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Dysplasia.html
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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>Dysplasia Form v 0.01</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data">
</div>
<form class="relevant-female" id="dysplasia_form" name="dysplasia_form">
<h2 class="text-center">Dysplasia Form v 0.01</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" required="required">
<option value="">...</option>
<option>...</option>
<option value="84" data-location="AMPATH-MTRH">AMPATH-MTRH</option>
<option value="19" data-location="Busia">Busia</option>
<option value="7" data-location="Chulaimbo">Chulaimbo</option>
<option value="17" data-location="Iten">Iten</option>
<option value="11" data-location="Kitale">Kitale</option>
<option value="2" data-location="Mosoriot Health Centre">Mosoriot Health Centre</option>
<option value="20" data-location="Port Victoria">Port Victoria</option>
<option value="12" data-location="Teso District Hospital">Teso District Hospital</option>
<option value="3" data-location="Turbo Health Centre">Turbo Health Centre</option>
<option value="8" data-location="Webuye">Webuye</option>
</select>
</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>Observation Details </h3>
<div class="form-group">
<label for="current_visit_type">
Visit Type:<span class="required">*</span>
</label>
<select class="form-control" id="current_visit_type" name="current_visit_type"
data-concept="1839^CURRENT VISIT TYPE^99DCT" required="required">
<option value="">...</option>
<option value="7850^INITIAL VISIT ^99DCT">New Visit</option>
<option value="2345^FOLLOW-UP^99DCT">Revisit</option>
<option value="7588^REVIEW OF PATHOLOGY RESULTS^99DCT">Review of pathology results</option>
</select>
</div>
<div class="form-group">
<label for="menstruation_status">
How are your menstrual periods?<span class="required">*</span>
</label>
<div>
<small><i>Screener to select one best option.</i></small>
</div>
<select class="form-control" id="menstruation_status" name="menstruation_status"
data-concept="2061^MENSTRUATION STATUS^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="1116^ABNORMAL^99DCT">Abnormal periods</option>
<option value="2060^AMENORRHEA^99DCT">Completely absent</option>
<option value="7023^PRE-MENOPAUSAL^99DCT">Pre-menopausal</option>
<option value="5990^MENOPAUSAL^99DCT">Menopausal</option>
<option value="6496^POST-MENOPAUSAL^99DCT">Post-menopausal</option>
<option value="6497^DYSFUNCTIONAL UTERINE BLEEDING^99DCT">Abnormal bleeding not related to periods</option>
</select>
</div>
<div class="form-group last_menstrual_period_date">
<label for="last_menstrual_period_date">
First day of your last period (LMP)<span class="required">*</span>
</label>
<input class="form-control datepicker nonFutureDate" id="last_menstrual_period_date"
name="last_menstrual_period_date" type="text" data-concept="1836^LAST MENSTRUAL PERIOD DATE^99DCT"
required="required" readonly>
</div>
<div class="form-group urine_pregnancy_test_qualitative">
<label for="urine_pregnancy_test_qualitative">
Urine pregnancy test<span class="required">*</span>
</label>
<div>
<small><i>Test that determines pregnancy status through measure of hormone content in urine.</i></small>
</div>
<select class="form-control" id="urine_pregnancy_test_qualitative" name="urine_pregnancy_test_qualitative"
data-concept="45^URINE PREGNANCY TEST, QUALITATIVE^99DCT" required="required">
<option value="">...</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="1138^INDETERMINATE^99DCT">Indeterminate</option>
<option value="1304^POOR SAMPLE QUALITY^99DCT">Poor sample quality</option>
<option value="1118^NOT DONE^99DCT">Not Done</option>
<option value="1958^REFUSAL^99DCT">Refusal</option>
</select>
</div>
<div class="form-group reason_for_lack_of_period">
<label for="reason_for_lack_of_period">
Do you know why you are not having your period?<span class="required">*</span>
</label>
<select class="form-control" id="reason_for_lack_of_period" name="reason_for_lack_of_period"
data-concept="8252^REASON FOR LACK OF PERIOD^99DCT" required="required">
<option value="">...</option>
<option value="1484^PREGNANT^99DCT">Pregnant</option>
<option value="1402^BREASTFED^99DCT">Breastfeeding</option>
<option value="6496^POST-MENOPAUSAL^99DCT">Due to age</option>
<option value="1624^DO NOT KNOW^99DCT">Do not know</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group">
<label for="gravida">
Number of previous pregnancies<span class="required">*</span>
</label>
<div>
<small><i>If client has never been pregnant, enter '0'.</i></small>
</div>
