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<html>
<head>
<meta name="viewport" content="width=device-width, initial-scale=1">
<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>Dispensary Form</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<form id="dispensary_form" name="dispensary_form">
<h2 class="text-center">Dispensary Confirmation 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" disabled="disabled">
<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" disabled="disabled">
</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">Screening Site:<span class="required">*</span></label>
<select class="form-control" id="encounter.location_id_select">
<option>...</option>
<option value="2" data-location="Mosoriot Health Centre">Mosoriot Health Centre</option>
<option value="3" data-location="Turbo Health Centre">Turbo Health Centre</option>
<option value="12" data-location="Teso District Hospital">Teso District Hospital</option>
<option value="60" data-location="Chepsaita Dispensary">Chepsaita Dispensary</option>
<option value="65" data-location="Angurai Health Centre">Angurai Health Centre</option>
<option value="90" data-location="Changara Dispensary">Changara Dispensary</option>
<option value="91" data-location="Malaba Dispensary">Malaba Dispensary</option>
<option value="106" data-location="Kamollo Dispensary">Kamollo Dispensary</option>
<option value="110" data-location="Mogoget Dispensary">Mogoget Dispensary</option>
<option value="111" data-location="Biribiriet Dispensary">Biribiriet Dispensary</option>
<option value="112" data-location="Itigo Dispensary">Itigo Dispensary</option>
<option value="113" data-location="Lelmokwo Dispensary">Lelmokwo Dispensary</option>
<option value="114" data-location="Kokwet Dispensary">Kokwet Dispensary</option>
<option value="115" data-location="Ngechek Dispensary">Ngechek Dispensary</option>
<option value="116" data-location="Cheramei Dispensary">Cheramei Dispensary</option>
<option value="117" data-location="Murgusi Dispensary">Murgusi Dispensary</option>
<option value="118" data-location="Cheplasgei Dispensary">Cheplasgei Dispensary</option>
<option value="119" data-location="Sigot Dispensary">Sigot Dispensary</option>
<option value="120" data-location="Sugoi A Dispensary">Sugoi A Dispensary</option>
<option value="121" data-location="Sugoi B Dispensary">Sugoi B Dispensary</option>
<option value="122" data-location="Chepkemel Dispensary">Chepkemel Dispensary</option>
<option value="124" data-location="Akichelesit Dispensary">Akichelesit Dispensary</option>
<option value="125" data-location="Aboloi Dispensary">Aboloi Dispensary</option>
<option value="126" data-location="Moding Dispensary">Moding Dispensary</option>
<option value="127" data-location="Sambut">Sambut</option>
<option value="128" data-location="Ngenyilel">Ngenyilel</option>
<option value="129" data-location="Sosiani">Sosiani</option>
</select>
</div>
<div class="form-group">
<label for="encounter.provider_id_select">Provider ID:</label>
<input class="form-control valid-provider-only" id="encounter.provider_id_select" type="text" placeholder="Start typing something...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group hidden">
<select id="select_providers">
<option value ="3356-3" data-provider ="David S. Pamba">David S. Pamba</option>
<option value ="237-8" data-provider ="Ariya Patrick">Ariya Patrick</option>
<option value ="3331-6" data-provider ="Benjamin Osiya Ekirapa">Benjamin Osiya Ekirapa</option>
<option value ="3332-4" data-provider ="Molly Omodek Aluku">Molly Omodek Aluku</option>
<option value ="3333-2" data-provider ="Mercyline Lubisya Omusolo">Mercyline Lubisya Omusolo</option>
<option value ="3334-0" data-provider ="Julita Auma Ndege">Julita Auma Ndege</option>
<option value ="3335-7" data-provider ="Caroline Fedha Injete">Caroline Fedha Injete</option>
<option value ="3336-5" data-provider ="Nelly Nabwire Shiundu">Nelly Nabwire Shiundu</option>
<option value ="3337-3" data-provider ="Nicholas Dekkers Shitaha">Nicholas Dekkers Shitaha</option>
<option value ="3338-1" data-provider ="Tezra Asangire Okaal">Tezra Asangire Okaal</option>
<option value ="3340-7" data-provider ="Sophy Ikarot Idele">Sophy Ikarot Idele</option>
<option value ="3339-9" data-provider ="Maureen Jacinta Muteitsi">Maureen Jacinta Muteitsi</option>
<option value ="3341-5" data-provider ="Gibson Musera Mutira">Gibson Musera Mutira</option>
<option value ="3342-3" data-provider ="Titus Chuma Khusua">Titus Chuma Khusua</option>
<option value ="3343-1" data-provider ="Pamela Ekuriai Emukule">Pamela Ekuriai Emukule</option>
<option value ="3344-9" data-provider ="Rhoda Jeruto Kurgat">Rhoda Jeruto Kurgat</option>
<option value ="3345-6" data-provider ="Zaitun Hassan Mohamed">Zaitun Hassan Mohamed</option>
