="9220^INPATIENT TRANSPORTION COST^99DCT">
<label for="obs.transport_cost_to_hospital_DK">Don't Know</label>
<input id="obs.transport_cost_to_hospital_RF" type="radio" name="obs.transport_cost_to_hospital_DR" value="-99"
data-concept="9220^INPATIENT TRANSPORTION COST^99DCT">
<label for="obs.transport_cost_to_hospital_RF">Refused</label><br>
</fieldset>
</div>
</div>
</div>
</div>
<div class="section">
<h3>SECTION C - NON-INPATIENT SERVICES</h3>
<div class="form-group">
<label for="obs.inpatient_admission">
Have you at any time during the past 3 months received medical care at a Health Centre or Dispensary
or a hospital where you did not spend at least one night? <span class="required">*</span>
</label>
<select class="form-control" id="obs.inpatient_admission" name="obs.inpatient_admission"
data-concept="9096^RECEIVED MEDICATION NOT ADMITTED^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="medical_not_admitted_quiz">
<label>In the past three months, how many times did you visit each of the following places:</label>
<div class="form-group sub-section">
<input id="obs.medical_not_admitted_visits.Health_center" name="obs.medical_not_admitted_visits.Health_center" type="checkbox"
data-concept="9097^HEALTH CARE PLACE VISITED^99DCT" value="Health center">
<label for="obs.medical_not_admitted_visits.Health_center">Health center</label><br>
<div class="sub-section" id="visit_Health_center">
Number of times you visited Health center? <span class="required">*</span>
<div class="form-group">
<input class="form-control" id="visit_Health_center_VC" name="obs.visit_Health_center_VC" type="number"
data-concept="9134^NUMBER OF TIMES VISITED HEALTH CENTER IN 3 MONTHS^99DCT" required="required">
</div>
<div class="section dRepeat HealthCenterVisits" id="HealthCenterVisits" data-name="HealthCenterVisits"
data-concept="9195^HEALTH CENTER VISIT, DETAILED^99DCT">
<div class="alert alert-info" id="displayHcVisitCount">Health center Visit 1</div>
<div class="form-group">
<label for="obs.hc_injury_visit_select">
Was the Health center visit the result of an accident or injury? <span class="required">*</span>
</label>
<select class="form-control" id="obs.hc_injury_visit_select" name="obs.hc_injury_visit_select"
data-concept="9098^HEALTH CENTER VISIT DUE TO INJURY^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group hc_visit_disease_select">
<label for="obs.health_center_visit_disease_select">
Was the Health center a result of any specific disease e.g malaria,
typhoid, hypertension etc?<span class="required">*</span>
</label>
<select class="form-control obs.health_center_visit_disease_select" name="obs.health_center_visit_disease_select"
data-concept="9116^HEALTH CENTER VISIT DUE TO DISEASE^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="hcVisit_disease_input">
<label>
What was/were the reason(s)/disease(s)? <span class="required">*</span>
</label>
<div class="sub-section concept-set" data-concept="9203^REASON FOR HEALTH CENTER VISIT, DETAILED^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_hypertension" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="903^HYPERTENSION^99DCT">
Hypertension
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_diabetes" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="175^DIABETES MELLITUS^99DCT">
Diabetes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_malaria" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="123^MALARIA^99DCT">
Malaria
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_typhoid" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="141^TYPHOID FEVER^99DCT">
Typhoid
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_others" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="5622^OTHER NON-CODED^99DCT">
Others
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_dk" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="1624^DO NOT KNOW^99DCT">
Don't Know
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_rf" type="checkbox"
data-concept="9202^REASON FOR HEALTH CENTER VISIT^99DCT" value="1958^REFUSAL^99DCT">
Refused/No Answer
</label>
</div>
<div class="repeat sub-section other_disease_selection"
id="other_disease_selection" data-name="diseases">
<div class="form-group">
<label>
Specify other reason/disease: <span class="required">*</span>
</label>
<input class="form-control obs.other_admission_disease"
name="obs.other_admission_disease" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT"
required="required">
</div>
</div>
</div>
</div>
<div class="form-group visit_drugs">
<label for="obs.visit_drugs">
During the visit were you prescribed or given any drugs to use? <span class="required">*</span>
</label>
<select class="form-control" id="obs.visit_drugs" name="obs.visit_drugs"
data-concept="9115^HEALTH CENTER VISIT ISSUED DRUGS^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group health_center_bill dRepeatWithUniqueElementAttrs">
<label for="obs.health_center_bill">How much did you pay out of pocket for the visit including
drug costs if applicable?<span class="required">*</span></label>
