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HTSInitialForm.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>HTS INITIAL v1.0</title>
<style>
h4 {
text-align: center;
}
</style>
</head>
<body class="col-md-8 col-md-offset-2">
<div id="result"></div>
<form id="hts_form" name="hts_form">
<h2 class="text-center">HTS INITIAL FORM v1.0</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">FACES-HTS ID:</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" value="">
</div>
</div>
<div class="section">
<div class="form-group">
<label for="encounter.location_id">Facility Name:<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">Facility Name: <span class="required">*</span></label>
<select class="form-control" id="encounter.location_id_select" required="required">
<option>...</option>
</select>
</div>
<div class="form-group">
<label for="encounter.provider_id_select">Provider Name:<span class="required">*</span></label>
<input class="form-control valid-provider-only" id="encounter.provider_id_select" type="text"
placeholder="Start typing something...">
<input class="form-control" name="encounter.provider_id_select" type="hidden">
</div>
<div class="form-group hidden">
<select id="select_providers">
</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 nonFutureDate past-date datepicker" readonly="readonly"
id="encounter.encounter_datetime"
name="encounter.encounter_datetime" type="text" 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">
<h4>Population Type</h4>
<div class="form-group">
<h5><strong>Patient population type</strong></h5>
<fieldset name="7766^Population_Type^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="pt" id="general_p" type="radio"
data-concept="7766^Population_Type^99DCT"
value="7767^Gen Pop^99DCT">
General Population
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="pt" id="key_p" type="radio"
data-concept="7766^Population_Type^99DCT"
value="7771^Key Pop^99DCT">
Key Population
</label>
</div>
</fieldset>
</div>
<div id="key_p_details" style="display:none">
<div class="form-group">
<label>
<input id="drug_injection" type="checkbox"
data-concept="7771^Key Pop^99DCT"
value="7770^PWID^99DCT"/>
People who inject drugs[PWID]
</label>
</div>
<div class="form-group men_relevant">
<label>
<input id="msm" type="checkbox"
data-concept="7771^Key Pop^99DCT"
value="7768^MSM^99DCT"/>
Men who have sex with men[MSM]
</label>
</div>
<div class="form-group women_relevant">
<label>
<input id="fsw" type="checkbox"
data-concept="7771^Key Pop^99DCT"
value="7769^FSW^99DCT"/>
Female sex Worker[FSW]
</label>
</div>
</div>
</div>
<div class="section">
<h4>Disability</h4>
<div class="form-group">
<h5><strong>Patient has any disability? </strong></h5>
<fieldset name="8136^Disability?^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="disability" id="disability_yes" type="radio"
data-concept="8136^Disability?^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="disability" id="disability_no" type="radio"
data-concept="8136^Disability?^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
</fieldset>
</div>
<div id="disability_details" style="display:none">
<label>
Please indicate the type of disability<span class="required">*</span>
</label>
<div class="form-group">
<label class="font-normal">
<input id="disability_deaf" type="checkbox"
data-concept="7923^Disability^99DCT"
value="7919^Deaf/Hearing Impaired^99DCT"/>
Deaf
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="disability_blind" type="checkbox"
data-concept="7923^Disability^99DCT"
value="7920^Blind/Visually Impaired^99DCT"/>
Blind
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="disability_mc" type="checkbox"
data-concept="7923^Disability^99DCT"
value="7921^Mental^99DCT"/>
Mentally Challenged
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="disability_pc" type="checkbox"
data-concept="7923^Disability^99DCT"
value="7922^Physically Challenged^99DCT"/>
Physically Challenged
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="disability_other" type="checkbox"
data-concept="7923^Disability^99DCT"
