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LocationTesterForm.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>Breast Cancer Screening Form v 0.01</title>
</head>
<body class="col-md-10 col-md-offset-1">
<div id="pre_populate_data"></div>
<h2 class="text-center">Breast Cancer Screening Form v 0.01</h2>
<form class="relevant-female" id="breastcancer_form" name="breastcancer_form">
<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.birthdate">Date Of Birth:</label>
<input class="form-control" id="patient.birthdate" name="patient.birthdate" type="text" readonly="readonly">
</div>
</div>
<div class="section">
<h3>Encounter Details</h3>
<div class="form-group">
<label for="encounter.location_id">Screening Site:<span class="required">*</span></label>
<select class="form-control" name="encounter.location_id" id="encounter.location_id" required="required">
<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="Webuy">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">
<h4>How did you learn about this service (check all that apply)?<span class="required">*</span></h4>
<fieldset name="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.radio" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="6391^RADIO, AUDIO DEVICE^99DCT"/>
Radio
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.newspaper" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="8249^NEWSPAPER^99DCT"/>
Newspaper
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.word_of_mouth" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="8248^WORD OF MOUTH^99DCT"/>
Word of mouth
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.ampath" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="1286^AMPATH^99DCT"/>
AMPATH
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.mtrh" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="1274^MOI TEACHING AND REFERRAL HOSPITAL^99DCT"/>
Moi teaching and referral hospital
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.non_mtrh" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="6479^NON-MTRH CONSULTANT^99DCT"/>
Non-MTRH consultant
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="service_referrals.patient_refusal" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="1504^PATIENT REFUSAL^99DCT"/>
Patient referral
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="service_referrals.other" type="checkbox"
data-concept="8250^COMMUNICATION CHANNEL OF KNOWING THE PROGRAM OR SERVICE^99DCT"
value="5622^OTHER NON-CODED^99DCT"/>
Other
</label>
</div>
<div class="form-group freetext">
<label for="service_referrals.freetext_general">Specify:<span class="required">*</span></label>
<textarea class="form-control" name="service_referrals.freetext_general"
id="service_referrals.freetext_general"
data-concept="1915^FREETEXT GENERAL^99DCT"></textarea>
</div>
</fieldset>
</div>
<div class="section">
<h3>Past Medical History</h3>
<div class="form-group">
<label for="review_of_medical_history">
Prior history of breast cancer?<span class="required">*</span>
</label>
<select class="form-control" id="review_of_medical_history" name="with-tmp.review_of_medical_history"
required="required" data-concept="6245^REVIEW OF MEDICAL HISTORY^99DCT">
<option value="">...</option>
<option value="6544^BREAST CANCER^99DCT">Yes</option>
<option value="with-temp.NO">No</option>
</select>
</div>
<div class="form-group">
<label for="previous_radiation_location">
Previous history of radiation to the chest?<span class="required">*</span>
</label>
<select class="form-control" id="previous_radiation_location" name="with-temp.previous_radiation_location"
required="required" data-concept="8263^PREVIOUS RADIATION LOCATION^99DCT">
<option value="">...</option>
<option value="1349^CHEST^99DCT">Yes</option>
<option value="with-temp.NO">No</option>
</select>
</div>
<div class="form-group">
<label for="ever_smoked_cigarettes">
Do you presently, or have you in the past smoked cigarettes?<span class="required">*</span>
</label>
<select class="form-control" id="ever_smoked_cigarettes" name="ever_smoked_cigarettes"
required="required" data-concept="6473^EVER SMOKED CIGARETTES^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="have_you_ever_drunk_alcohol">