<input class="form-control obs.health_center_bill" type="number" id="obs.health_center_bill"
data-concept="9121^HEALTH CENTER VISIT COST^99DCT" required="required">
<input class="form-control hiddenInput health_center_bill_DK_RF" type="text">
<div class="form-group">
<fieldset name="obs.health_center_bill_DR">
<input class="obs.health_center_bill_DK" id="obs.health_center_bill_DK" type="radio"
value="-77" data-concept="9121^HEALTH CENTER VISIT COST^99DCT">
<label for="obs.health_center_bill_DK">Don't Know</label>
<input id="obs.health_center_bill_RF" class="obs.health_center_bill_RF"
type="radio" value="-99"
data-concept="9121^HEALTH CENTER VISIT COST^99DCT">
<label for="obs.health_center_bill_RF">Refused</label><br>
</fieldset>
</div>
</div>
</div>
</div>
<input id="obs.medical_not_admitted_visits.Dispensary" name="obs.medical_not_admitted_visits.Dispensary" type="checkbox"
data-concept="9097^HEALTH CARE PLACE VISITED^99DCT" value="Dispensary">
<label for="obs.medical_not_admitted_visits.Dispensary">Dispensary</label><br>
<div class="sub-section" id="visit_dispensary">
Number of times you visited dispensary? <span class="required">*</span>
<div class="form-group">
<input class="form-control" id="visit_dispensary_VC" name="obs.visit_dispensary_VC" type="number"
data-concept="9135^NUMBER OF TIMES VISITED DISPENSARY IN 3 MONTHS^99DCT" required="required">
</div>
<div class="section eRepeat dispensaryVisits" id="dispensaryVisits" data-name="dispensaryVisits"
data-concept="9196^DISPENSARY VISIT, DETAILED^99DCT">
<div class="alert alert-info" id="displayDispVisitCount">Dispensary visit 1</div>
<div class="form-group">
<label for="obs.dispensary_injury_visit_select">
Was the dispensary visit the result of an accident or injury? <span class="required">*</span>
</label>
<select class="form-control" id="obs.dispensary_injury_visit_select" name="obs.dispensary_injury_visit_select"
data-concept="9099^DISPENSARY VISIT DUE TO INJURY^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group dispensary_visit_disease_select">
<label for="obs.dispensary_visit_disease_select">
was the dispensary visit a result of any specific disease e.g malaria, typhoid, hypertension etc? <span class="required">*</span>
</label>
<select class="form-control obs.dispensary_visit_disease_select" name="obs.dispensary_visit_disease_select"
data-concept="9103^DISPENSARY VISIT DUE TO DISEASE^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="dispensaryVisit_disease_input">
<label>
What was/were the reason(s)/disease(s). <span class="required">*</span>
</label>
<div class="sub-section concept-set" data-concept="9205^REASON FOR DISPENSARY VISIT, DETAILED^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_hypertension" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="903^HYPERTENSION^99DCT">
Hypertension
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_diabetes" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="175^DIABETES MELLITUS^99DCT">
Diabetes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_malaria" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="123^MALARIA^99DCT">
Malaria
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_typhoid" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="141^TYPHOID FEVER^99DCT">
Typhoid
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_others" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="5622^OTHER NON-CODED^99DCT">
Others
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_dk" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="1624^DO NOT KNOW^99DCT">
Don't Know
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_rf" type="checkbox"
data-concept="9204^REASON FOR DISPENSARY VISIT^99DCT" value="1958^REFUSAL^99DCT">
Refused/No Answer
</label>
</div>
<div class="repeat sub-section other_disease_selection"
id="other_disease_selection" data-name="diseases">
<div class="form-group">
<label>
Specify other reason/disease: <span class="required">*</span>
</label>
<input class="form-control obs.other_dispensary_visit_disease"
name="obs.other_dispensary_visit_disease" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT"
required="required">
</div>
</div>
</div>
</div>
<div class="form-group dispensary_visit_drugs">
<label for="obs.dispensary_visit_drugs">
During the visit were you prescribed or given any drugs to use? <span class="required">*</span>
</label>
<select class="form-control" id="obs.dispensary_visit_drugs" name="obs.dispensary_visit_drugs"
data-concept="9111^DISPENSARY VISIT ISSUED DRUGS^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group dispensary_center_bill eRepeatWithUniqueElementAttrs">
<label for="obs.dispensary_center_bill">How much did you pay out of pocket for the
dispensary visit including drug costs if applicable?<span class="required">*</span></label>
<input class="form-control obs.dispensary_center_bill" type="number"
data-concept="9118^DISPENSARY VISIT COST^99DCT" required="required">
<input class="form-control hiddenInput dispensary_center_bill_DK_RF" type="text">
