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This page has been mostly superseded by the Form Bank, which includes versions of OpenMRS forms that can be imported using the Metadata Sharing Module.
In order to use the sample forms listed on this page, you need to make sure that all concepts referred to in the form are in your concept dictionary, and this is usually not the case. We're leaving this page here since some people may find it useful to see actual production form definitions.

If you want to share the HTML description of any cool HTML Forms you've created, you can put them here. (You should go to Wiki Markup and put

 

before and after the HTML.)

HAS-Haiti TB Registry Form

<htmlform>
<macros>
lightgrey=#e0e0e0
lightblue=#95ADCA
darkblue=#4444ff
</macros>
<div style="background-color: $lightblue" align="center"><b>TB REJIS</b></div>
<br></br>
<center>Encounter Location<encounterLocation   order="15,1,2,4,5,8,9"/>Encounter Date <encounterDate default="today"  /></center>
<br/>
<table border="1" cellspacing="0" cellpadding="1" align="center" width="50%">

<tr>
<td colspan="2" bgcolor="#95ADCA"><b><center>TB SPECIFIC DATA</center></b></td>
</tr>
<tr>
<td colspan="2">Accompagnateur<obs conceptId="1603" /> Add relationship in OpenMRS <enrollInProgram programId="2"/>  </td>
</tr>
<tr>
<td colspan="2" bgcolor="whitesmoke"><obs conceptId="1004" style="checkbox" />Crachats <br/> <obs conceptId="2032" style="checkbox" /> Clinic<br/><obs conceptId="1860" style="checkbox" /> X-Ray</td>
</tr>
<tr>
<td colspan="2">TB Type<obs conceptId="2058" /><br/>TB Patient Type<obs conceptId="1623" /></td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td width="40%">Pre-Traitement Bacilloscopie</td><td><obs conceptId="2048" answers="A+B+C+,A+B+C-,A+B-C-,A-B-C-,A-B-C+,A-B+C+,A+B-C+,A-B+C-" answerLabels="A+B+C+,A+B+C-,A+B-C-,A-B-C-,A-B-C+,A-B+C+,A+B-C+,A-B+C-" style="dropdown"  showDate="true" />Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td> Fin du: 2e mois Bacilloscopie</td><td><obs conceptId="2050"  answers="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" answerLabels="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" style="dropdown" showDate="true" />Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Fin du:3e mois Bacilloscopie</td><td><obs conceptId="2052" answers="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" answerLabels="1+2+3+,1+2+3-,1+2-3-,1-2-3-,1-2-3+,1-2+3+,1+2-3+,1-2+3-" style="dropdown" showDate="true" />Date </td>
</tr>
<tr><td colspan="3" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Fin du: 5e mois Bacilloscopie</td><td><obs conceptId="2054"  answers="-\--,--+" answerLabels="+-+\--,+"  style="dropdown" showDate="true" />Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Fin du Traitement Bacilloscopie</td><td><obs conceptId="2055"  answers="-\--,--+" answerLabels="+-+\--,+"  style="dropdown" showDate="true" />Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Résultat Test Hiv</td><td><obs conceptId="1040" showDate="true" size="15"/>Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>CD4 Count</td><td><obs conceptId="5497" showDate="true" />Date </td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Date début Traitement ARV</td><td><obs conceptId="101" /></td>
</tr>
<tr><td colspan="2" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Resultat de Traitement TB</td><td><obs conceptId="1607" showDate="true" />Date </td>
</tr>
<tr><td colspan="3" bgcolor="whitesmoke"><font color="whitesmoke">.</font></td></tr>
<tr>
<td>Remarque</td><td><obs conceptId="1602" /></td>
</tr>

</table>
<center><encounterProvider role="Provider" /><submit /></center>
</htmlform>

HAS-Haiti Surgery Form

<htmlform>
<macros>
lightgrey=#e0e0e0
lightblue=#2ea991
green=#2ea991
white=#ffffff
</macros>
<div style="background-color: $green;color:$white"><b><center>Surgery Form</center></b></div>
<br/>
<table border="1" width="80%"  cellspacing="0" align="center" bgcolor="whitesmoke">
<tr>