Do you presently, or have you in the past consumed alcohol?<span class="required">*</span>
</label>
<select class="form-control" id="have_you_ever_drunk_alcohol" name="have_you_ever_drunk_alcohol"
required="required" data-concept="6474^HAVE YOU EVER DRUNK ALCOHOL^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="diagnosis_based_on_biopsy">Have you ever had a breast biopsy?<span class="required">*</span></label>
<select class="form-control" id="diagnosis_based_on_biopsy" name="with-temp.diagnosis_based_on_biopsy"
required="required" data-concept="6509^DIAGNOSIS BASED ON BIOPSY TYPE^99DCT">
<option value="">...</option>
<option value="8184^BREAST BIOPSY^99DCT">Yes</option>
<option value="with-temp.NO">No</option>
</select>
</div>
<div class="form-group">
<label for="history_of_surgeries">Have you ever had breast surgery?<span class="required">*</span></label>
<select class="form-control" id="history_of_surgeries" name="with-tmp.history_of_surgeries"
required="required" data-concept="6478^HISTORY OF SURGERIES^99DCT">
<option value="">...</option>
<option value="8251^BREAST^99DCT">Yes</option>
<option value="with-temp.NO">No</option>
</select>
</div>
</div>
<div class="section">
<h3>Gynecologic History</h3>
<div class="form-group">
<label for="age_of_menarche">
Age of menarche (first period)?<span class="required">*</span>
</label>
<div>
<small><i>Menarche is the first menstrual cycle, or first menstrual bleeding, in female humans.</i></small>
</div>
<input class="form-control isDecimal" id="age_of_menarche" name="age_of_menarche" type="number"
required="required" data-concept="8185^AGE OF MENARCHE^99DCT">
</div>
<div class="form-group">
<label for="gravida">Number of previous pregnancies?<span class="required">*</span></label><br/>
<div>
<small><i>If client has never been pregnant, enter '0'.</i></small>
</div>
<input class="form-control isDecimal gravida" id="gravida" name="gravida" type="number"
required="required" data-concept="5624^GRAVIDA^99DCT">
</div>
<div class="form-group relevant_gravida">
<label for="age_of_first_pregnancy">
Age at first pregnancy?<span class="required">*</span>
</label>
<div>
<small><i>What is the age of first pregnancy?</i></small>
</div>
<input class="form-control isDecimal" id="age_of_first_pregnancy" name="age_of_first_pregnancy" type="number"
required="required" data-concept="8186^AGE OF FIRST PREGNANCY^99DCT">
</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 isDecimal lessThanGravida" id="parity" name="parity" type="number"
required="required" data-concept="1053^PARITY^99DCT">
</div>
<div class="form-group relevant_parity">
<label for="mother_breast_feeding_history">Did you breastfeed your children?</label>
<select class="form-control" id="mother_breast_feeding_history"
name="mother_breast_feeding_history"
required="required" data-concept="8187^MOTHER'S BREAST FEEDING HISTORY^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="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"
required="required" data-concept="2061^MENSTRUATION STATUS^99DCT">
<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 past-date" id="last_menstrual_period_date"
name="last_menstrual_period_date"
type="text" required="required" data-concept="1836^LAST MENSTRUAL PERIOD DATE^99DCT">
</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?</label>
<select class="form-control" id="reason_for_lack_of_period" name="reason_for_lack_of_period"
required="required" data-concept="8252^REASON FOR LACK OF PERIOD^99DCT">
<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="section">
<h4>Select all family planning methods the patient has ever used?<span class="required">*</span></h4>
<fieldset name="8253^FAMILY PLANNING METHOD EVER USED^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.condoms" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="190^CONDOMS^99DCT"/>
Condoms
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.female_sterilization" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5276^FEMALE STERILIZATION^99DCT"/>
Sterilization/Hysterectomy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.intrauterine_device" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5275^INTRAUTERINE DEVICE^99DCT"/>
Intrauterine device
