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Pediatric Initial Clinical Evaluation
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Pediatric Initial Clinical Evaluation
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<htmlform>
<!-- Autogenerated example form (template from 01-Nov-2010 -->
<macros>
paperFormId = (Fill this in)
headerColor =#2f1c55
fontOnHeaderColor = white
</macros>
<style>
.section {
border: 1px solid $headerColor;
padding: 2px;
text-align: left;
margin-bottom: 1em;
}
.sectionHeader {
background-color: #2f1c55;
color: white;
/* display: block; */
padding: 2px;
font-weight: bold;
}
table tr:nth-child(even) {
background: #ffffff;
}
.alnright{
text-align: right;
color:#000000;
width: 25%;
}
.alnright_s{
text-align: right;
color:#000000;
width: 13%;
}
.alnleft_s{
text-align: left;
color:#000000;
width: 13%;
}
.alnleft{
text-align: left;
color:#000000;
width: 25%;
}
td {
border: none;
}
table th, table td {
padding: 5px 10px;
border: None;
}
.legend_style {
max-width: 35%;
background: #FAFAFA;
<!--padding: 5px;-->
margin: 0px left;
box-shadow: 1px 1px 25px rgba(0,0,0,0.10);
border-radius: 2px;
border: 1px solid #305a72;
border-bottom-left-radius: 2px;
text-transform:initial;
}
form fieldset, .form fieldset {
min-width: 98%;
border: none;
border-top: 1px solid #305a72;
}
table th, table td {
padding: 5px 10px;
/* border: 1px solid #DDD; */
}
table tr {
border: None;
}
ul.select, .form input, .form select, .form textarea, .form ul.select {
padding: 2px 10px;
}
form input, form select, form textarea, form ul.select, .form input, .form select, .form textarea, .form ul.select {
padding: 2px 10px;
}
form select, .form select {
max-width: 150px;
min-width: 100px;
}
.standard {
max-width: 200px;
min-width: 150px;
}
body {
font-family: "OpenSans", Arial, sans-serif;
color: #363463;
font-size: 14px;
}
<!--table.baseline-aligned td {-->
<!--vertical-align: baseline;-->
<!--}-->
</style>
<script type="text/javascript">
beforeSubmit.push(function() {
var val_encounterDate = getValue('encounterDate.value');
var val_next_appointment = getValue('next_appointment.value');
if (val_encounterDate > val_next_appointment) {
getField('next_appointment.error').html('Next appointment date has to be later than visit date').show();
return false;
}
return true;
});
</script>
<div class="hidden" id="encounter-details" sectionTag="section" headerStyle="title" headerLabel="Encounter Details">
<fieldset>
<legend class="legend_style">When?</legend>
<label>When?</label>
<encounterDate default="now" showTime="false" allowFutureDates="false"/>
</fieldset>
<fieldset>
<legend>Who?</legend>
<label>Who?</label>
<encounterProviderAndRole default="currentUser" encounterRole="240b26f9-dd88-4172-823d-4a8bfeb7841f" required="true"/>
</fieldset>
<fieldset>
<legend>Where?</legend>
<label>Where?</label>
<encounterLocation default="SessionAttribute:emrContext.sessionLocationId"/>
</fieldset>
</div>
<table style="margin-bottom: 20px;">
<thead>
<tr><th style="text-align: center">Pediatric Initial Clinical Evaluation</th></tr>
</thead>
</table>
<table class="table" width="100%">
<tr>
<td class="alignright">Visit Date:</td>
<td>
<encounterDate id="encounterDate" default="now" />
</td>
</tr>
</table>
<span style="float:right">Paper Form ID: $paperFormId</span>
<fieldset>
<legend class="legend_style">Caregiver Information</legend>
<table width="100%">
<tr>
<td class="alnleft">Is mother of child alive?</td>
<td class="alnleft">
<obs id="mother" style="yes_no_dropdown" conceptId="5588">
<controls>
<when value="true" thenDisplay="#mother_result"/>
</controls>
</obs>
</td>
<td colspan="2">
<table>
<tr>
<td width="40%" id="mother_result">
<table>
<tr>
<td class="alnleft">Mother's Name</td>
<td class="alnleft"><obs conceptId="1593"/></td>
</tr>
<tr>
<td class="alnleft">Mother's Address</td>
<td class="alnleft"><obs conceptId="164936"/></td>
</tr>
</table>
</td >
</tr>
</table>
</td>
</tr>