<input class="form-control gravida" id="gravida" name="gravida" type="number" data-concept="5624^GRAVIDA^99DCT"
required="required">
</div>
<div class="form-group relevant_gravida">
<label for="parity">
Number of previous deliveries<span class="required">*</span>
</label>
<div>
<small><i>The number of children a woman has delivered?</i></small>
</div>
<input class="form-control lessThanGravida" id="parity" name="parity" type="number"
data-concept="1053^PARITY^99DCT" required="required">
</div>
<div class = "section">
<div class="form-group">
<label>Current family planning method</label>
<fieldset name="374^METHOD OF FAMILY PLANNING^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.condoms" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="190^CONDOMS^99DCT">
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.female_sterilization" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="5276^FEMALE STERILIZATION^99DCT">
Sterilization / Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.intrauterine_device" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="5275^INTRAUTERINE DEVICE^99DCT">
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.diaphragm" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="5278^DIAPHRAGM^99DCT">
Diaphragm / Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.oral_contraceptive_pills" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="780^ORAL CONTRACEPTION^99DCT">
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.natural_family_planning" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="5277^NATURAL FAMILY PLANNING^99DCT">
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.injectable_contraceptives" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="5279^INJECTABLE CONTRACEPTIVES^99DCT">
Injectable hormonesa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.contraceptive_implant" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="6220^CONTRACEPTIVE IMPLANT^99DCT">
Implant / Patching
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.none" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="method_of_family_planning.do_not_know" type="checkbox"
data-concept="374^METHOD OF FAMILY PLANNING^99DCT"
value="1624^DO NOT KNOW^99DCT">
Do not know
</label>
</div>
</fieldset>
</div>
</div>
<div class="form-group">
<label for="hiv_status">HIV status</label>
<select class="form-control" id="hiv_status" name="hiv_status" type="text"
data-concept="6709^HIV STATUS^99DCT">
<option value="">...</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="1067^UNKNOWN^99DCT">Unknown</option>
</select>
</div>
</div>
<div class="section">
<h3>Most Recent Observations</h3>
<div class="form-group relevant_hiv_status">
<label for="last_cd4_by_facs">Latest CD4 count</label>
<input class="form-control" id="last_cd4_by_facs" name="last_cd4_by_facs" type="number"
data-concept="1871^LAST CD4, BY FACS^99DCT">
</div>
<div class="form-group relevant_hiv_status">
<label for="date_of_last_cd4_by_facs">Date of latest CD4 count</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_of_last_cd4_by_facs"
name="with-tmp.date_last_cd4_by_facs" type="text" data-obsdatetimefor="last_cd4_by_facs" readonly>
</div>
<div class="form-group">
<label for="history_of_dysplasia">History of Dysplasia</label>
<select class="form-control" id="history_of_dysplasia" name="history_of_dysplasia"
data-concept="7379^HISTORY OF DYSPLASIA ^99DCT">
<option value="">...</option>
<option value="1065^YES^99DCT">Yes</option>
<option value="1066^NO^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="recent_via_result">
Prior Visual Inspection with Acetic Acid (VIA)
</label>
<select class="form-control" id="recent_via_result"
name="recent_via_result"
data-concept="7381^MOST RECENT VISUAL INSPECTION WITH ACETIC ACID RESULT^99DCT">
<option value="">...</option>
<option value="703^POSITIVE^99DCT">Positive</option>
<option value="664^NEGATIVE^99DCT">Negative</option>
<option value="1624^DO NOT KNOW^99DCT">Do not know</option>
<option value="1175^NOT APPLICABLE^99DCT">Not Applicable</option>
</select>
</div>
<div class="form-group">
<label for="recent_via_result_date">
Date of most recent VIA result
</label>
<input class="form-control datepicker nonFutureDate past-date" id="recent_via_result_date"
name="with-tmp.recent_via_result_date" type="text" data-obsdatetimefor="recent_via_result" readonly>
</div>
<div class = "section">
<div class="form-group">
<h4>Prior PAP results</h4>
<fieldset name="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.normal" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.atypical_squamous_cells_of_undetermined_significance" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7417^ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE ^99DCT">