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.diaphragm" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5278^DIAPHRAGM^99DCT"/>
Diaphragm/Cervical cap
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.via_oral_contraceptive_pills" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5274^FAMILY PLANNING VIA ORAL CONTRACEPTIVE PILLS^99DCT"/>
Oral contraceptive pills
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.natural_family_planning" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5277^NATURAL FAMILY PLANNING^99DCT"/>
Natural family planning
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.injectable_contraceptives" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5279^INJECTABLE CONTRACEPTIVES^99DCT"/>
Injectable hormones
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="family_planning_method_ever_used.other_non_coded" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="5622^OTHER NON-CODED^99DCT"/>
Other
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.none" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="1624^DO NOT KNOW^99DCT"/>
None
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_planning_method_ever_used.do_not_know" type="checkbox"
data-concept="8253^FAMILY PLANNING METHOD EVER USED^99DCT"
value="1107^NONE^99DCT"/>
Don't know
</label>
</div>
<div class="form-group freetext">
<label for="family_planning_method_ever_used.freetext_general">
Specify:<span class="required">*</span>
</label>
<textarea class="form-control" name="family_planning_method_ever_used.freetext_general"
id="family_planning_method_ever_used.freetext_general"
data-concept="1915^FREETEXT GENERAL^99DCT"></textarea>
</div>
</fieldset>
</div>
</div>
<div class="section">
<h3>Family Breast Cancer History</h3>
<div class="section" data-concept="6805^FAMILY CHRONIC ILLNESSNESS HISTORY, DETAILED^99DCT">
<div class="form-group">
<label for="family_chronic_illnesses_history">
Any history of breast cancer in the family?<span class="required">*</span>
</label>
<select class="form-control" id="family_chronic_illnesses_history"
name="with-temp.family_chronic_illnesses_history"
required="required" data-concept="6802^FAMILY CHRONIC ILLNESSES HISTORY^99DCT">
<option value="">...</option>
<option value="6544^BREAST CANCER^99DCT">Yes</option>
<option value="with-temp.NO">No</option>
</select>
</div>
<div class="form-group relevant_family_chronic_illnesses_history">
<label>
Relative(s) in the family with history of breast cancer?<span class="required">*</span>
</label>
<fieldset name="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="family_member_with_chronic_illnesses_history.sibling" type="checkbox"
data-concept="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT"
value="972^SIBLING^99DCT"/>
Sibling(s)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_member_with_chronic_illnesses_history.mother" type="checkbox"
data-concept="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT"
value="970^MOTHER^99DCT"/>
Mother
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_member_with_chronic_illnesses_history.maternal_aunt" type="checkbox"
data-concept="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT"
value="2037^MATERNAL AUNT^99DCT"/>
Maternal aunt(s)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_member_with_chronic_illnesses_history.paternal_aunt" type="checkbox"
data-concept="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT"
value="2038^PATERNAL AUNT^99DCT"/>
Paternal aunt(s)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="family_member_with_chronic_illnesses_history.other_non_coded" type="checkbox"
data-concept="8254^FAMILY MEMBER WITH CHRONIC ILLNESSES HISTORY^99DCT"
value="5622^OTHER NON-CODED^99DCT"/>
Other
</label>
</div>
</fieldset>
</div>
<div class="form-group relevant_family_chronic_illnesses_history">
<label for="number_of_family_members_with_chronic_illnesses_history">
Number of family members with history of breast cancer?<span class="required">*</span>
</label>
<input class="form-control isDecimal" id="number_of_family_members_with_chronic_illnesses_history"
name="number_of_family_members_with_chronic_illnesses_history"
type="number" required="required"