<tr>
<td>Is the father of child alive?</td>
<td class="alnleft">
<obs id="father" style="yes_no_dropdown" conceptId="5589">
<controls>
<when value="true" thenDisplay="#father_result"/>
</controls>
</obs>
</td>
<td>
<table>
<tr>
<td id="father_result">
<table>
<tr>
<td class="alnleft">Father's Name</td>
<td class="alnleft"><obs conceptId="1594"/></td>
</tr>
<tr>
<td class="alnleft">Father's Address</td>
<td class="alnleft"><obs conceptId="164939"/></td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td> </td>
</tr>
<tr><td>Child's parent/caregivers are:</td>
<td ><obs conceptId="164942"/></td>
<td colspan="2"> </td>
</tr>
<tr>
<td>How many siblings does the child have? </td>
<td><obs conceptId="5573"/></td>
<td colspan="2"> </td>
</tr>
</table>
</fieldset>
<fieldset>
<legend class="legend_style">Medical History</legend>
<table width="100%" border="0">
<tr>
<td colspan="9"><b>Symptom review</b></td>
</tr>
<tr>
<td><b>Symptoms </b></td>
<td><font color='red'>Please tick</font></td>
<td><b>Duration Value </b></td>
<td><b>Duration Unit</b></td>
<td></td>
<td><b>Symptoms </b></td>
<td><font color='red'>Please tick</font></td>
<td><b>Duration Value </b></td>
<td><b>Duration Unit</b></td>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Fever/Chills </td>
<td><obs conceptId="1728" answerConceptId="140238" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td></td>
<obsgroup groupingConceptId="1727">
<td>Pain on micturition</td>
<td><obs conceptId="1728" answerConceptId="163606" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td>Recent Weight loss</td>
<td> <obs conceptId="1728" answerConceptId="832" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td></td>
<obsgroup groupingConceptId="1727">
<td>Genital Sores</td>
<td><obs conceptId="1728" answerConceptId="864" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Night Sweats</td><td><obs conceptId="1728" answerConceptId="133027" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td></td>
<obsgroup groupingConceptId="1727">
<td>Numbness/tingling</td>
<td><obs conceptId="1728" answerConceptId="163074" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Irritability</td>
<td><obs conceptId="1728" answerConceptId="6023" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td></td>
<obsgroup groupingConceptId="1727">
<td>Convulsion</td>
<td><obs conceptId="1728" answerConceptId="113054" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Difficulty Sleeping</td>
<td> <obs conceptId="1728" answerConceptId="142371" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td> </td>
<obsgroup groupingConceptId="1727">
<td>Rash</td>
<td><obs conceptId="1728" answerConceptId="512" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Headache </td>
<td><obs conceptId="1728" answerConceptId="139084" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td></td>
<obsgroup groupingConceptId="1727">
<td>Itching</td>
<td><obs conceptId="1728" answerConceptId="879" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> New Visual Impairment</td>
<td><obs conceptId="1728" answerConceptId="159298" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td> </td>
<obsgroup groupingConceptId="1727">
<td>Others Specify</td>
<td><obs conceptId="1728" answerConceptId="5622" answerLabel=""/></td>
<td><obs conceptId="1731" /></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Ear discharge</td>
<td> <obs conceptId="1728" answerConceptId="873" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td> </td>
<obsgroup groupingConceptId="1727">
<td> Oral Sores </td>
<td><obs conceptId="1728" answerConceptId="5244" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Difficulty Breathing</td>
<td><obs conceptId="1728" answerConceptId="142373" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td> </td>
<obsgroup groupingConceptId="1727">
<td> Food refusal</td>
<td><obs conceptId="1728" answerConceptId="135595" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Diarrhoea</td>