value="7918^Other(Specify)^99DCT"/>
Other
</label>
</div>
</div>
</div>
<div class="section">
<h4>HIV Test History</h4>
<div class="form-group">
<label>
Patient ever been tested for HIV? <span class="required">*</span></label>
<fieldset name="7136^HIV test done^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="ever_tested" id="Hiv_test_yes" type="radio"
data-concept="7136^HIV test done^99DCT"
value="1065^Yes^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="ever_tested" id="hiv_test_no" type="radio"
data-concept="7136^HIV test done^99DCT"
value="1066^No^99DCT">
No
</label>
</div>
</fieldset>
</div>
<div id="duration_of_test" style="display:none">
<div class="form-group">
<label>
Duration Since Last HIV Test? <span class="required">*</span></label>
<fieldset name="7658^Duration Since Last HIV Test^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="duration_of_test" id="0_3_months" type="radio"
data-concept="7658^Duration Since Last HIV Test^99DCT"
value="7659^Duration 0-3 Months ago^99DCT">
Duration 0-3 Months ago
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="duration_of_test" id="4_12_months" type="radio"
data-concept="7658^Duration Since Last HIV Test^99DCT"
value="7660^Duration 4-12 months ago^99DCT">
Duration 4-12 months ago
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="duration_of_test" id="above_12_months" type="radio"
data-concept="7658^Duration Since Last HIV Test^99DCT"
value="7661^Duration more than 12 months ago^99DCT">
Duration more than 12 months ago
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="duration_of_test" id="unknown" type="radio"
data-concept="7658^Duration Since Last HIV Test^99DCT"
value="1729^DON'T KNOW^99DCT">
Don't know
</label>
</div>
</fieldset>
</div>
</div>
</div>
<div class="section">
<h4>Consent</h4>
<div class="form-group">
<label>
Patient has informed consent <span class="required">*</span></label>
<fieldset name="8168^INFORMED CONSENT^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="patient_consent" name="client_consent" id="consent_yes" type="radio"
data-concept="8168^INFORMED CONSENT^99DCT"
value="1^Yes^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="patient_consent" name="client_consent" id="consent_no" type="radio"
data-concept="8168^INFORMED CONSENT^99DCT"
value="0^No^99DCT">
No
</label>
</div>
</fieldset>
</div>
</div>
<div class="client_consent_informed">
<div class="section">
<h4>Couple testing</h4>
<div class="form-group">
<label>
Client tested as? <span class="required">*</span></label>
<fieldset name="8138^Client tested as?^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="individual_mode" name="couple_testing" id="couple" type="radio"
data-concept="8138^Client tested as?^99DCT"
value="1756^COUPLE OR FAMILY SESSION^99DCT">
Couple
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="individual_mode" name="couple_testing" id="individual" type="radio"
data-concept="8138^Client tested as?^99DCT"
value="8137^Individual^99DCT">
Individual
</label>
</div>
</fieldset>
</div>
</div>
<div class="section">
<h4>HTS Strategy</h4>
<fieldset name="8145^HTS STRATEGY^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_pitc" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8139^Provider Initiated Testing^99DCT">
HP/Provider Initiated Testing(PITC)
</label>
</div>
<div id="select_depart" class="form-group" style="display:none">
<label class="font-normal"><strong>Select Department:</strong><span class="required">*</span></label><br/>
<input name="facility_depart" id="facility_depart_opd" type="radio"
data-concept="8174^Facility Department^99DCT"
value="1357^OUT PATIENT DEPARTMENT^99DCT">
OPD<br/>
<input name="facility_depart" id="facility_depart_ipd" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8170^In Patient Department^99DCT">
IPD<br/>
<input name="facility_depart" id="facility_depart_vct" type="radio"
data-concept="8174^Facility Department^99DCT"
value="1354^VOLUNTARY COUNSELLING AND TESTING CENTER^99DCT">
VCT<br/>
<input name="facility_depart" id="facility_depart_mch" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8172^MCH Department^99DCT">