<option value ="3346-4" data-provider ="Grace Gichanga Nyathogora">Grace Gichanga Nyathogora</option>
<option value ="3347-2" data-provider ="Gabriel Silas Okapes">Gabriel Silas Okapes</option>
<option value ="3348-0" data-provider ="Henry Samson Obonyo">Henry Samson Obonyo</option>
<option value ="3349-8" data-provider ="Rebecca M. Wambura">Rebecca M. Wambura</option>
<option value ="3350-6" data-provider ="Zeruya Amwatok Barua">Zeruya Amwatok Barua</option>
<option value ="3351-4" data-provider ="Immaculate Otengo Namibia">Immaculate Otengo Namibia</option>
<option value ="3352-2" data-provider ="Pamela Were Wamoyi">Pamela Were Wamoyi</option>
<option value ="3357-1" data-provider ="Caroline Wafula Nandisi">Caroline Wafula Nandisi</option>
<option value ="3353-0" data-provider ="Markins Opuko Cresent">Markins Opuko Cresent</option>
<option value ="3354-8" data-provider ="Benedict Kifufuli Wafula">Benedict Kifufuli Wafula</option>
<option value ="3355-5" data-provider ="Clementine Ingosi Osiel">Clementine Ingosi Osiel</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 class="form-group">
<label for="obs.current_visit_type">Visit Type:<span class="required">*</span></label>
<select class="form-control" id="obs.current_visit_type" name="obs.current_visit_type"
data-concept="1839^CURRENT VISIT TYPE^99DCT" required="required">
<option value="">...</option>
<option value="7034^FIRST DISPENSARY VISIT AFTER HCT^99DCT">First Dispensary Visit After pHCT</option>
<option value="7035^SECOND DISPENSARY VISIT AFTER HCT^99DCT">Second Dispensary Visit After pHCT</option>
<option value="7036^RETURN DISPENSARY VISIT^99DCT">Return Dispensary Visit</option>
<option value="7037^REFERRED FROM CLINIC^99DCT">Referred from Clinic</option>
<option value="7875^WALK IN^99DCT">WALK IN</option>
</select>
</div>
<div class="form-group">
<label for="patient.phone">Phone:</label>
<input class="form-control phoneNumber" id="patient.phone" name="patient.phone" type="tel">
</div>
</div>
<div class="section" id="phct_review">
<h3>pHCT REVIEW</h3>
<div class="form-group">
<label for="obs.date_of_initial_phct_encounter">pHCT Encounter Date:</label>
<input class="form-control datepicker nonFutureDate" id="obs.date_of_initial_phct_encounter"
name="obs.date_of_initial_phct_encounter" type="text" readonly="readonly"
data-concept="7038^DATE OF INITIAL HCT ENCOUNTER^99DCT">
</div>
<div class="form-group">
<label for="systolic_blood_pressure_phct">Systolic Blood Pressure from pHCT Screening card:</label>
<input class="form-control systolicBloodPressure" id="systolic_blood_pressure_phct"
name="systolic_blood_pressure_phct"
type="number" data-concept="5085^SYSTOLIC BLOOD PRESSURE^99DCT">
</div>
<div class="form-group">
<label for="diastolic_blood_pressure_phct">Diastolic Blood Pressure from pHCT Screening card:</label>
<input class="form-control lessThankSystolic" id="diastolic_blood_pressure_phct"
name="diastolic_blood_pressure_phct"
type="number" data-concept="5086^DIASTOLIC BLOOD PRESSURE^99DCT">
</div>
<div class="form-group">
<label for="serum_glucose_fasting_phct">Fasting Blood Sugar (FBS) from pHCT Screening card:</label>
<input class="form-control glucose" id="serum_glucose_fasting_phct" name="serum_glucose_fasting_phct"
placeholder="Blood glucose is measured on a fasting basis (collected after an 8 to 10 hour fast)"
type="number"
data-concept="6252^SERUM GLUCOSE, FASTING^99DCT">
</div>
<div class="form-group">
<label for="serum_glucose_phct">Random Blood Sugar (RBS) from pHCT Screening card:</label>
<input class="form-control glucose" id="serum_glucose_phct" name="serum_glucose_phct"
placeholder="Laboratory measurement of the glucose level in the blood" type="number"
data-concept="887^SERUM GLUCOSE^99DCT">
</div>
</div>
<div class="section">
<h3>Your current medications</h3>
<label>Do you take any of the following medications?</label>
<div class="form-group">
<fieldset name="obs.tmp_drugs">
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Metformin" type="checkbox" name="obs.tmp_drugs" value="metformin">
Metformin
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Glibenclamide" type="checkbox" name="obs.tmp_drugs" value="glibenclamide">
Glibenclamide
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Enalapril" type="checkbox" name="obs.tmp_drugs" value="enalapril">
Enalapril
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.HCTZ" type="checkbox" name="obs.tmp_drugs" value="hctz">
HCTZ
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Losartan" type="checkbox" name="obs.tmp_drugs" value="losartan">
Losartan
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Nifedipine" type="checkbox" name="obs.tmp_drugs" value="nifedipine">
Nifedipine
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Amlodipine" type="checkbox" name="obs.tmp_drugs" value="amlodipine">
