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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>
<style>
tr:nth-child(even) {background-color: #f2f2f2;}
td{padding-top: 10px; padding-bottom: 10px;}
th{ background-color: green; color: white; }
</style>
<title>PHR Registration Details Form</title>
</head>
<body class="col-md-8 col-md-offset-2">
<div id="pre_populate_data">
</div>
<form id="registration_form" name="registration_form">
<div class="section">
<h3>REGISTRATION DETAILS</h3>
<div class="concept-set" data-concept="51^REGISTRATION^99DCT">
<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.age">AGE <span class="required">*</span></label>
<input class="form-control" id="patient.age" name="patient.age" data-concept="46^AGE^99DCT" required>
</div>
<div class="form-group">
<label for="patient.participant_id_no">PARTICIPANT ID NO<span class="required">*</span></label>
<input class="form-control" id="patient.participant_id_no" name="patient.participant_id_no" data-concept="59^PARTICIPANT ID NO^99DCT" required>
</div>
<div class="form-group">
<label for="patient.marital_status">MARITAL STATUS: <span class="required">*</span></label>
<input class="form-control" id="patient.marital_status" name="patient.marital_status" data-concept="47^MARITAL STATUS^99DCT" required>
</div>
<div class="form-group">
<label for="patient.contact_number">CONTACT NUMBER: <span class="required">*</span></label>
<input class="form-control" id="patient.contact_number" name="patient.contact_number" data-concept="48^CONTACT^99DCT" required>
</div>
<div class="form-group">
<label for="patient.residence">RESIDENCE: <span class="required">*</span></label>
<input class="form-control" id="patient.residence" name="patient.residence" data-concept="49^RESIDENCE^99DCT" required>
</div>
<div class="form-group">
<label for="patient.next_of_kin">NEXT OF KIN NAME: <span class="required">*</span></label>
<input class="form-control" id="patient.next_of_kin" name="patient.next_of_kin" data-concept="50^NEXT OF KIN^99DCT" required>
</div>
<div class="form-group">
<label for="patient.next_of_kin_contact">NEXT OF KIN CONTACT: <span class="required">*</span></label>
<input class="form-control" id="patient.next_of_kin_contact" name="patient.next_of_kin_contact" data-concept="60^NEXT OF KIN CONTACT^99DCT" required>
</div>
<div class="form-group">
<label for="patient.primary_maternity_assistant_name">PRIMARY MATERNITY ASSISTANT NAME: <span class="required">*</span></label>
<input class="form-control" id="patient.primary_maternity_assistant_name" name="patient.primary_maternity_assistant_name" data-concept="62^PRIMARY MATERNITY ASSISTANT NAME^99DCT" required>
</div>
<div class="form-group">
<label for="patient.primary_maternity_assistant_contact">CONTACT NO OF PRIMARY ASSISTANT: <span class="required">*</span></label>
<input class="form-control" id="patient.primary_maternity_assistant_contact" name="patient.primary_maternity_assistant_contact" data-concept="61^CONTACT NO OF PRIMARY ASSISTANT^99DCT" required>
</div>
<div class="form-group">
<label for="patient.last_monthly_period">LAST MONTHLY PERIOD (LMP): <span class="required">*</span></label>
<input class="form-control datepicker past-date nonFutureDate" id="patient.last_monthly_period" name="patient.last_monthly_period" data-concept="40^DATE^99DCT" readonly="readonly" required>
</div>
<div class="form-group">
<label for="patient.allergies">
DO YOU HAVE ANY ALLERGIES? <span class="required">*</span>
</label>
<select class="form-control" id="patient.allergies" required
name="patient.allergies" data-concept="38^ALLERGY^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group specify_allergy" id="specify_allergy">
<label for="patient.specify_allergy">SPECIFY ALLERGIES: <span class="required">*</span></label>
<input class="form-control" type="text" id="patient.specify_allergy" name="patient.specify_allergy" data-concept="39^SPECIFY ALLEGIES^99DCT" required>
</div>
</div>
</div>
<div class="section">
<h3>HEALTH HISTORY</h3>
<h4>HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS </h4>
<div class="form-group">
<table border="1" width="100%">
<thead>
<tr>
<th width="60%">Condition</th>
<th width="20%" class="text-center">Yes</th>
<th width="20%" class="text-center">No</th>
</tr>
</thead>
<tbody>
<tr>
<td width="60%">PAST HISTORY OF ASTHMA<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="3^ASTHMA^99DCT" name="obs.personal_history.asthma" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.asthma" required> </td>
</tr>
<tr>
<td width="60%">RESPIRATORY DISEASE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="4^RESPIRATORY DISEASE^99DCT" name="obs.personal_history.respiratory_diseases" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.respiratory_diseases" required> </td>
</tr>
<tr>
<td width="60%">HIGH BLOOD PRESSURE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="5^HIGH BLOOD PRESSURE^99DCT" name="obs.personal_history.high_blood_pressure" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.high_blood_pressure" required> </td>
</tr>
<tr>
<td width="60%">HEART DISEASE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="6^HEART DISEASE^99DCT" name="obs.personal_history.heart_disease" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.heart_disease" required> </td>
</tr>
<tr>
<td width="60%">KIDNEY DISEASE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="7^KIDNEY DISEASE^99DCT" name="obs.personal_history.kidney_disease" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.kidney_disease" required> </td>
</tr>
<tr>
<td width="60%">SEXUALLY TRANSMITTED INFECTION<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="8^SEXUALLY TRANSMITTED INFECTION^99DCT" name="obs.personal_history.sexually_transmitted_infection" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.sexually_transmitted_infection" required> </td>