<td><obs conceptId="1728" answerConceptId="142412" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
<td> </td>
<obsgroup groupingConceptId="1727">
<td> Nausea and Vomiting</td>
<td><obs conceptId="1728" answerConceptId="133473" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
<tr>
<obsgroup groupingConceptId="1727">
<td> Cough </td>
<td><obs conceptId="1728" answerConceptId="143264" answerLabel=""/></td>
<td><obs conceptId="1731"/></td>
<td><obs conceptId="1732" answerConceptIds="1072,1073,1074"/></td>
</obsgroup>
</tr>
</table>
<table style="width: 100%;">
<tr>
<td class="alnleft">Patient assessed for TB </td>
<td class="alnleft"><obs conceptId="164800"/></td>
<td class="alnleft">Developmental Assessment</td>
<td class="alnleft"> <obs conceptId="1200" answerConceptIds="1115, 6022, 1116" answerLabels="Appropriate,Delayed,Retarted "/></td>
</tr>
<tr>
<td class="alnleft">Immunization: Complete for Age </td>
<td class="alnleft"><obs conceptId="164134"/></td>
<td class="alnleft">Mode of infant (≤ 6 months) feeding: </td>
<td class="alnleft"><obs conceptId="1151" answerConceptIds="5526,165298,6046" answerLabels="EBF, EBMS, Mixed"/></td>
</tr>
</table>
</fieldset>
<fieldset>
<legend class="legend_style">Previous Care Details</legend>
<table width="100%">
<tr>
<td class="alnright">21. Patient has received previous care for HIV/AIDS </td>
<td><obs id="pv" conceptId="160533" style="yes_no_dropdown" noLabel="No" yesLabel="Yes">
<controls>
<when value="true" thenDisplay="#pat_hiv"/>
</controls>
</obs></td>
<td></td>
<td></td>
</tr>
<tr id="pat_hiv">
<td>Name of Facility</td>
<td><obs conceptId="162724"/></td>
<td>Duration of Care</td>
<td>
<table>
<tr>
<td>From: <obs conceptId="165829"/></td>
<td> - </td>
<td>To: <obs conceptId="165830"/></td>
</tr>
</table>
</td>
</tr>
</table>
<table>
<tr>
<td class="alnleft">Previous ARV exposure other than PMTCT</td>
<td class="alnleft"><obs id="pr" conceptId="165301" answerConceptIds="1107,165712,1185" answerLabels="None, Earlier ARV but not a transfer in, Treatment">
<controls>
<when value="1185" thenDisplay="#trm"/>
<when value="165712" thenDisplay="#exp"/>
</controls>
</obs></td>
<td id="exp">
<table>
<tr>
<td>
<table>
<tr>
<td >Months on Treatment</td>
<td ><obs conceptId="165924" answerLabel=""/> </td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td >Specify drugs</td>
<td><obs conceptId="165704" style="autocomplete"/> </td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td id="trm">
<table>
<tr>
<td>
<table>
<tr>
<td >Months on Treatment</td>
<td ><obs conceptId="165924" answerLabel=""/> </td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td >Specify drugs</td>
<td><obs conceptId="165704" style="autocomplete"/> </td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
<table>
<tr>
<td class="alnleft">Patient has any known drug allergies? </td>
<td class="alnleft"><obs conceptId="165675" answerConceptIds="162228,160556" answerLabels="Known drug allergies,No known drug allergies" /></td>
<td class="alnleft">Past medical history (including hospitalization and surgery)</td>
<td class="alnleft"><obs conceptId="160221" style="textarea"/></td>
</tr>
</table>
<table style="width:100%;">
<tr>
<td class="alnleft">Previous ARV exposure through PMTCT</td>
<td class="alnleft"><obs conceptId="165928" /></td>
<td class="alnleft">Current Medication (Care-giver should probe and specify)</td>
<td class="alnleft"><obs conceptId="165305" answerConceptIds="1107,105281,165303,165304" answerLabels="None, CTX, ART, Anti-TB drugs" /></td>
</tr>
</table>
</fieldset>
<fieldset>
<table width="100%" border="0">
<tr>
<td colspan="3"><b>Physical exam</b></td>
</tr>
<tr>
<td>
<table>
<tr>
<td class="alnright_s">Temp (<sup>o</sup>C)</td>
<td class="alnright_s"><obs conceptId="5088" /></td>
<td class="alnright_s">Pulse (bpm)</td>
<td class="alnright_s"><obs conceptId="5087"/></td>
<td class="alnright_s">Weight (kg)</td>