Amlodipine
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.Other" type="checkbox" name="obs.tmp_drugs" value="other">
Other Medications
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.tmp_drugs.None" type="checkbox" name="obs.tmp_drugs" value="none">
None
</label>
</div>
</fieldset>
</div>
<label class="alert alert-info" id="obs.on_enalapril">
If patient has been on <span style="text-decoration: underline;">Enalapril</span> for over a year
<ul>
<li>Check creatinine and potasium</li>
</ul>
</label>
<label class="alert alert-info" id="obs.on_losartan">
If patient has been on <span style="text-decoration: underline;">Losartan</span> for over a year
<ul>
<li>Check creatinine and potasium</li>
</ul>
</label>
</div>
<div class="section" id="medication_metformin" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^2">
<h3>Metformin</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="2261^METFORMIN^99DCT">
<div class="form-group">
<label for="metformin_number_of_milligram">
Metformin dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="metformin_number_of_milligram" required="required"
name="metformin_number_of_milligram" type="number"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_metformin.medication_frequency_per_day">
Metformin frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_metformin.medication_frequency_per_day"
name="obs.medication_metformin.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_metformin.number_of_pills_taken">
Number of scheduled [Metformin] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_metformin.number_of_pills_taken"
name="obs.medication_metformin.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group metformin_missed_medication_reason">
<label for="obs.medication_metformin.missed_medication_reason">
Specify the reason for missing some of your [Metformin] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_metformin.missed_medication_reason"
name="obs.medication_metformin.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT" required="required">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_glibenclamide" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^3">
<h3>Glibenclamide</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="2257^GLIBENCLAMIDE^99DCT">
<div class="form-group">
<label for="glibenclamide_number_of_milligram">
Glibenclamide dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="glibenclamide_number_of_milligram"
name="glibenclamide_number_of_milligram" type="number" required="required"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_glibenclamide.medication_frequency_per_day">
Glibenclamide frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_glibenclamide.medication_frequency_per_day"
name="obs.medication_glibenclamide.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_glibenclamide.number_of_pills_taken">
Number of scheduled [Glibenclamide] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_glibenclamide.number_of_pills_taken"
name="obs.medication_glibenclamide.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group glibenclamide_missed_medication_reason">
<label for="obs.medication_glibenclamide.missed_medication_reason">
Specify the reason for missing some of your [Glibenclamide] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_glibenclamide.missed_medication_reason"
name="obs.medication_glibenclamide.missed_medication_reason" required="required"
data-concept="1668^MISSED MEDICATION REASON^99DCT">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_enalapril" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^4">
<h3>Enalapril</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="1242^ENALAPRIL^99DCT">
<div class="form-group">
<label for="enalapril_number_of_milligram">
Enalapril dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="enalapril_number_of_milligram"
name="enalapril_number_of_milligram" type="number" required="required"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_enalapril.medication_frequency_per_day">
Enalapril frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_enalapril.medication_frequency_per_day"
name="obs.medication_enalapril.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_enalapril.number_of_pills_taken">
Number of scheduled [Enalapril] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_enalapril.number_of_pills_taken"
name="obs.medication_enalapril.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group enalapril_missed_medication_reason">
<label for="obs.medication_enalapril.missed_medication_reason">
Specify the reason for missing some of your [Enalapril] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_enalapril.missed_medication_reason" required="required"
name="obs.medication_enalapril.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_hctz" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^5">