data-concept="8255^NUMBER OF FAMILY MEMBERS WITH CHRONIC ILLNESSES HISTORY^99DCT">
</div>
</div>
</div>
<div class="section">
<h4>Symptoms related to breast?<span class="required">*</span></h4>
<fieldset name="6492^REVIEW OF SYSTEMS - BREAST^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.negative" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="664^NEGATIVE^99DCT"/>
No complaints
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.breast_pain" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="6667^PAIN - BREAST^99DCT"/>
Breast pain
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.breast_lumps" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="6250^BREAST LUMPS^99DCT"/>
Breast mass
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.nipple_discharge" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="6493^NIPPLE DISCHARGE^99DCT"/>
Nipple discharge
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.breast_skin_changes" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="6499^BREAST SKIN CHANGES^99DCT"/>
Breast skin changes
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="review_of_systems_breast.mastitis" type="checkbox"
data-concept="6492^REVIEW OF SYSTEMS - BREAST^99DCT" value="115^MASTITIS^99DCT"/>
Breast skin inflammation / abscess
</label>
</div>
</fieldset>
<div class="form-group breast_pain_duration">
<label for="breast_pain_duration">Breast pain duration?</label>
<select class="form-control" id="breast_pain_duration" name="breast_pain_duration"
required="required" data-concept="8256^BREAST PAIN DURATION^99DCT">
<option value="">...</option>
<option value="1072^DAYS^99DCT">Days</option>
<option value="1073^WEEKS^99DCT">Weeks</option>
<option value="1074^MONTHS^99DCT">Months</option>
<option value="1079^CONTINUOUS^99DCT">Continous</option>
</select>
</div>
<div class="form-group breast_mass_duration">
<label for="breast_mass_duration">Breast mass duration?</label>
<select class="form-control" id="breast_mass_duration" name="breast_mass_duration"
required="required" data-concept="8257^BREAST MASS DURATION^99DCT">
<option value="">...</option>
<option value="1072^DAYS^99DCT">Days</option>
<option value="1073^WEEKS^99DCT">Weeks</option>
<option value="1074^MONTHS^99DCT">Months</option>
<option value="1079^CONTINUOUS^99DCT">Continous</option>
</select>
</div>
<div class="form-group nipple_discharge_duration">
<label for="nipple_discharge_duration">Nipple discharge duration?</label>
<select class="form-control" id="nipple_discharge_duration" name="nipple_discharge_duration"
required="required" data-concept="8258^NIPPLE DISCHARGE DURATION^99DCT">
<option value="">...</option>
<option value="1072^DAYS^99DCT">Days</option>
<option value="1073^WEEKS^99DCT">Weeks</option>
<option value="1074^MONTHS^99DCT">Months</option>
<option value="1079^CONTINUOUS^99DCT">Continous</option>
</select>
</div>
<div class="form-group breast_skin_changes_duration">
<label for="breast_skin_changes_duration">Breast sking changes duration?</label>
<select class="form-control" id="breast_skin_changes_duration" name="breast_skin_changes_duration"
required="required" data-concept="8260^BREAST SKIN CHANGES DURATION^99DCT">
<option value="">...</option>
<option value="1072^DAYS^99DCT">Days</option>
<option value="1073^WEEKS^99DCT">Weeks</option>
<option value="1074^MONTHS^99DCT">Months</option>
<option value="1079^CONTINUOUS^99DCT">Continous</option>
</select>
</div>
<div class="form-group breast_inflammation_duration">
<label for="breast_inflammation_duration">Breast skin inflammation / abscess duration?</label>
<select class="form-control" id="breast_inflammation_duration" name="breast_inflammation_duration"
required="required" data-concept="8259^BREAST INFLAMMATION DURATION^99DCT">
<option value="">...</option>
<option value="1072^DAYS^99DCT">Days</option>
<option value="1073^WEEKS^99DCT">Weeks</option>
<option value="1074^MONTHS^99DCT">Months</option>
<option value="1079^CONTINUOUS^99DCT">Continuous</option>
</select>
</div>
</div>
<div class="section">
<h3>Physical Examination</h3>
<div class="form-group">
<label for="systolic_blood_pressure">
Systolic blood pressure (mmHg):<span class="required">*</span>
</label>
<input class="form-control systolicBloodPressure" id="systolic_blood_pressure"