MCH<br/>
<input name="facility_depart" id="facility_depart_tb" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8175^TB-Department^99DCT">
TB<br/>
<input name="facility_depart" id="facility_depart_pns" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8173^PNS-Department^99DCT">
PNS<br/>
<input name="facility_depart" id="facility_depart_ft" type="radio"
data-concept="8174^Facility Department^99DCT"
value="7656^Family Hiv Testing and Counseling^99DCT">
FAMILY TESTING<br/>
<input name="facility_depart" id="facility_depart_vmmc" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8171^VMMC Department^99DCT">
VMMC<br/>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_np" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="7629^HTS for Non-Patient^99DCT">
HTS for Non-Patient[NP]
</label>
</div>
<div id="select_depart1" class="form-group" style="display:none">
<label class="font-normal"><strong>Select Department:</strong><span class="required">*</span></label><br/>
<input name="facility_depart" id="facility_depart_opd" type="radio"
data-concept="8174^Facility Department^99DCT"
value="1357^OUT PATIENT DEPARTMENT^99DCT">
OPD<br/>
<input name="facility_depart" id="facility_depart_ipd" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8170^In Patient Department^99DCT">
IPD<br/>
<input name="facility_depart" id="facility_depart_vct" type="radio"
data-concept="8174^Facility Department^99DCT"
value="1354^VOLUNTARY COUNSELLING AND TESTING CENTER^99DCT">
VCT<br/>
<input name="facility_depart" id="facility_depart_mch" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8172^MCH Department^99DCT">
MCH<br/>
<input name="facility_depart" id="facility_depart_tb" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8175^TB-Department^99DCT">
TB<br/>
<input name="facility_depart" id="facility_depart_pns" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8173^PNS-Department^99DCT">
PNS<br/>
<input name="facility_depart" id="facility_depart_ft" type="radio"
data-concept="8174^Facility Department^99DCT"
value="7656^Family Hiv Testing and Counseling^99DCT">
FAMILY TESTING<br/>
<input name="facility_depart" id="facility_depart_vmmc" type="radio"
data-concept="8174^Facility Department^99DCT"
value="8171^VMMC Department^99DCT">
VMMC<br/>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_npi" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8140^Non Provider Initiated Testing^99DCT">
Non Provider Initiated Testing
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_ivct" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8141^Integrated VCT Center^99DCT">
Integrated VCT Center
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_svct" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8142^Stand Alone VCT Center^99DCT">
Stand Alone VCT Center
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_hbt" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8143^Home Based Testing^99DCT">
Home Based Testing
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="strategy" id="strategy_mor" type="radio"
data-concept="8145^HTS STRATEGY^99DCT"
value="8144^Mobile Outreach HTS^99DCT">
Mobile Outreach HTS
</label>
</div>
</fieldset>
</div>
<!--<div class="section">
<h4>Type of Test</h4>
<fieldset name="6708^TYPES OF HIV TESTS DONE^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="initial_test" id="initial" type="radio"
data-concept="6708^TYPES OF HIV TESTS DONE^99DCT"
value="6698^TYPE OF HIV TEST 1^99DCT">
Initial
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="initial_test" id="confirmation" type="radio"
data-concept="6708^TYPE OF TEST^99DCT"
value="6700^TYPE OF HIV TEST 2^99DCT">
Confirmation
</label>
</div>
</fieldset>
</div>-->
<div class="section" ><!-- data-concept="8151^TEST LABORATORY NUMBER CONSTRUCT^99DCT" -->
<h4>HIV Test 1[Screening Test]</h4>
<fieldset name="1040^HIV RAPID TEST 1^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_one" id="hiv_1_p" type="radio"
data-concept="1040^HIV RAPID TEST 1^99DCT"
value="703^POSITIVE^99DCT">
Positive