Atypical squamous cells of undetermined significance
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.atypical_glandular_cells_of_undetermined_significance" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7418^ATYPICAL GLANDULAR CELLS OF UNDETERMINED SIGNIFICANCE ^99DCT">
Atypical glandular cells of undetermined significance
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.low_grade_squamous_intraepithelial_lesion" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7419^LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION^99DCT">
Low grade squamous intraepithelial lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.high_grade_squamous_intraepithelial_lesion" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7420^HIGH GRADE SQUAMOUS INTRAEPITHELIAL LESION^99DCT">
High grade squamous intraepithelial lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.squamous_cell_carcinoma_not_otherwise_specified" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7421^SQUAMOUS CELL CARCINOMA, NOT OTHERWISE SPECIFIED ^99DCT">
Squamous cell carcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.adenocarcinoma" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="7422^ADENOCARCINOMA ^99DCT">
Adenocarcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="papanicolaou_result.do_not_know" type="checkbox"
data-concept="7423^MOST RECENT PAPANICOLAOU SMEAR RESULT^99DCT"
value="1624^DO NOT KNOW^99DCT">
Do not know
</label>
</div>
</fieldset>
</div>
<div class="form-group">
<label for="date_most_recent_papanicolaou_smear_performed">Date of most recent PAP result</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_most_recent_papanicolaou_smear_performed"
name="date_most_recent_papanicolaou_smear_performed" type="text" readonly
data-concept="6727^DATE MOST RECENT PAPANICOLAOU SMEAR PERFORMED^99DCT">
</div>
</div>
<div class = "section">
<div class="form-group">
<h4>Prior colposcopy results</h4>
<fieldset name="colposcopy_result">
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.normal" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.cervical_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="7424^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Cervical intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.cervical_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Cervical intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.cervical_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3 ^99DCT">
Cervical intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.cervical_cancer" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="6537^CERVICAL CANCER^99DCT">
Cervical cancer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.not_applicable" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="1175^NOT APPLICABLE^99DCT">
Not Applicable
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="colposcopy_result.do_not_know" type="checkbox"
data-concept="7426^MOST RECENT COLPOSCOPY RESULT^99DCT"
value="1624^DO NOT KNOW^99DCT">
Do not know
</label>
</div>
</fieldset>
</div>
<div class="form-group">
<label for="date_of_colposcopy_result">Date of most recent colposcopy result</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_of_colposcopy_result"
name="with-tmp.date_of_colposcopy_result" type="text" data-obsdatetimefor="colposcopy_result" readonly>
</div>
</div>
<div class="form-group">
<label for="most_recent_biopsy_result">Other biopsy results</label>
<input class="form-control" id="most_recent_biopsy_result" name="most_recent_biopsy_result" type="text"
data-concept="7400^MOST RECENT BIOPSY RESULT^99DCT">
</div>
<div class="form-group">
<label for="date_of_most_recent_biopsy_result">Date of most recent biopsy result</label>
<input class="form-control datepicker nonFutureDate past-date" id="date_of_most_recent_biopsy_result"
name="with-tmp.date_of_most_recent_biopsy_result" type="text" data-obsdatetimefor="most_recent_biopsy_result" readonly>
</div>
</div>
<div class="section repeat past_treatment_of_dysplasia_detailed" id="past_treatment_of_dysplasia_detailed"
data-concept="7580^PAST TREATMENT OF DYSPLASIA, DETAILED^99DCT" data-name="past_treatment_of_dysplasia_detailed">
<div class="sub-section form-group">
<h4>Past treatment of dysplasia</h4>
<div>
<small><i>A question set to ask what past treatments the patient has received for Dysplasia, the date of
that treatment, and the pathology of the treatment.</i></small>
</div>
<fieldset name="7467^PAST TREATMENT OF DYSPLASIA^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.loop_electrosurgical_excision_procedure" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="7147^LOOP ELECTROSURGICAL EXCISION PROCEDURE^99DCT">
