MI | Update Mental Emotional Assessment form #433

Signed-off-by: mib.iqbal <[email protected]>

opensrp-sdidtk/src/main/assets/www/form/masalah_mental_emosional/form.json

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+{"name":"masalah_mental_emosional","title":"Deteksi Dini Masalah Mental Emosional","sms_keyword":"masalah_mental_emosional","default_language":"Bahasa","instance":{"encounter_type":"Deteksi Dini Masalah Mental Emosional"},"version":"201703310720","id_string":"masalah_mental_emosional","type":"survey","children":[{"instance":{"openmrs_entity_id":"encounter_start","openmrs_entity":"encounter"},"type":"start","name":"start"},{"instance":{"openmrs_entity_id":"encounter_date","openmrs_entity":"encounter"},"type":"today","name":"today"},{"type":"deviceid","name":"deviceid"},{"type":"simserial","name":"simserial"},{"type":"phonenumber","name":"phonenumber"},{"type":"hidden","name":"Village"},{"type":"hidden","name":"Sub-village"},{"type":"note","name":"generated_note_name_10","label":{"Bahasa":"Desa : ${Village}","English":"Desa : ${Village}"}},{"type":"note","name":"generated_note_name_11","label":{"Bahasa":"Dusun : ${Sub-village}","English":"Dusun : ${Sub-village}"}},{"bind":{"calculate":"${Village}"},"type":"hidden","name":"existing_location","instance":{"openmrs_entity_id":"location_id","openmrs_entity":"encounter"}},{"bind":{"calculate":"${Village}"},"type":"calculate","name":"desa","instance":{"openmrs_entity_parent":"usual_residence","openmrs_entity_id":"cityVillage","openmrs_entity":"person_address"}},{"instance":{"openmrs_entity_id":"160753AAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"date","name":"mental_test_date","label":{"Bahasa":"Tanggal Entry","English":"Entry Date"}},{"label":{"Bahasa":"1. Apakah anak Anda __seringkali terlihat marah__ tanpa sebab yang jelas (seperti banyak menangis, mudah tersinggung atau bereaksi berlebihan terhadap hal-hal yang sudah biasa dihadapinya)","English":"1. Does your child often __look angry__ for no apparent reason (such as crying a lot, being irritable or overreacting to common things)"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_marah"},{"label":{"Bahasa":"2. Apakah anak Anda tampak menghindar dari teman-teman atau anggota keluarganya (seperti ingin merasa sendirian, menyendiri atau merasa sedih sepanjang waktu, kehilangan minat terhadap hal-hal yang biasa sangat dinikmati)","English":"2. Does your child often __shun from his/her friends__ or family members (like want to be alone, withdrawn, or feel sad all the time, lost interest in things he/she usually enjoyed)"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_menghindar"},{"label":{"Bahasa":"3. Apakah anak Anda terlihat __berperilaku merusak dan menentang__ terhadap lingkungan di sekitarnya? (seperti melanggar peraturan yang ada, mencuri, seringkali melakukan perbuatan yang berbahaya bagi dirinya, atau menyiksa binatang atau anak-anak lainnya) dan tampak tidak perduli dengan nasihat-nasihat yang sudah diberikan kepadanya?","English":"3. Does your child __behave destructively and oppose the surroundings__? (e.g. Violate the existing rules, steal, often does something harmful to him/herself, or torture animals or other children) and not seem to care the advice he/she received?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_merusak"},{"label":{"Bahasa":"4. Apakah anak Anda memperlihatkan adanya __perasaan ketakutan atau kecemasan yang berlebihan__ yang tidak dapat dijelaskan asalnya dan tidak sebanding dengan anak lain seusianya?","English":"4. Does your child show __unreasonable fear or anxiety excessively__ more than other children in his/her age?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_takut_cemas"},{"label":{"Bahasa":"5. Apakah anak Anda mengalami keterbatasan oleh karena adanya __konsentasi yang buruk atau mudah teralih perhatiannya__, sehingga mengalami penurunan dalam aktivitas sehari-hari atau prestasi belajarnya?","English":"5. Does your child have limitation because of __poor concentration or being easily distracted__, that he/she experiences a deterioritation on daily activities or study performances?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_konsentrasi"},{"label":{"Bahasa":"6. Apakah anak Anda menunjukkan __perilaku kebingung__ sehingga mengalami kesulitan dalam berkomunikasi dan membuat keputusan?","English":"6. Does your child __seem perplexed__ that he/she is unable to communicate and make decision properly?