name="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="diastolic_blood_pressure">
Diastolic blood pressure (mmHg):<span class="required">*</span>
</label>
<input class="form-control diastolicBloodPressure lessThanSystolic" id="diastolic_blood_pressure"
name="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):<span class="required">*</span></label>
<input class="form-control" id="pulse" name="pulse" type="number"
placeholder="Please record today's pulse" required="required"
data-concept="5087^PULSE^99DCT">
</div>
<div class="form-group">
<label for="pulse">Respiratory rate:<span class="required">*</span></label>
<input class="form-control" id="respiratory_rate" name="respiratory_rate" type="number"
placeholder="Please record today's respiratory rate" required="required"
data-concept="5242^RESPIRATORY RATE^99DCT">
</div>
<div class="form-group">
<label for="temperature_c">Temperature (centigrade):<span class="required">*</span></label>
<input class="form-control" id="temperature_c" name="temperature_c" type="number"
placeholder="Please record today's temperature" required="required"
data-concept="5088^TEMPERATURE (C)^99DCT">
</div>
<div class="form-group">
<label for="weight_kg">Weight (kg):<span class="required">*</span></label>
<input class="form-control" id="weight_kg" name="weight_kg" type="number"
placeholder="Please record today's weight" required="required"
data-concept="5089^WEIGHT (KG)^99DCT">
</div>
<div class="form-group">
<label for="height_cm">Height (cm):<span class="required">*</span></label>
<input class="form-control" id="height_cm" name="height_cm" type="number"
placeholder="Please record today's height" required="required"
data-concept="5090^HEIGHT (CM)^99DCT">
</div>
<div class="section">
<div class="form-group">
<label for="body_surface_area">Body surface area (m^2)</label>
<input class="form-control" id="body_surface_area" name="body_surface_area" type="number"
disabled="disabled"
data-concept="980^BODY SURFACE AREA^99DCT">
</div>
</div>
</div>
<div class="section">
<h3>Breast Exam Findings</h3>
<div class="section repeat breast_exam_findings_detailed" id="breast_exam_findings_detailed"
data-counter="1" data-concept="8269^BREAST EXAM FINDINGS, DETAILED^99DCT"
data-name="breast_exam_findings_detailed">
<div class="form-group">
<label for="breast_exam_findings">
Breast exam findings?<span class="required">*</span>
</label>
<select class="form-control" id="breast_exam_findings" required="required"
name="breast_exam_findings" data-concept="6251^BREAST EXAM FINDINGS^99DCT">
<option value="">...</option>
<option value="1118^NOT DONE^99DCT">Not done</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="6250^BREAST LUMPS^99DCT">Breast mass</option>
<option value="6499^BREAST SKIN CHANGES^99DCT">Breast skin changes</option>
<option value="115^MASTITIS^99DCT">Breast skin inflammation / abscess</option>
<option value="8188^CALOR^99DCT">Abnormally warm</option>
<option value="8189^PEAU DORANGE^99DC">Peau D'Orange</option>
</select>
</div>
<div class="form-group relevant_breast_exam_findings">
<label for="laterality">
Which breast has finding?:<span class="required">*</span>
</label>
<select class="form-control" id="laterality" required="required"
name="laterality" data-concept="8264^LATERALITY^99DCT">
<option value="">...</option>
<option value="5141^RIGHT^99DCT">Right</option>
<option value="5139^LEFT^99DCT">Left</option>
</select>
</div>
<div class="form-group relevant_breast_exam_findings">
<label for="anatomic_location_description">
Specific location?<span class="required">*</span>
</label>
<select class="form-control" id="anatomic_location_description" required="required"
name="anatomic_location_description" data-concept="8268^ANATOMIC LOCATION DESCRIPTION^99DCT">
<option value="">...</option>
<option value="6589^UPPER INNER QUADRANT^99DCT">Upper inner quadrant</option>
<option value="6591^UPPER OUTER QUADRANT^99DCT">Upper outer quadrant</option>
<option value="6590^LOWER INNER QUADRANT^99DCT">Lower inner quadrant</option>
<option value="6592^LOWER OUTER QUADRANT^99DCT">Lower outer quadrant</option>
</select>
</div>
</div>
</div>
<div class="section">
<h4>Lymph node exam findings?<span class="required">*</span></h4>