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_one" id="hiv_1_n" type="radio"
data-concept="1040^HIV RAPID TEST 1^99DCT"
value="664^NEGATIVE^99DCT">
Negative
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_one" id="hiv_1_i" type="radio"
data-concept="1040^HIV RAPID TEST 1^99DCT"
value="1304^POOR SAMPLE QUALITY^99DCT">
Invalid
</label>
</div>
<div>
<div class="form-group">
<label>Kit Name<span class="required">*</span></label>
<select class="form-control" id="hiv_1_kit" name="hiv_1_kit" required="required"
data-concept="8148^HIV TEST KIT USED^99DCT" >
<option value="">...</option>
<option value="8146^DETERMINE TEST KIT^99DCT">Determine</option>
<option value="8147^FIRST RESPONSE TEST KIT^99DCT">FR</option>
</select>
</div>
<div class="form-group">
<label>Lot Number<span class="required">*</span></label>
<input class="form-control" id="lot_nu" name="lot_nu" type="text"
data-concept="8153^Lot Number2^99DCT" required="required">
</div>
</div>
<div class="form-group">
<label>Expiry Date <span class="required">*</span></label>
<input class="form-control datepicker future-date" readonly="readonly" id="expiry_date_1"
data-concept="8150^EXPIRATION DATE^99DCT" name="expiry_date_1" type="text" required="required">
<label class="date_alert" style="color: red;display:none">Please note that the test kit used has
expired</label>
</div>
</fieldset>
</div>
<div id="hiv_confirmatory_test" style="display:none">
<div class="section" ><!-- data-concept="8151^TEST LABORATORY NUMBER CONSTRUCT^99DCT^2"-->
<h4>HIV Test 2[Confirmatory Test]</h4>
<fieldset name="1326^HIV RAPID TEST 2^99DCT">
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_two" id="hiv_1_p" type="radio"
data-concept="1326^HIV RAPID TEST 2^99DCT"
value="703^POSITIVE^99DCT">
Positive
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_two" id="hiv_1_n" type="radio"
data-concept="1326^HIV RAPID TEST 2^99DCT"
value="664^NEGATIVE^99DCT">
Negative
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_two" id="hiv_1_i" type="radio"
data-concept="1326^HIV RAPID TEST 2^99DCT"
value="1304^POOR SAMPLE QUALITY^99DCT">
Invalid
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="final_auto_check" name="hiv_test_two" id="hiv_2_na" type="radio"
data-concept="1326^HIV RAPID TEST 2^99DCT"
value="1175^NOT APPLICABLE^99DCT"/>
Not Applicable
</label>
</div>
<div>
<div class="form-group">
<label>Kit Name<span class="required">*</span></label>
<select class="form-control" id="hiv_2_kit" name="hiv_2_kit"
data-concept="8148^HIV TEST KIT USED^99DCT" required="required">
<option value="">...</option>
<option value="8146^DETERMINE TEST KIT^99DCT">Determine</option>
<option value="8147^FIRST RESPONSE TEST KIT^99DCT">FR</option>
</select>
</div>
<div class="form-group">
<label>Lot Number<span class="required">*</span></label>
<input class="form-control" id="hiv_2_lot" name="hiv_2_kit" type="text"
data-concept="8153^Lot Number2^99DCT" required="required">
</div>
</div>
<div class="form-group">
<label>Expiry Date <span class="required">*</span></label>
<input class="form-control datepicker kit-expiry-date" readonly="readonly" id="expiry_date_2"
data-concept="8150^EXPIRATION DATE^99DCT" name="expiry_date_1" type="text" required="required">
<label class="date_alert" style="color: red;display:none">Please note that the test kit used hasexpired</label>
</div>
</fieldset>
</div>
</div>
<div class="section">
<h4>Final Results</h4>
<div>
<div class="form-group">
<label>Final Results: <span class="required">*</span></label>
<fieldset name="8155^FINAL HIV RESULT^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="final_result" id="hiv_final_p" type="radio"
data-concept="8155^FINAL HIV RESULT^99DCT"
value="703^POSITIVE^99DCT">
Positive
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="final_result" id="hiv_final_n" type="radio"
data-concept="8155^FINAL HIV RESULT^99DCT"
value="664^NEGATIVE^99DCT">
Negative
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="final_result" id="hiv_final_i" type="radio"
data-concept="8155^FINAL HIV RESULT^99DCT"
value="7864^Inconclusive^99DCT">