<h3>HCTZ</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="1243^HYDROCHLOROTHIAZIDE^99DCT">
<div class="form-group">
<label for="hctz_number_of_milligram">
HCTZ dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="hctz_number_of_milligram"
name="hctz_number_of_milligram" type="number" required="required"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_hctz.medication_frequency_per_day">
HCTZ frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_hctz.medication_frequency_per_day"
name="obs.medication_hctz.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_hctz.number_of_pills_taken">
Number of scheduled [HCTZ] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_hctz.number_of_pills_taken"
name="obs.medication_hctz.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group hctz_missed_medication_reason">
<label for="obs.medication_hctz.missed_medication_reason">
Specify the reason for missing some of your [HCTZ] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_hctz.missed_medication_reason" required="required"
name="obs.medication_hctz.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_losartan" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^6">
<h3>Losartan</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="2265^LOSARTAN^99DCT">
<div class="form-group">
<label for="losartan_number_of_milligram">
Losartan dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="losartan_number_of_milligram"
name="losartan_number_of_milligram" type="number" required="required"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_losartan.medication_frequency_per_day">
Losartan frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_losartan.medication_frequency_per_day"
name="obs.medication_losartan.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_losartan.number_of_pills_taken">
Number of scheduled [Losartan] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_losartan.number_of_pills_taken"
name="obs.medication_losartan.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group losartan_missed_medication_reason">
<label for="obs.medication_losartan.missed_medication_reason">
Specify the reason for missing some of your [Losartan] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_losartan.missed_medication_reason" required="required"
name="obs.medication_losartan.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_nifedipine" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^8">
<h3>Nifedipine</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="250^NIFEDIPINE^99DCT">
<div class="form-group">
<label for="nifedipine_number_of_milligram">
Nifedipine dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="nifedipine_number_of_milligram"
name="nifedipine_number_of_milligram" type="number" required="required"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_nifedipine.medication_frequency_per_day">
Nifedipine frequency per day:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_nifedipine.medication_frequency_per_day"
name="obs.medication_nifedipine.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_nifedipine.number_of_pills_taken">
Number of scheduled [Nifedipine] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_nifedipine.number_of_pills_taken"
name="obs.medication_nifedipine.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group nifedipine_missed_medication_reason">
<label for="obs.medication_nifedipine.missed_medication_reason">
Specify the reason for missing some of your [Nifedipine] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_nifedipine.missed_medication_reason" required="required"
name="obs.medication_nifedipine.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section" id="medication_amlodipine" data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^2">
<h3>Amlodipine</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="2272^AMLODIPINE^99DCT">
<div class="form-group">
<label for="amlodipine_number_of_milligram">
Amlodipine dose in Milligrams (mg):<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="amlodipine_number_of_milligram" required="required"
name="amlodipine_number_of_milligram" type="number"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_amlodipine.medication_frequency_per_day">
Amlodipine frequency per day:<span class="required">*</span></label>
<select class="form-control" id="obs.medication_amlodipine.medication_frequency_per_day"
name="obs.medication_amlodipine.medication_frequency_per_day" required="required"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group">
<label for="obs.medication_metformin.number_of_pills_taken">
Number of scheduled [Amlodipine] you took:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_amlodipine.number_of_pills_taken"