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_bingung"},{"label":{"Bahasa":"7. Apakah anak Anda menunjukkan adanya __perubahan pola tidur__? (seperti sulit tidur sepanjang waktu, terjaga sepanjang hari, sering terbangun di waktu tidur malam oleh karena mimpi buruk, mengigau)","English":"7. Does your child show any __changes in sleep pattern__? (such as difficult to sleep all the time, stay up all the night, often wake up at night because of nightmare, delirious)"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_pola_tidur"},{"label":{"Bahasa":"8. Apakah anak Anda mengalami __perubahan pola makan__? (seperti kehilangan nafsu makan, makan berlebihan atau tidak mau makan sama sekali)","English":"8. Does your child show any __dietary changes__? (such as loss of appetite, overeating or not eating at all)"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_pola_makan"},{"label":{"Bahasa":"9. Apakah anak Anda seringkali __mengeluh sakit kepala, sakit perut, atau keluhan-keluhan fisik__ lainnya?","English":"9. Does you child often __complain of headaches, stomachaches, or other physical complaints__?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_keluhan_fisik"},{"label":{"Bahasa":"10. Apakah anak Anda seringkali __mengeluh putus asa__ atau berkeinginan untuk mengakhiri hidupnya?","English":"10. Does your child often __complain of despair__ or want to end his/her life?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_putus_asa"},{"label":{"Bahasa":"11. Apakah anak Anda menunjukkan adanya __kemunduran perilaku__ atau kemampuan yang sudah dimilikinya? (seperti mengompol kembali, menghisap jempol, atau tidak mau berpisah dengan orangtua/pengasuhnya)","English":"11. Does your child show __deterioritation of behavior__ or ability? (e.g. Bedwetting, thumb-sucking, or being attached to his/her parents/caregivers)"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_kemunduran_perilaku"},{"label":{"Bahasa":"12. Apakah anak Anda melakukan __perbuatan yang berulang-ulang__ tanpa alasan yang jelas?","English":"12. Does your child __do things repetitively)__ for no apparent reason?"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}],"name":"mme_berulang_ulang"},{"type":"note","name":"hasil_mental_emosional","label":{"Bahasa":"Pilih \"Curiga ada gangguan\" jika ada satu atau lebih jawaban YA","English":"Select \"Suspected of development disorder\" if there is one or more YES anwer"}},{"control":{"appearance":"horizontal-compact"},"name":"mental_emosional","label":{"Bahasa":"Hasil Tes Mental Emosional","English":"Mental Emotional Assessment Result"},"instance":{"openmrs_entity_id":"160721AAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"select one","children":[{"instance":{"openmrs_code":"1115AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"normal","label":{"Bahasa":"Normal","English":"Normal"}},{"instance":{"openmrs_code":"1116AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ada_gangguan","label":{"Bahasa":"Curiga ada gangguan","English":"Suspected of development disorder"}}]},{"control":{"appearance":"multiline"},"instance":{"openmrs_entity_id":"160716AAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"text","name":"kesimpulan","label":{"Bahasa":"__KESIMPULAN__","English":"__SUMMARY__"}},{"instance":{"openmrs_entity":"n/a"},"type":"note","name":"tindakan_intervensi","label":{"Bahasa":"__TINDAKAN INTERVENSI__","English":"__INTERVENTION MEASURE__"}},{"control":{"appearance":"horizontal"},"name":"konseling_stimulasi","label":{"Bahasa":"Konseling stimulasi bagi ibu:","English":"Stimulation consultation for the mother"},"instance":{"openmrs_entity_id":"1651AAAAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"diberikan","label":{"Bahasa":"Diberikan","English":"Received"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak_diberikan","label":{"Bahasa":"Tidak diberikan","English":"Not received"}}]},{"control":{"appearance":"multiline"},"instance":{"openmrs_entity_id":"162165AAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"text","name":"tindakan_lain","label":{"Bahasa":"Tindakan pengobatan lain","English":"Other measure:"}},{"control":{"appearance":"horizontal"},"name":"rujukan","label":{"Bahasa":"Apakah anak dirujuk?","English":"Is the child referred to other facility?"},"instance":{"openmrs_entity":"n/a"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}]},{"instance":{"openmrs_entity_id":"161562AAAAAAAAAAAAAAAAAAAAAAAAAA","openmrs_entity":"Concept"},"type":"text","name":"dirujuk_ke","label":{"Bahasa":"Dirujuk ke","English":"Place of referral"}},{"control":{"appearance":"horizontal"},"name":"surat_rujukan","label":{"Bahasa":"Ada surat rujukan?","English":"Referral letter"},"instance":{"openmrs_entity":"n/a"},"type":"select one","children":[{"instance":{"openmrs_code":"1065AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"ya","label":{"Bahasa":"Ya","English":"Yes"}},{"instance":{"openmrs_code":"1066AAAAAAAAAAAAAAAAAAAAAAAAAAAA"},"name":"tidak","label":{"Bahasa":"Tidak","English":"No"}}]},{"instance":{"openmrs_entity_id":"encounter_end","openmrs_entity":"encounter"},"type":"end","name":"end"},{"control":{"bodyless":true},"type":"group","children":[{"bind":{"readonly":"true()","calculate":"concat('uuid:', uuid())"},"type":"calculate","name":"instanceID"}],"name":"meta"}]}