Inconclusive
</label>
</div>
</fieldset>
</div>
<div class="form-group">
<label>Results given to Client?<span class="required">*</span></label>
<fieldset name="7936^FINAL RESULTS GIVEN^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="final_result_given" id="hiv_final_given_y" type="radio"
data-concept="7936^FINAL RESULTS GIVEN^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="final_result_given" id="hiv_final_given_n" type="radio"
data-concept="7936^FINAL RESULTS GIVEN^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
</fieldset>
</div>
</div>
</div>
<div class="section">
<h4>Discordance</h4>
<div class="form-group">
<h5><strong>Couple is discordant:</strong></h5>
<fieldset name="6096^DISCORDANT COUPLE^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="discordant" id="discordant_a" type="radio"
data-concept="6096^DISCORDANT COUPLE^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="discordant" id="discordant_b" type="radio"
data-concept="6096^DISCORDANT COUPLE^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="discordant" id="discordant_c" type="radio"
data-concept="6096^DISCORDANT COUPLE^99DCT"
value="1175^NOT APPLICABLE^99DCT">
N/A
</label>
</div>
</fieldset>
</div>
</div>
<div class="section">
<h4>TB Screening</h4>
<div class="form-group">
<label>Tb Screening results:<span class="required">*</span></label>
<fieldset name="7791^TB SCREENING^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="tb_screening" id="tb_screening_no_signs" type="radio"
data-concept="7791^TB SCREENING^99DCT"
value="7788^No TB^99DCT">
No TB Signs
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="tb_screening" id="tb_screening_presumed" type="radio"
data-concept="7791^TB SCREENING^99DCT"
value="7787^Pr TB^99DCT">
Presumed TB
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="tb_screening" id="tb_screening_confirmed" type="radio"
data-concept="7791^TB SCREENING^99DCT"
value="7789^INH^99DCT">
TB Confirmed
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="tb_screening" id="tb_screening_not_done" type="radio"
data-concept="7791^TB SCREENING^99DCT"
value="1118^NOT DONE^99DCT">
Not Done
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="tb_screening" id="tb_screening_on_treatment" type="radio"
data-concept="7791^TB SCREENING^99DCT"
value="7790^TB Rx^99DCT">
On TB Treatment
</label>
</div>
</fieldset>
</div>
</div>
<!--<div class="section">
<h4>HIV Self Test</h4>
<div class="form-group">
<h5><strong>Has the client done HIV self test in the last 12 months? </strong></h5>
<fieldset name="7937^Ever Self-Tested?^99DCT">
<div class="form-group">
<label class="font-normal">
<input name="self_test" id="self_test_yes" type="radio"
data-concept="7937^Ever Self-Tested?^99DCT"
value="1065^YES^99DCT">
Yes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input name="self_test" id="self_test_no" type="radio"
data-concept="7937^Ever Self-Tested?^99DCT"
value="1066^NO^99DCT">
No
</label>
</div>
</fieldset>
</div>
</div>-->
</div>
<div class="section form-group">
<label>Remarks</label>
<textarea class="form-control" name="freetext_general_2" id="freetext_general_2" rows="5"
data-concept="7734^General Remarks^99DCT"
placeholder="Provider notes/comments."></textarea>
</div>
</form>
</body>
<script type="text/javascript">
$(document).ready(function () {
var dateFormat = "dd-mm-yy";
var currentDate = $.datepicker.formatDate(dateFormat, new Date());
var encounterDatetime = $('#encounter\\.encounter_datetime');
if ($(encounterDatetime).val() == "") {
$(encounterDatetime).val(currentDate);
}
var currentYear = new Date().getFullYear();
var birthdate_start_year = currentYear - 140;
$('.birth_date_picker').datepicker({
dateFormat: dateFormat,
changeMonth: true,
changeYear: true,
yearRange: birthdate_start_year + ':' + currentYear,
});
$('#save_draft').click(function () {
// pre process the medications
$(this).prop('disabled', true);
document.saveDraft(this);
$(this).prop('disabled', false);
});
$('#submit_form').click(function () {
// pre process the medications
$(this).prop('disabled', true);
document.submit();