Loop electrosurgical excision procedure
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.hysterectomy" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="5276^HYSTERECTOMY^99DCT">
Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.cryotherapy" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="7466^CRYOTHERAPY^99DCT">
Cryotherapy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.other_non_coded" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.none" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="past_treatment_of_dysplasia.not_applicable" type="checkbox"
data-concept="7467^PAST TREATMENT OF DYSPLASIA^99DCT"
value="1175^NOT APPLICABLE^99DCT">
Not Applicable
</label>
</div>
</fieldset>
</div>
<div class="form-group sub-section">
<h4>Pathological diagnosis for cervical specimen</h4>
<div>
<small><i>The histo-pathological findings regarding dysplasia as found by the most recent treatment for
the condition.</i></small>
</div>
<fieldset name="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.normal" type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.cervical_intraepithelial_neoplasia_grade_1"
type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="7424^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Mild cervical intraepithelial neoplasia (CIN 1)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.cervical_intraepithelial_neoplasia_grade_2"
type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Moderate cervical intraepithelial neoplasia (CIN 2)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.cervical_intraepithelial_neoplasia_grade_3"
type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Severe cervical intraepithelial neoplasia (CIN 3)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.adenocarcinoma" type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="8275^CERVICAL ADENOCARCINOMA^99DCT">
Cervical adenocarcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.squamous_cell_carcinoma_not_otherwise_specified"
type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="7421^SQUAMOUS CELL CARCINOMA, NOT OTHERWISE SPECIFIED ^99DCT">
Cervical squamous cell carcinoma
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="dysplasia_histopathological_findings.other_non_coded" type="checkbox"
data-concept="7579^DYSPLASIA HISTOPATHOLOGICAL FINDINGS BASED ON LAST TREATMENT^99DCT"
value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>
<div class="form-group sub-section">
<h4>Visual cervical exam findings</h4>
<fieldset name="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.normal" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.cervical_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7424^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Cervical intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.cervical_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7425^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Cervical intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.cervical_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7216^CERVICAL INTRAEPITHELIAL NEOPLASIA GRADE 3 ^99DCT">
Cervical intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.cervical_cancer" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="6537^CERVICAL CANCER^99DCT">
Cervical cancer
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.positive_via_with_aceto_white_area"
type="checkbox" data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7507^POSITIVE VISUAL INSPECTION WITH ACETIC ACID WITH ACETO WHITE AREA^99DCT">
Positive visual inspection with acetic acid with aceto white area
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.positive_via_with_suspicious_lesion"
type="checkbox" data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT"
value="7508^POSITIVE VISUAL INSPECTION WITH ACETIC ACID WITH SUSPICIOUS LESION^99DCT">
Positive visual inspection with acetic acid with suspicious lesion
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_cervical_exam_findings.other_non_coded" type="checkbox"
data-concept="7484^VISUAL CERVICAL EXAM FINDINGS^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>
<div class="form-group sub-section">
<h4>Visual vaginal exam findings</h4>
<fieldset name="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="visual_vaginal_exam_findings.normal" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vaginal_exam_findings.vaginal_intraepithelial_neoplasia_grade_1" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7492^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Vaginal intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vaginal_exam_findings.vaginal_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7491^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 2 ^99DCT">