<fieldset name="1121^LYMPH NODE EXAM FINDINGS^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.submandibular" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="504^SUBMANDIBULAR^99DCT"/>
Submandibular
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.supraclavicular" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="505^SUPRACLAVICULAR^99DCT"/>
Supraclavicular
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.cervical" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="643^CERVICAL^99DCT"/>
Cervical
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.axillary" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="5112^AXILLARY^99DCT"/>
Axillary
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.lymphadenopathy" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="161^LYMPHADENOPATHY^99DCT"/>
Generalized lympadenopathy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.normal" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="1115^NORMAL^99DCT"/>
Normal
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="lymph_node_exam_findings.not_done" type="checkbox"
data-concept="1121^LYMPH NODE EXAM FINDINGS^99DCT" value="1118^NOT DONE^99DCT"/>
Not done
</label>
</div>
</fieldset>
</div>
<div class="section">
<h3>Skin Exams Findings</h3>
<div class="section repeat skin_exam_findings_detailed" id="skin_exam_findings_detailed"
data-counter="1" data-concept="8272^SKIN EXAM FINDINGS, DETAILED^99DCT"
data-name="skin_exam_findings_detailed">
<div class="form-group">
<label for="skin_exam_findings">
Skin exam findings?<span class="required">*</span>
</label>
<select class="form-control" id="skin_exam_findings" required="required"
name="skin_exam_findings" data-concept="1120^SKIN EXAM FINDINGS^99DCT">
<option value="">...</option>
<option value="1118^NOT DONE^99DCT">Not done</option>
<option value="1115^NORMAL^99DCT">Normal</option>
<option value="582^MASS, OTHER^99DCT">Mass</option>
<option value="8188^CALOR^99DCT">Abnormally warm</option>
</select>
</div>
<div class="form-group relevant_skin_exam_findings">
<label for="skin_exam_findings_detailed_body_part">
Body part with finding?:<span class="required">*</span>
</label>
<select class="form-control" id="skin_exam_findings_detailed_body_part" required="required"
name="skin_exam_findings_detailed_body_part" data-concept="8265^BODY PART^99DCT">
<option value="">...</option>
<option value="6599^FACE^99DCT">Face</option>
<option value="6598^NECK^99DCT">Neck</option>
<option value="1237^UPPER EXTREMITIES^99DCT">Arm</option>
<option value="1236^LOWER EXTREMITIES^99DCT">Leg</option>
<option value="1349^CHEST^99DCT">Chest</option>
<option value="6601^BACK^99DCT">Back</option>
<option value="1350^ABDOMINAL^99DCT">Abdomen</option>
<option value="6600^GENITALS^99DCT">Genitals</option>
<option value="6597^BUTTOCKS^99DCT">Buttocks</option>
</select>
</div>
<div class="form-group relevant_skin_exam_findings">
<label for="skin_exam_findings_detailed_laterality">
Specific location?<span class="required">*</span>
</label>
<select class="form-control" id="skin_exam_findings_detailed_laterality" required="required"
name="skin_exam_findings_detailed_laterality" data-concept="8264^LATERALITY^99DCT">
<option value="">...</option>
<option value="5139^LEFT^99DCT">Left</option>
<option value="5141^RIGHT^99DCT">Right</option>
<option value="1175^NOT APPLICABLE^99DCT">Not applicable</option>
</select>
</div>
<div class="form-group relevant_skin_exam_findings_mass">
<label for="mass_measurement_in_cm_first_direction">Mass measurement in cm, first direction:</label>
<input class="form-control" id="mass_measurement_in_cm_first_direction"
name="mass_measurement_in_cm_first_direction" type="number"
data-concept="8270^MASS MEASUREMENT IN CM, FIRST DIRECTION^99DCT">
</div>
<div class="form-group relevant_skin_exam_findings_mass">
<label for="mass_measurement_in_cm_second_direction">Mass measurement in cm, second direction:</label>
<input class="form-control" id="mass_measurement_in_cm_second_direction"
name="mass_measurement_in_cm_second_direction" type="number"
data-concept="8271^MASS MEASUREMENT IN CM, SECOND DIRECTION^99DCT">
</div>
</div>
</div>
<div class="section">