$(this).prop('disabled', false);
});
$.fn.calculateFields = function () {
var tempAgeInYears = $.trim($("#tmp\\.age_in_years").val());
if (tempAgeInYears != '') {
$('#patient\\.birthdate_estimated').val('true');
$('#patient\\.birth_date').val($.fn.getTempBirthDate(tempAgeInYears));
}
return true;
};
$.fn.customValidationCheck = function () {
return $.fn.calculateFields();
};
var dobType = $('#tmp\\.birthdate_type');
dobType.change(function () {
var $show_birth_date = $('.show_birthdate');
var $show_age = $('.show_age');
if ($('#tmp\\.birthdate_type').val() == 'age') {
$show_age.show();
$show_birth_date.find('input').val('');
$show_birth_date.hide();
} else {
$show_age.hide();
$show_age.find('input').val('');
$show_birth_date.show();
}
});
dobType.trigger('change');
jQuery.validator.addClassRules({
'check-confirm-identifier': {
validateConfirmIdentifierElement: true
}
});
var $negativeSelect = $('.negativeSelect');
$negativeSelect.change(function () {
var $negativeSectionToShow = $(this).closest('.section').find('.negativeSectionToShow');
var $positiveSectionToShow = $(this).closest('.section').find('.positiveSectionToShow');
var divToShowVal = $(this).val();
if (divToShowVal == '664^NEGATIVE^99DCT') {
$negativeSectionToShow.show();
$positiveSectionToShow.hide();
} else if (divToShowVal == '703^POSITIVE^99DCT') {
$positiveSectionToShow.show();
$negativeSectionToShow.hide();
} else {
$negativeSectionToShow.hide();
$positiveSectionToShow.hide();
}
});
$negativeSelect.trigger('change');
var $inCareSelect = $('.inCareSelect');
$inCareSelect.change(function () {
var $inCareSelectSectionToShow = $(this).closest('.section').find('.inCareSelectSectionToShow');
var divToShowVal = $(this).val();
if (divToShowVal == '1065^Yes^99DCT') {
$inCareSelectSectionToShow.show();
} else {
$inCareSelectSectionToShow.hide();
}
});
$inCareSelect.trigger('change');
var $testResults = $('.testResults');
$testResults.change(function () {
var $testResultSectionToShow = $(this).closest('.section').find('.testResultSectionToShow');
var divToShowVal = $(this).val();
if (divToShowVal == '...') {
$testResultSectionToShow.hide();
} else {
$testResultSectionToShow.show();
}
});
$testResults.trigger('change');
var $yesClass = $('.yesClass');
$yesClass.change(function () {
var $yeClassToShow = $(this).closest('.section').find('.yesClassToShow');
var divToShowVal = $(this).val();
if (divToShowVal == '1065^YES^99DCT') {
$yeClassToShow.show();
} else {
$yeClassToShow.hide();
}
});
$yesClass.trigger('change');
document.setupAutoCompleteData('encounter\\.location_id');
document.setupAutoCompleteDataForProvider('encounter\\.provider_id_select');
$('#registration_form').validate({
rules: {
'tmp.age_in_years': {
range: [0, 120]
}
}
});
$("input[name='pt']:radio")
.change(function () {
$("#key_p_details").toggle($(this).val() == "7771^Key Pop^99DCT");
});
$("input[name='disability']:radio")
.change(function () {
$("#disability_details").toggle($(this).val() == "1065^YES^99DCT");
});
$("input[name='linked']:radio")
.change(function () {
$("#ccc_no_div").toggle($(this).val() == "1065^YES^99DCT");
});
var $patientSex = $('#patient\\.sex');
var $menOnly = $('.men_relevant');
var $womenOnly = $('.women_relevant');
if ($patientSex.val() != 'F') {
$menOnly.show();
$womenOnly.hide();
} else {
$menOnly.hide();
$womenOnly.show();
}
$('.kit-expiry-date').change(function () {
var dateFormat = "dd-mm-yy";
var currentDate = $.datepicker.formatDate(dateFormat, new Date());
var $date = $(this).val();
if ($date < currentDate) {
$(this).closest('.section').find('.date_alert').show();
} else {
$(this).closest('.section').find('.date_alert').hide();
}
});
$('.final_auto_check').change(function () {
if ($("input:radio[name=hiv_test_one]").is(":checked")) {
var $test_one = $('input[name=hiv_test_one]:checked').val();
var $test_two = $('input[name=hiv_test_two]:checked').val();
if ($test_one === "664^NEGATIVE^99DCT") {
$("#hiv_final_n").prop("checked", true);
$('.other_tests').hide();
} else {
$('.other_tests').show();
$("#hiv_final_n").prop("checked", false);