<td class="alnright_s"><obs conceptId="5089"/></td>
</tr>
<tr>
<td class="alnright_s">Height (cm)</td>
<td class="alnright_s"><obs conceptId="5090"/></td>
<td class="alnright_s">Head circumference (cm)</td>
<td class="alnright_s"><obs conceptId="5318" /></td>
<td class="alnright_s">Surface area (cm<sup>2</sup>)</td>
<td><obs conceptId="980"/></td>
</tr>
<tr>
<td class="alnright_s">MUAC</td>
<td class="alnright_s"><obs conceptId="165935" answerConceptIds="165932, 165933,165934" answerLabels="Over, Under, Normal"/></td>
<td class="alnright_s">BMI/MUAC</td>
<td class="alnright_s"><obs conceptId="165243" /></td>
<td class="alnright_s"> </td>
<td> </td>
</tr>
</table>
</td>
</tr>
</table>
<br/>
<table width="100%" border="0">
<tr>
<td width="25%"><b>General appearance</b></td>
<td width="25%"><b>Skin</b></td>
<td width="25%"><b>Head/Eye/ENT</b></td>
<td width="25%"><b>Glands</b></td>
</tr>
<tr>
<td>Pale <obs conceptId="165313" answerConceptId="147096" answerLabel="" /></td>
<td>Pruritic paplar dermatitis <obs conceptId="165318" answerConceptId="1249" answerLabel="" /></td>
<td>Gingivitis <obs conceptId="165327" answerConceptId="5192" answerLabel="" /></td>
<td>Parotid swelling <obs conceptId="165331" answerConceptId="130792" answerLabel="" /></td>
</tr>
<tr>
<td>Dehydrated <obs conceptId="165313" answerConceptId="142630" answerLabel="" /></td>
<td>Abscesses <obs conceptId="165318" answerConceptId="150632" answerLabel="" /></td>
<td>Thrush<obs conceptId="165327" answerConceptId="165598" answerLabel="" /></td>
<td>Lymphadenopathy <obs conceptId="165331" answerConceptId="135488" answerLabel="" /></td>
</tr>
<tr>
<td>Jaundice <obs conceptId="165313" answerConceptId="136443" answerLabel="" /></td>
<td>Herpes zoster <obs conceptId="165318" answerConceptId="117543" answerLabel="" /></td>
<td>Oral KS <obs conceptId="165327" answerConceptId="644" answerLabel="" /></td>
<td> </td>
</tr>
<tr>
<td>Edematous<obs conceptId="165313" answerConceptId="165311" answerLabel="" /></td>
<td>Kaposi's lesions <obs conceptId="165318" answerConceptId="165317" answerLabel="" /></td>
<td>Otitis media <obs conceptId="165327" answerConceptId="131113" answerLabel="" /></td>
<td ></td>
</tr>
<tr>
<td> </td>
<td>Seborrheic dermatitis <obs conceptId="165318" answerConceptId="113116" answerLabel="" /></td>
<td>Ear discharge<obs conceptId="165327" answerConceptId="873" answerLabel="" /></td>
<td> </td>
</tr>
<tr>
<td>
</td>
<td>Fungal infections <obs conceptId="165318" answerConceptId="171" answerLabel="" /></td>
<td>Oral ulcer<obs conceptId="165327" answerConceptId="111721" answerLabel="" /></td>
<td></td>
</tr>
<tr>
<td>
</td>
<td>Scabies <obs conceptId="165318" answerConceptId="140" answerLabel="" toggle="skin" /></td>
<td> </td>
<td> </td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>
</table>
<table class="table" width="100%">
<tr>
<td width="25%"><b>Respiratory</b></td>
<td width="25%"><b>Gastrointestinal</b></td>
<td width="25%"><b>Neurological</b></td>
<td width="25%"><b>Mental status</b></td>
</tr>
<tr>
<td>Auscultation findings <obs conceptId="165316" answerConceptId="165315" answerLabel="" /></td>
<td>Distention <obs conceptId="165330" answerConceptId="165329" answerLabel="" /></td>
<td>Disorientation to TPP <obs conceptId="165325" answerConceptId="165319" answerLabel="" /></td>
<td>Slow mentation <obs conceptId="165339" answerConceptId="165335" answerLabel="" /></td>
</tr>
<tr>
<td>Labored breathing <obs conceptId="165316" answerConceptId="136201" answerLabel="" /></td>
<td>Hepatomegaly <obs conceptId="165330" answerConceptId="5008" answerLabel="" /></td>
<td>Speech slurs <obs conceptId="165325" answerConceptId="126351" answerLabel="" /></td>
<td>Memory loss <obs conceptId="165339" answerConceptId="121657" answerLabel="" /></td>
</tr>
<tr>
<td>Cyanosis <obs conceptId="165316" answerConceptId="143050" answerLabel="" /></td>
<td>Splenomegaly <obs conceptId="165330" answerConceptId="5009" answerLabel="" /></td>