name="obs.medication_amlodipine.number_of_pills_taken" required="required"
data-concept="7059^NUMBER OF PILLS TAKEN IN THE LAST WEEK, ANY MEDICATION, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="1163^ALL^99DCT">All</option>
<option value="1162^MOST^99DCT">More than half</option>
<option value="1161^HALF^99DCT">Half</option>
<option value="1160^FEW^99DCT">Less than half</option>
<option value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group amlodipine_missed_medication_reason">
<label for="obs.medication_amlodipine.missed_medication_reason">
Specify the reason for missing some of your [Amlodipine] doses:<span class="required">*</span>
</label>
<select class="form-control" id="obs.medication_amlodipine.missed_medication_reason"
name="obs.medication_amlodipine.missed_medication_reason"
data-concept="1668^MISSED MEDICATION REASON^99DCT" required="required">
<option value="">...</option>
<option value="6295^FINANCIAL BARRIER^99DCT">No money</option>
<option value="7043^FACILITY STOCKED OUT OF MEDICATION^99DCT">Facility stocked out of medication</option>
<option value="1448^MISSED APPOINTMENT^99DCT">Missed Appointment</option>
<option value="1587^HEALED BY FAITH^99DCT">Healed by faith</option>
<option value="1648^FORGOT TO TAKE MEDICINE^99DCT">Forgot to take medicine</option>
<option value="1663^MEDICATION NOT USEFUL^99DCT">Medicine not useful</option>
<option value="1664^SIDE EFFECTS FROM TAKING MEDICATIONS^99DCT">Side effects</option>
<option value="820^TRANSPORT PROBLEMS^99DCT">Lack of Transport</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
</div>
<div class="section repeat medication_other" id="medication_other"
data-concept="1919^PATIENT REPORTED CURRENT OTHER TREATMENT^99DCT^9">
<h3>Other Medication</h3>
<input class="form-control" name="medication_added" type="hidden"
data-concept="1895^MEDICATION ADDED^99DCT" value="5622^OTHER NON-CODED^99DCT">
<div class="form-group">
<label for="obs.medication_other.medication_name">Medication Name</label>
<input class="form-control" id="obs.medication_other.medication_name"
name="obs.medication_other.medication_name" type="text"
data-concept="1779^MEDICATION NAME, FREETEXT^99DCT">
</div>
<div class="form-group">
<label for="other_medication_number_of_milligram">Dose in Milligrams (mg):</label>
<input class="form-control isDecimal otherMedicationNumberOfMilligram" id="other_medication_number_of_milligram"
name="other_medication_number_of_milligram" type="number"
data-concept="1899^NUMBER OF MILLIGRAM^99DCT">
</div>
<div class="form-group">
<label for="obs.medication_other.medication_frequency_per_day">Frequency per day:</label>
<select class="form-control" id="obs.medication_other.medication_frequency_per_day"
name="obs.medication_other.medication_frequency_per_day"
data-concept="1896^MEDICATION FREQUENCY^99DCT">
<option value="">...</option>
<option value="1639^MORNING^99DCT">Every Morning</option>
<option value="1730^EVENING^99DCT">Every Evening</option>
<option value="1891^ONCE A DAY^99DCT">Once Daily</option>
<option value="1888^TWICE A DAY^99DCT">Twice Daily</option>
</select>
</div>
<div class="form-group other_medication_number_of_milliliter_group">
<label for="other_medication_number_of_milliliter">Dose in Milliliters (ml):</label>
<input class="form-control isDecimal" id="other_medication_number_of_milliliter"
name="other_medication_number_of_milliliter" type="number"
data-concept="1940^NUMBER OF MILLILITER^99DCT"
placeholder="You MUST provide dosage">
</div>
</div>
<div class="section">
<h3>Symptoms</h3>
<label>Do you have any of the following symptoms?</label>
<div class="form-group">
<fieldset data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.edema_legs" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="590^EDEMA, LEGS^99DCT">
Leg Swelling (Oedema)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.shortness_of_breath_with_exertion" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="5963^SHORTNESS OF BREATH WITH EXERTION^99DCT">
Shortness of breath with activity
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.focal_weakness" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="6005^FOCAL WEAKNESS^99DCT">
Weakness in one part of the body
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.oliguria" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="6021^OLIGURIA^99DCT">
Reduced urine output
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.heart_racing" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="7044^HEART RACING^99DCT">
Heart Racing
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.dizziness" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="877^DIZZINESS^99DCT">
Recurrent Dizziness
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.fainting" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="7045^FAINTING^99DCT">