Vaginal intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vaginal_exam_findings.vaginal_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT"
value="7435^VAGINAL INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Vaginal intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vaginal_exam_findings.other_non_coded" type="checkbox"
data-concept="7490^VISUAL VAGINAL EXAM FINDINGS ^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>
<div class="form-group sub-section">
<h4>Visual vulval exam findings</h4>
<fieldset name="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="visual_vulval_exam_findings.normal" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT" value="1115^NORMAL^99DCT">
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vulval_exam_findings.condyloma_or_vulvar_intraepithelial_neoplasia_grade_1"
type="checkbox" data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7489^CONDYLOMA OR VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 1^99DCT">
Condyloma or vulvar intraepithelial neoplasia grade 1
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vulval_exam_findings.vulvar_intraepithelial_neoplasia_grade_2" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7488^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 2^99DCT">
Vulvar intraepithelial neoplasia grade 2
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vulval_exam_findings.vulvar_intraepithelial_neoplasia_grade_3" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT"
value="7483^VULVAR INTRAEPITHELIAL NEOPLASIA GRADE 3^99DCT">
Vulvar intraepithelial neoplasia grade 3
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="visual_vulval_exam_findings.other_non_coded" type="checkbox"
data-concept="7487^VISUAL VULVAL EXAM FINDINGS ^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>
</div>
<div class="section">
<div class="form-group">
<label for="ccsp_satisfactory_colpo">Is Provider Satisfied With Quality of Colposcopy Done During Today's
Visit? <span class="required">*</span></label>
<select class="form-control" id="ccsp_satisfactory_colpo" name="ccsp_satisfactory_colpo" type="text"
data-concept="7428^Satisfactory Colposcopy^99DCT" required="required">
<option value="">...</option>
<option value="1065^Yes^99DCT">Yes</option>
<option value="1066^No^99DCT">No, entire squamocolumnar junction (SCJ)not seen</option>
<option value="1118^Colposcopy not done today^99DCT">Colposcopy not done today</option>
</select>
</div>
<div class="form-group">
<label for="ccsp_lesion">Extent of Visualized Lesion</label>
<select class="form-control" id="ccsp_lesion" name="ccsp_lesion"
data-concept="7477^SIZE OF CERVICAL LESION, CODED^99DCT">
<option value="">...</option>
<option value="7474^Less than 50% of cervix^99DCT"><50% of cervix</option>
<option value="7475^Greater than 50% of cervix^99DCT">>50% of cervix</option>
<option value="7476^Extends into canal^99DCT">Extends into canal</option>
</select>
</div>
<div class="form-group">
<label for="ccsp_findings">Findings: <span class="required">*</span></label>
<select class="form-control" id="ccsp_findings" name="ccsp_findings"
data-concept="7383^COLPOSCOPY^99DCT" required="required">
<option value="">...</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="7470^Punctuation^99DCT">Punctuation</option>
<option value="7469^Acetowhite lesion^99DCT">Acetowhite lesion</option>
<option value="7471^Mosaicism^99DCT">Mosaicism</option>
<option value="7472^Atypical Vessels^99DCT">Atypical Vessels</option>
<option value="7473^Internal borders (variegated)^99DCT">Internal borders (variegated)</option>
<option value="5622^OTHER NON-CODED^99DCT">Other non-coded</option>
<option value="1624^DO NOT KNOW^99DCT">Do not know</option>
</select>
</div>
</div>
<div class="section">
<div class="section repeat procedures_detailed" id="procedures_detailed"
data-name="procedures_detailed"
data-concept="7480^PROCEDURES DONE THIS VISIT, DETAILED^99DCT">
<h3>Procedures Done</h3>
<div class="form-group">
<label for="procedures_done_this_visit">Procedure done this visit: <span class="required">*</span></label>
<select class="form-control" id="procedures_done_this_visit"
name="procedures_done_this_visit"
data-concept="7479^PROCEDURES DONE THIS VISIT^99DCT" required="required">
<option value="">...</option>
<option value="6511^EXCISIONAL OR SURGICAL BIOPSY^99DCT">Biopsies</option>
<option value="7478^ENDOCERVICAL CURETTAGE^99DCT">Endocervical curettage (ECC)</option>