<td>Neck stiffness <obs conceptId="165325" answerConceptId="5170" answerLabel="" /></td>
<td>Mood swings <obs conceptId="165339" answerConceptId="165336" answerLabel="" /></td>
</tr>
<tr>
<td>Wheezing <obs conceptId="165316" answerConceptId="122863" answerLabel="" /></td>
<td>Tenderness <obs conceptId="165330" answerConceptId="165328" answerLabel="" /></td>
<td>Blindness 1/2 eyes <obs conceptId="165325" answerConceptId="165321" answerLabel="" /></td>
<td>Depression <obs conceptId="165339" answerConceptId="119537" answerLabel="" /></td>
</tr>
<tr>
<td>Intercostal (sub) recession <obs conceptId="165316" answerConceptId="165314" answerLabel="" /></td>
<td> </td>
<td>Weakness/paralysis <obs conceptId="165325" answerConceptId="165322" answerLabel="" /></td>
<td>Anxiety <obs conceptId="165339" answerConceptId="121543" answerLabel="" /></td>
</tr>
<tr>
<td>Other <obs conceptId="165316" answerConceptId="5622" answerLabel="" toggle="cani"/></td>
<td> </td>
<td>Numbness of extremities <obs conceptId="165325" answerConceptId="165323" answerLabel="" /></td>
<td>Suicidal ideation <obs conceptId="165339" answerConceptId="165338" answerLabel="" /></td>
</tr>
<tr>
<td>
<table>
<tr>
<td id="cani"><obs conceptId="165906" answerLabel="" /></td>
</tr>
</table>
</td>
<td> </td>
<td>Impaired consciousness<obs conceptId="165325" answerConceptId="165320" answerLabel="" /></td>
<td></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td>Fisting/spasticity<obs conceptId="165325" answerConceptId="165324" answerLabel="" /> </td>
<td> </td>
</tr>
</table>
<table class="table" width="100%">
<tr>
<td width="25%"><b>Cardiovascular</b></td>
<td width="25%"><b>Genitalia</b></td>
<td width="25%"></td>
<td width="25%"></td>
</tr>
<tr>
<td>Irregular pulse<obs conceptId="165326" answerConceptId="136522" answerLabel="" /></td>
<td>Genital ulcer/other lesion <obs conceptId="165333" answerConceptId="165332" answerLabel="" /></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Auscultation finding <obs conceptId="165326" answerConceptId="165315" answerLabel="" /></td>
<td>Tanner stage<obs conceptId="5311" answerLabel="" /></td>
<td></td>
<td></td>
</tr>
<tr>
<td>Additional physical examination findings</td>
<td colspan="3"><obs rows="5" conceptId="165600" answerLabel=""/></td>
<td></td>
<td></td>
</tr>
</table>
<table>
<tr>
<td class="alnleft"><b>Assessment:</b></td>
<td class="alnleft"><obs id="ass" conceptId="165602" answerConceptIds="1068,5006" answerLabels="Symptomatic,Asymptomatic">
<controls>
<when value="1068" thenDisplay="#aids_def,#opp"/>
</controls>
</obs></td>
<td>
<table>
<tr>
<td id="aids_def" class="alnleft">AIDS Defining Illness<obs conceptId="165602" answerConceptId="165307" answerLabel=""/></td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td id="opp" class="alnleft">Opportunistic Infectious Disease<obs conceptId="165602" answerConceptId="131768" answerLabel=""/></td>
</tr>
</table>
</td>
</tr>
</table>
<table>
<tr>
<td width="25%"><b>WHO stage</b></td>
<td width="25%"><obs conceptId="5356" answerConceptIds="1220,1221,1222, 1223" answerLabels="Stage 1,Stage 2,Stage 3,Stage 4"/></td>
<td width="50%"> </td>
</tr>
</table>
<table width="100%">
<tr><td colspan="4"><b>Plan (Order on specific requisition form)</b></td></tr>
<tr>
<td>Lab Evaluation <obs conceptId="165352" answerConceptId="165341" answerLabel=""/></td>
<td>OI therapy <obs conceptId="165352" answerConceptId="165342" answerLabel=""/></td>
<td>Screen for tuberculosis <obs conceptId="165352" answerConceptId="164800" answerLabel=""/></td>
<td>Admission <obs conceptId="165352" answerConceptId="165343" answerLabel=""/></td>
</tr>
<tr>
<td>OI Prohylaxis <obs conceptId="165352" answerConceptId="165344" answerLabel=""/></td>
<td>Symptomatic treatment/pain control (specify) <obs conceptId="165352" answerConceptId="165345" answerLabel=""/></td>
<td>Palliative Care <obs conceptId="165352" answerConceptId="165346" answerLabel=""/></td>