Fainting
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.unconscious" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="2295^UNCONSCIOUS^99DCT">
Loss of consciousness
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.vision_difficulties" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="5953^VISION DIFFICULTIES^99DCT">
Vision Difficulties
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.foot_complaints" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="7046^FOOT COMPLAINTS^99DCT">
Foot Complaints
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.nausea" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="5978^NAUSEA^99DCT">
Nausea
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.vomiting" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="5980^VOMITING^99DCT">
Vomiting
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.abdominal_pain" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="151^ABDOMINAL PAIN^99DCT">
Abdominal Discomfort
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.diarrhea" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="16^DIARRHEA^99DCT">
Diarrhea
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.constipation" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="996^CONSTIPATION^99DCT">
Constipation
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.confusion" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="6006^CONFUSION^99DCT">
Confusion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.convulsions" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="206^CONVULSIONS^99DCT">
Convulsions
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.chronic_cough" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="1470^CHRONIC COUGH^99DCT">
Recurrent Cough
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.hypoglycemia" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="7047^HYPOGLYCEMIA^99DCT">
Hunger, Sweating, dizziness and shaking
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="obs.review_of_systems_general.none" type="checkbox"
data-concept="1069^REVIEW OF SYSTEMS, GENERAL^99DCT"
value="1107^NONE^99DCT">
None of the above
</label>
</div>
</fieldset>
<label class="alert alert-info" id="stdColumnC">
<b>Patient likely with complication in cardiovascular or neurological system</b>
<ul>
<li>Call <span style="text-decoration: underline;">0718980323</span> <br> for input from consultant</li>
</ul>
</label>
<label class="alert alert-info" id="obs.symptomReminders_enalapril_and_cough">
<b>Rule out TB</b>
<ul>
<li>Change enalapril to losartan</li>
<li>Rule out TB</li>
</ul>
</label>
</div>
</div>
<div class="section">
<h3>Others</h3>
<div class="form-group menstrualPeriod">
<label for="obs.last_menstrual_period_qualitative">
How long ago was the first day of your menstrual period?
</label>
<select class="form-control" id="obs.last_menstrual_period_qualitative"
name="obs.last_menstrual_period_qualitative"
data-concept="7048^LAST MENSTRUAL PERIOD, QUALITATIVE^99DCT">
<option value="">...</option>
<option value="7049^LESS THAN 35 DAYS^99DCT">Less than 35 days ago</option>
<option value="7050^MORE THAN 35 DAYS^99DCT">Over 35 days ago</option>
<option value="1624^DO NOT KNOW^99DCT">Don't know</option>
</select>
</div>
<div class="form-group">
<label for="obs.systolic_blood_pressure">Systolic Blood Pressure (mmHg):<span class="required">*</span></label>
<input class="form-control systolicBloodPressure" id="obs.systolic_blood_pressure"
name="obs.systolic_blood_pressure" type="number"
placeholder="Please record today's SBP" data-concept="5085^SYSTOLIC BLOOD PRESSURE^99DCT"
required="required">
</div>
<div class="form-group">
<label for="obs.diastolic_blood_pressure">Diastolic Blood Pressure (mmHg):<span
class="required">*</span></label>
<input class="form-control diastolicBloodPressure lessThankSystolic" id="obs.diastolic_blood_pressure"
name="obs.diastolic_blood_pressure" type="number"
placeholder="Please record today's DBP" data-concept="5086^DIASTOLIC BLOOD PRESSURE^99DCT"
required="required">
</div>
<div class="form-group">
<label for="pulse">Pulse Rate (per minute):</label>
<input class="form-control" id="pulse" name="pulse" type="number" placeholder="Please record today's pulse"
data-concept="5087^PULSE^99DCT">
</div>
<div class="form-group">
<label for="temperature_c">Temperature (centigrade):</label>
<input class="form-control" id="temperature_c" name="temperature_c" type="number"
placeholder="Please record today's temperature"
data-concept="5088^TEMPERATURE (C)^99DCT">
</div>
<div class="form-group">
<label for="weight_kg">Weight (KG):</label>
<input class="form-control" id="weight_kg" name="weight_kg" type="number"
placeholder="Please record today's weight"
data-concept="5089^WEIGHT (KG)^99DCT">
</div>
<div class="form-group">