</tr>
<tr>
<td width="60%">DIABETES<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="9^DIABETES^99DCT" name="obs.personal_history.diabetes" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.diabetes" required> </td>
</tr>
<tr>
<td width="60%">EPILEPSY<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="10^EPILEPSY^99DCT" name="obs.personal_history.epilepsy" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.epilepsy" required> </td>
</tr>
<tr>
<td width="60%">GENETIC DISORDER<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="11^GENETIC DISORDER^99DCT" name="obs.personal_history.genetic_disorder" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.genetic_disorder" required> </td>
</tr>
<tr>
<td width="60%">CEASERIAN SECTION<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="13^CEASERIAN SECTION ^99DCT" name="obs.personal_history.ceaserian_section" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.ceaserian_section" required> </td>
</tr>
<tr>
<td width="60%">DO YOU SMOKE CIGARRETTE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="14^SMOKER^99DCT" name="obs.personal_history.cigarette_smoking" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.cigarette_smoking" required> </td>
</tr>
<tr>
<td width="60%">DO YOU DRINK ALCOHOL<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="52^HEALTH HISTORY^99DCT" value="15^ALCOHOLIC^99DCT" name="obs.personal_history.alcohol_consumption" required></td>
<td width="20%" align="center"><input type="radio" name="obs.personal_history.alcohol_consumption" required> </td>
</tr>
<tbody>
</table>
</div>
</div>
<div class="section">
<h3>FAMILY HEALTH HISTORY</h3>
<h4>DOES ANY OF THE FOLLOWING CONDITIONS OCCUR IN YOUR FAMILY OR THE BABY’S FATHER FAMILY</h4>
<div class="concept-set">
<table border="1" width="100%">
<thead>
<tr>
<th width="60%">Condition</th>
<th width="20%" class="text-center">Yes</th>
<th width="20%" class="text-center">No</th>
</tr>
</thead>
<tbody>
<tr>
<td width="60%">MULTIPLE PREGNANCIES<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="16^MULTIPLE PREGNANCIES^99DCT" name="obs.family_history.multiple_pregnancies" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.multiple_pregnancies" required> </td>
</tr>
<tr>
<td width="60%">GENETIC DISORDERS<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="17^GENETIC DISORDERS^99DCT" name="obs.family_history.genetic_disorders" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.genetic_disorders" required> </td>
</tr>
<tr>
<td width="60%">CONGENITAL ANOMALIES<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="18^CONGENITAL ANOMALIES^99DCT" name="obs.family_history.congenital_anomalies" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.congenital_anomalies" required> </td>
</tr>
<tr>
<td width="60%">HEART DISEASE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="19^HEART DISEASES^99DCT" name="obs.family_history.heart_disease" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.heart_disease" required> </td>
</tr>
<tr>
<td width="60%">DEPRESSION<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="20^DEPRESSION^99DCT" name="obs.family_history.depression" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.depression" required> </td>
</tr>
<tr>
<td width="60%">BIPOLAR DISORDER<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="21^BIPOLAR DISORDER^99DCT" name="obs.family_history.bipolar_disorder" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.bipolar_disorder" required> </td>
</tr>
<tr>
<td width="60%">HIGH BLOOD PRESSURE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="5^HIGH BLOOD PRESSURE^99DCT" name="obs.family_history.high_blood_pressure" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.high_blood_pressure" required> </td>
</tr>
<tr>
<td width="60%">SICKLE CELL DISEASE<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="23^SICKLE CELL DISEASE^99DCT" name="obs.family_history.sickle_cell_disease" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.sickle_cell_disease" required> </td>
</tr>
<tr>
<td width="60%">EPILEPSY<span class="required">*</span></td>
<td width="20%" align="center"><input type="radio" data-concept="53^FAMILY HISTORY^99DCT" value="10^EPILEPSY^99DCT" name="obs.family_history.epilepsy" required></td>
<td width="20%" align="center"><input type="radio" name="obs.family_history.epilepsy" required> </td>
</tr>
<tbody>
</table>
</div>
</div>
<div class="section">
<h3>Encounter Details</h3>
<div class="form-group">
<label for="encounter.location_id">Encounter Location:<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">
<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 something...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group show_provider_id_text">
<label for="encounter.provider_id">Provider system-id:<span class="required">*</span></label>
<input class="form-control checkDigit" id="encounter.provider_id" disabled name="encounter.provider_id"
type="text" required="required" placeholder="Provider Id">
</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">
<input class="form-control" id="encounter.user_system_id" name="encounter.user_system_id" type="hidden">
</div>
</div>
</form>
</body>
<script type="text/javascript">
$(document).ready(function () {
$('#patient\\.allergies').change(function(){
if($(this).val() == "1^YES^99DCT"){
$('#specify_allergy').show();
} else {
$('#specify_allergy').hide();
}
});
$('#patient\\.allergies').trigger('change');
document.setupAutoCompleteDataForProvider('encounter\\.provider_id_select');
document.setupAutoCompleteData('encounter\\.location_id');
document.setupValidationForProvider($('#encounter\\.provider_id_select').val(),$("#encounter\\.provider_id"));
document.setupValidationForLocation($('#encounter\\.location_id').val(),$("encounter\\.location_id"));
});
</script>
</html>