<h4>Select all referrals made during this visit:<span class="required">*</span></h4>
<fieldset name="1272^REFERRALS ORDERED^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.referral_to_pathology" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="6573^REFERRAL TO PATHOLOGY^99DCT">
Pathology
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.referral_to_surgery" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="6571^REFERRAL TO SURGERY^99DCT">
Surgery
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.radiology" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="6572^RADIOLOGY^99DCT">
Radiology
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.oncology_services" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="8053^ONCOLOGY SERVICES^99DCT">
Oncology
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.moi_teaching_and_referral_hospital" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT"
value="1274^MOI TEACHING AND REFERRAL HOSPITAL^99DCT">
MTRH
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="referrals_ordered.other_non_coded" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="referrals_ordered.none" type="checkbox"
data-concept="1272^REFERRALS ORDERED^99DCT" value="1107^NONE^99DCT">
None
</label>
</div>
<div class="form-group freetext">
<label for="referrals_ordered.freetext_general">
Specify:<span class="required">*</span>
</label>
<textarea class="form-control" name="referrals_ordered.freetext_general"
id="referrals_ordered.freetext_general"
data-concept="1915^FREETEXT GENERAL^99DCT"></textarea>
</div>
</fieldset>
</div>
<div class="section relevant_referral_ordered">
<h4>Reasons for referral<span class="required">*</span></h4>
<fieldset name="2327^REASONS FOR REFERRAL^99DCT">
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.fine_needle_aspiration_nos" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="7190^FINE NEEDLE ASPIRATION, NOS^99DCT">
Fine needle aspiration (FNA)
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.core_needle_biopsy" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="6510^CORE NEEDLE BIOPSY^99DCT">
Core needle biopsy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.excisional_or_surgical_biopsy" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="6511^EXCISIONAL OR SURGICAL BIOPSY^99DCT">
Excisional or surgical biopsy
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.surgery" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="7465^SURGERY^99DCT">
Surgery
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.debridement" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="8262^DEBRIDEMENT^99DCT">
Wound debridement
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input id="reasons_for_referral.ultrasound" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="6502^ULTRASOUND^99DCT">
Ultrasound
</label>
</div>
<div class="form-group">
<label class="font-normal">
<input class="has-freetext" id="reasons_for_referral.other_non_coded" type="checkbox"
data-concept="2327^REASONS FOR REFERRAL^99DCT" value="5622^OTHER NON-CODED^99DCT">
Other
</label>
</div>
<div class="form-group freetext">
<label for="reasons_for_referral.freetext_general">
Specify:<span class="required">*</span>
</label>
<textarea class="form-control" name="reasons_for_referral.freetext_general"
id="reasons_for_referral.freetext_general"
data-concept="1915^FREETEXT GENERAL^99DCT"></textarea>
</div>
</fieldset>
</div>
<div class="section">
<div class="form-group">
<label for="encounter.provider_id_select">Provider Name:</label>
<input class="form-control" id="encounter.provider_id_select" type="text"
placeholder="Start typing provider name here ...">
<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">Enter provider's system-id:<span class="required">*</span></label>
<input class="form-control checkDigit" id="encounter.provider_id" name="encounter.provider_id" type="text"
placeholder="Or enter the provider system id here ..." required="required">
</div>
<div class="form-group">
<label for="return_visit_date">Return visit date:</label>
<input class="form-control datepicker checkFutureDate future-date" data-concept="5096^RETURN VISIT DATE^99DCT"
id="return_visit_date" name="return_visit_date" type="text"
readonly="readonly">
</div>