<div class="form-group">
<fieldset name="obs.dispensary_center_bill_DR">
<input class="obs.dispensary_center_bill_DK" id="obs.dispensary_center_bill_DK"
type="radio" value="-77"
data-concept="9118^DISPENSARY VISIT COST^99DCT">
<label for="obs.dispensary_center_bill_DK">Don't Know</label>
<input class="obs.dispensary_center_bill_RF" id="obs.dispensary_center_bill_RF"
type="radio" value="-99"
data-concept="9118^DISPENSARY VISIT COST^99DCT">
<label for="obs.dispensary_center_bill_RF">Refused</label><br>
</fieldset>
</div>
</div>
</div>
</div>
<input id="obs.medical_not_admitted_visits.Hospital_day_visit"
name="obs.medical_not_admitted_visits.Hospital_day_visit" type="checkbox"
data-concept="9097^HEALTH CARE PLACE VISITED^99DCT" value="Hospital Day Visit ">
<label for="obs.medical_not_admitted_visits.Hospital_day_visit">Hospital day visit</label><br>
<div class="sub-section" id="hospital_day_visit">
Number of times you had hospital day visits?<span class="required">*</span>
<div class="form-group">
<input class="form-control" id="hospital_day_visit_VC" name="obs.hospital_day_visit_VC" type="number"
data-concept="9136^NUMBER OF TIMES FOR HOSPITAL DAY VISITS IN 3 MONTHS^99DCT" required="required">
</div>
<div class="section iRepeat hospitalDayVisit" id="hospitalDayVisit" data-name="hospitalDayVisit"
data-concept="9197^HOSPITAL VISIT, DETAILED^99DCT">
<div class="alert alert-info" id="displayHospitalDayVisitCount">1st Hospital day visit</div>
<p>
<div class="form-group">
<label for="obs.hospital_day_visit_select">
Was the Hospital day visit the result of an accident or injury? <span class="required">*</span>
</label>
<select class="form-control" id="obs.hospital_day_visit_select" name="obs.hospital_day_visit_select"
data-concept="9100^HOSPITAL DAY VISIT DUE TO INJURY^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group day_visit_disease_select">
<label for="obs.hospital_day_visit_disease_select">
was the Hospital day visit a result of any specific disease e.g malaria, typhoid, hypertension etc? <span class="required">*</span>
</label>
<select class="form-control obs.hospital_day_visit_disease_select" name="obs.hospital_day_visit_disease_select"
data-concept="9104^HOSPITAL DAY VISIT DUE TO DISEASE^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="dayVisit_disease_input">
<label>
What was/were the reason(s)/disease(s). <span class="required">*</span>
</label>
<div class="sub-section concept-set" data-concept="9207^REASON FOR HOSPITAL DAY VISIT, DETAILED^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_hypertension" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="903^HYPERTENSION^99DCT">
Hypertension
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_diabetes" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="175^DIABETES MELLITUS^99DCT">
Diabetes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_malaria" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="123^MALARIA^99DCT">
Malaria
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_typhoid" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="141^TYPHOID FEVER^99DCT">
Typhoid
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_others" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="5622^OTHER NON-CODED^99DCT">
Others
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_dk" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="1624^DO NOT KNOW^99DCT">
Don't Know
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="disease_selection disease_selection_rf" type="checkbox"
data-concept="9206^REASON FOR HOSPITAL DAY VISIT^99DCT" value="1958^REFUSAL^99DCT">
Refused/No Answer
</label>
</div>
<div class="repeat sub-section other_disease_selection"
id="other_disease_selection" data-name="diseases">
<div class="form-group">
<label>
Specify other reason/disease: <span class="required">*</span>
</label>
<input class="form-control obs.other_hospital_day_visit_disease"
name="obs.other_hospital_day_visit_disease" type="text"
data-concept="1915^FREETEXT GENERAL^99DCT"
required="required">
</div>
</div>
</div>
</div>
<div class="form-group hospital_day_visit_drugs">
<label for="obs.hospital_day_visit_drugs">
During the visit were you prescribed or given any drugs to use? <span class="required">*</span>
</label>
<select class="form-control" id="obs.hospital_day_visit_drugs" name="obs.hospital_day_visit_drugs"
data-concept="9112^HOSPITAL DAY VISIT ISSUED DRUGS^99DCT" required="required">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
<option value="1624^DO NOT KNOW^99DCT">Don't Know</option>
<option value="1958^REFUSAL^99DCT">Refused</option>
</select>
</div>
<div class="form-group hospital_day_bill iRepeatWithUniqueElementAttrs">
<label for="obs.hospital_day_bill">How much did you pay out of pocket for the
visit including drug costs if applicable?<span class="required">*</span></label>
<input class="form-control obs.hospital_day_bill" type="number"
data-concept="9119^HOSPITAL DAY VISIT COST^99DCT" required="required">
<input class="form-control hiddenInput hospital_day_bill_DK_RF" type="text">