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FirstVisitForm.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/jquery.datetimepicker.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/jquery.datetimepicker.js"></script>
<script src="js/muzima.js"></script>
<title>First Visit </title>
<style>
</style>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<form id="first_visit_form" name="first_visit_form">
<div class="section">
<div class="concept-set" data-concept="54^FIRST VISIT^99DCT">
<h3>FIRST VISIT</h3>
<h4>PLEASE DISCUSS ANY QUESTIONS OR CONCERNS ABOUT YOUR PREGNANCY DURING YOUR ANC CLINIC VISITS WITH YOUR CARE PROVIDERS</h4>
<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="obs.first_visit.visit_date">FIRST VISIT DATE: <span class="required">*</span></label>
<input class="form-control datepicker nonFutureDate" id="obs.first_visit.visit_date." name="obs.first_visit.visit_date" data-concept="42^DATE OF FIRST VISIT^99DCT" readonly="readonly" required>
</div>
<div class="form-group">
<label for="obs.first_visit.antenatal_blood_tests_done">
ANTENATAL BLOOD TESTS DONE? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.antenatal_blood_tests_done" required
name="obs.first_visit.antenatal_blood_tests_done" data-concept="24^ANTENATAL BLOOD TESTS DONE^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.pregnancy_confirmed">
PREGNANCY CONFIRMED? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.pregnancy_confirmed" required
name="obs.first_visit.pregnancy_confirmed" data-concept="25^PREGNANCY CONFIRMED^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.counselling_done">
COUNSELLING DONE? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.counselling_done" required
name="obs.first_visit.counselling_done" data-concept="26^COUNSELLING DONE^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.birth_plan_options">
BIRTH PLAN OPTIONS DISCUSSED? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.birth_plan_options" required
name="obs.first_visit.birth_plan_options" data-concept="27^BIRTHPLAN OPTIONS^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.normal_expected_body_changes">
NORMAL EXPECTED BODY CHANGES DISCUSSED? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.normal_expected_body_changes" required
name="obs.first_visit.normal_expected_body_changes" data-concept="28^NORMAL EXPECTED BODY CHANGES^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.physical_examination">
PHYSICAL EXAMINATION DONE? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.physical_examination" required
name="obs.first_visit.physical_examination" data-concept="29^PHYSICAL EXAMINATION^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
<div class="form-group">
<label for="obs.first_visit.next_visit_date_given">
NEXT VISIT DATE GIVEN? <span class="required">*</span>
</label>
<select class="form-control" id="obs.first_visit.next_visit_date_given" required
name="obs.first_visit.next_visit_date_given" data-concept="30^NEXT VISIT DATE GIVEN^99DCT">
<option value="">...</option>
<option value="1^YES^99DCT">Yes</option>
<option value="2^No^99DCT">No</option>
</select>
</div>
</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">
$(document).ready(function () {
document.setupAutoCompleteDataForProvider('encounter\\.provider_id_select');
document.setupAutoCompleteData('encounter\\.location_id');
document.setupValidationForProvider($('#encounter\\.provider_id_select').val(),$("#encounter\\.provider_id"));
document.setupValidationForLocation($('#encounter\\.location_id').val(),$("encounter\\.location_id"));
});
</script>
</html>