<td>Psychosocial Support<obs conceptId="165352" answerConceptId="5490" answerLabel=""/></td>
</tr>
<tr>
<td>OVC Care <obs conceptId="165352" answerConceptId="165347" answerLabel=""/></td>
<td>End of Life Care <obs conceptId="165352" answerConceptId="165348" answerLabel=""/></td>
<td>CXR <obs conceptId="165352" answerConceptId="12" answerLabel=""/></td>
<td>Counseling <obs conceptId="165352" answerConceptId="165350" answerLabel=""/></td>
</tr>
<tr>
<td>Adherence <obs conceptId="165352" answerConceptId="5488" answerLabel=""/></td>
<td>HTS <obs conceptId="165352" answerConceptId="1356" answerLabel=""/></td>
<td>Nutrition <obs conceptId="165352" answerConceptId="1380" answerLabel=""/></td>
<td>Peer Health Support <obs conceptId="165352" answerConceptId="165349" answerLabel=""/></td>
</tr>
<tr>
<td>Referrals <obs conceptId="165352" answerConceptId="1272" answerLabel=""/></td>
<td>Support <obs conceptId="165352" answerConceptId="5486" answerLabel="" /></td>
<td>PMTCT <obs conceptId="165352" answerConceptId="5576" answerLabel="" /></td>
<td>Other <obs conceptId="165352" answerConceptId="5622" answerLabel="" toggle="other_plan"/></td>
</tr>
<tr>
<td> </td>
<td> </td>
<td> </td>
<td id="other_plan"><obs conceptId="165925" answerLabel=""/> </td>
</tr>
</table>
<table width="100%">
<tr>
<td colspan="4"><b>Enroll in:</b> </td>
</tr>
<tr>
<td>General Medical Follow-Up<obs conceptId="165355" answerConceptId="165353" answerLabel="" /></td>
<td>Antiretroviral Therapy<obs conceptId="165355" answerConceptId="165303" answerLabel="" /></td>
<td>Pending Lab Results<obs conceptId="165355" answerConceptId="165354" answerLabel=""/></td>
<td></td>
</tr>
</table>
<table class="table" width="100%">
<tr>
<td class="alnleft"><b>Plan for ARV therapy:</b> </td>
<td class="alnleft">
<obs id="art_plan" conceptId="165361" answerConceptIds="165356,162904,165357,165360,165358" answerLabel="Ongoing monitoring,Restart treatment,Start new treatment,Stop treatment,Change treatment">
<controls>
<when value="165360" thenDisplay="#stop"/>
<when value="165358" thenDisplay="#change"/>
</controls>
</obs></td>
<td id="stop">
<table>
<tr>
<td>
<table>
<tr>
<td class="alnleft" id="reason_label">Reason</td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td class="alnleft" id="reason">
<obs conceptId="165360" answerConceptIds="165359,127750,165129,160584,1754,102,160569,163523,141748,160566,5622 " answerLabels="Cannot adhere to schedule,
Patient refusal/preference,Doctor's Instruction,Ran out of medicine,Drugs not available,Toxicity,Virologic failure, Clinical failure,Drug interaction,
Immunologic failure,Other (specify)"/>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td id="change">
<table>
<tr>
<td>
<table>
<tr>
<td class="alnleft" id="reason_label">Reason</td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td class="alnleft" id="reason">
<obs conceptId="165360" answerConceptIds="165359,127750,165129,160584,1754,102,160569,163523,141748,160566,5622 " answerLabels="Cannot adhere to schedule,
Patient refusal/preference,Doctor's Instruction,Ran out of medicine,Drugs not available,Toxicity,Virologic failure, Clinical failure,Drug interaction,
Immunologic failure,Other (specify)"/>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</fieldset>
<fieldset>
<table width="100%">
<tr>
<td class="alnleft"><b>Additional comments</b></td>
<td><obs conceptId="161011" style="textarea"/></td>
</tr>
</table>
</fieldset>
<fieldset>
<legend class="legend_style">Appointment and Signature</legend>
<table class="table" width="100%">
<tr>
<td width="25%">Next appointment</td>
<td colspan="alnleft"><obs conceptId="165036" id="next_appointment" allowFutureDates="true"/></td>
<td>Clinician's name </td>
<td><encounterProviderAndRole default="currentUser" encounterRole="240b26f9-dd88-4172-823d-4a8bfeb7841f" required="true"/></td>
</tr>
</table>
</fieldset><br/>
<submit/>
</htmlform>