<option value="7466^CRYOTHERAPY^99DCT">Cryotherapy</option>
<option value="7147^LOOP ELECTROSURGICAL EXCISION PROCEDURE^99DCT">
Loop Electrosurgical Excision Procedure (LEEP)
</option>
<option class="procedure_done_none" value="1107^NONE^99DCT">None</option>
</select>
</div>
<div class="form-group relevant_procedures_done_this_visit_leep">
<label for="anatomic_location_description">Provide Location of specimen</label>
<select class="form-control" id="anatomic_location_description"
name="anatomic_location_description"
data-concept="8268^ANATOMIC LOCATION DESCRIPTION^99DCT">
<option value="">...</option>
<option value="8266^SUPERFICIAL^99DCT">Superficial</option>
<option value="8267^DEEP^99DCT">Deep</option>
<option value="5622^OTHER NON-CODED^99DCT">Other</option>
</select>
</div>
<div class="form-group relevant_procedures_done_this_visit_biopsies">
<label for="clock_face_cervical_biopsy_location">Provide location where biopsy for
specimen was done: __O'clock</label>
<input class="form-control" id="clock_face_cervical_biopsy_location"
name="clock_face_cervical_biopsy_location" type="number"
data-concept="7481^CLOCK FACE CERVICAL BIOPSY LOCATION ^99DCT">
</div>
<div class="form-group relevant_procedures_done_this_visit_leep">
<label for="number_of_specimen_collected">Number of speciment collected</label>
<input class="form-control" id="number_of_specimen_collected"
name="number_of_specimen_collected" type="number"
data-concept="7481^CLOCK FACE CERVICAL BIOPSY LOCATION ^99DCT">
</div>
</div>
<div class="form-group">
<label for="ccsp_plan">Management Plan: <span class="required">*</span></label>
<select class="form-control" id="ccsp_plan" name="ccsp_plan"
data-concept="7500^GYNECOLOGIC ONCOLOGY PLAN^99DCT" required="required">
<option value="">...</option>
<option value="1107^NONE^99DCT">None</option>
<option value="6102^DISCONTINUE^99DCT">Discharged from Clinic</option>
<option value="7498^ROUTINE VIA IN 6-MONTHS^99DCT">VIA 6 Months follow up</option>
<option value="7496^ROUTINE VIA IN 1-YEAR^99DCT">Routine VIA in 1-year</option>
<option value="7497^ROUTINE VIA IN 3-YEARS^99DCT">Routine VIA in 3-years</option>
<option value="7383^REFERRAL FOR COLPOSCOPY^99DCT">Referral for Colposcopy</option>
<option value="7499^REFERRAL TO GYNAE-ONCOLOGY^99DCT">Referral to Gynae-Oncology</option>
<option value="5622^OTHER NON-CODED^99DCT"></option>
</select>
</div>
<div class="form-group">
<label for="ccsp_directive_fp">Directive family planning counseling performed: </label>
<div class="form-group">
<label class="font-normal">
<input name="ccsp_directive_fp" type="radio"
data-concept="6681^FAMILY PLANNING COUNSELING PERFORMED^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="ccsp_directive_fp" type="radio"
data-concept="6681^FAMILY PLANNING COUNSELING PERFORMED^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
</div>
</div>
<div class="section">
<h4>Family planning refills dispensed</h4>
<fieldset name="7495^FAMILY PLANNING REFILL PROVIDED^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.condoms" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="190^CONDOMS^99DCT">
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.female_sterilization" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5276^FEMALE STERILIZATION^99DCT">
Sterilization / Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.intrauterine_device" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5275^INTRAUTERINE DEVICE^99DCT">
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.diaphragm" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5278^DIAPHRAGM^99DCT">
Diaphragm / Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.family_planning_via_oral_contraceptive_pills" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="780^ORAL CONTRACEPTION^99DCT">
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.natural_family_planning" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5277^NATURAL FAMILY PLANNING^99DCT">
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.injectable_contraceptives" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5279^INJECTABLE CONTRACEPTIVES^99DCT">
Injectable hormonesa
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.contraceptive_implant" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="6220^CONTRACEPTIVE IMPLANT^99DCT">
Implant / Patching
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="ccsp_refill_dispense.none" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="hasOther" id="ccsp_refill_dispense.other_non_coded" type="checkbox"
data-concept="7495^FAMILY PLANNING REFILL PROVIDED^99DCT"
value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
</fieldset>
</div>