<td>Operation Date <encounterDate /></td><td>Operation Time <obs conceptId="6164" allowFutureDates="true"/></td><td >Emergency Type <obs conceptId="6162" /></td>

</tr>
<tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>ANESTHESIA</B></td></tr>
<tr>

<td>Anesthesia Type<obs conceptId="6142" /></td><td width="40%">Start time <obs conceptId="6143" allowFutureDates="true"/>  / End Time <obs conceptId="6144" allowFutureDates="true"/> </td><td >Anesthesiologist <obs conceptId="6165" answers="Nonine Vernéus,Yves-Rose Pierre Louis,Espinel Solius" /></td>

</tr>
<tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>DIAGNOSIS</B></td></tr>

<tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete"  size="80" /></td></tr>

<tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete"  size="80" /></td></tr>

<tr ><td colspan="3"><obs conceptId="6178" answerClasses="Diagnosis" style="autocomplete"  size="80" /></td></tr>

<tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>PROCEDURE</B></td></tr>
<tr>
<td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr>
<tr>
<td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr>
<tr>
<td colspan="3"><obs conceptId="6179" answerClasses="Procedure" style="autocomplete" /></td></tr>
<tr ><td colspan="3" align="center" style="background-color: $green;color:$white"><B>NURSES</B></td></tr>
<tr><td><b>Scrub</b></td><td><b>Circulating</b></td><td><b>Comments</b></td></tr>
<tr>

<td>1. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" /> <br>
2. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" /> </br> <br>
3. <obs conceptId="6167" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Rosette Vilna,Wastaline Charles" />
</br>
</td>
<td>1. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" /> <br>
2. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" />
</br> <br>
3. <obs conceptId="6168" answers="Alourdes Emile,Anaromie Blanc,Edline Exinord,Elioné Billion,Jeanine Jean Lor,Jeronne Thelusmé,Marjorie Etienne,Mireille Jean,Nacha Betty Benoit,Rosette Vilna,Wastaline Charles,Wilner Alcene" />
</br></td>

<td> <obs conceptId="1602" style="textarea" /></td>
</tr>
<tr>
<td  colspan="3" align="center"> Lieu <encounterLocation default="15" order="15"/> Surgeon Name <encounterProvider role="Surgeon"/>
<submit />
</td>
</tr>
</table>
</htmlform>

HAS-Haiti Family Registry Form

<htmlform>
<macros>
lightgrey=#e0e0e0
lightblue=#95ADCA
darkblue=#4444ff
</macros>
<div style="background-color: $lightblue" align="center"><b>REJIS FANMI</b></div>
<br></br>
<center><encounterLocation   order="1,2,4,5,8,9"/><encounterDate default="today"  /></center>
<table bgcolor="#f9f9f9" border="1" cellspacing="6" cellpadding="4" width="75%" align="center">
<tr>
<td align="center" >
<table  border="1" cellspacing="0" cellpadding="3" width="95%">
<tr>
<td>Pwa (Kg) / Dat yo pran pwa a </td><td><obs conceptId="5089" showDate="true" /></td><td style="font-weight:bold" align="center">Koz Vizit la  /  Dat vizit </td>
</tr>
<tr>
<td>Etat pwa a</td><td><obs conceptId="2974" /></td><td><obs conceptId="2959" showDate="true" /></td>
</tr>
<tr >
<td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td>
</tr>
<tr>
<td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td>
</tr>
<tr>
<td colspan="2"></td><td><obs conceptId="2959" showDate="true" /></td>
</tr>
</table>
</td>
</tr>

<tr>
<td align="center" ><table border="1" cellspacing="0" cellpadding="3" width="95%">
<tr>

<td align="center" style="font-weight:bold" colspan="4" bgcolor="#95ADCA"> VAKSINASYON</td>
</tr>
<tr style="font-weight:bold">
<td >Vaksen</td><td>Dat vaksinasyon</td><td>fabrikan </td><td>nimewo estòk</td>
</tr>
<obsgroup groupingConceptId="3025">
<tr>
<td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td>
</tr>
</obsgroup>
<obsgroup groupingConceptId="3025">
<tr>
<td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td>
</tr>
</obsgroup>
<obsgroup groupingConceptId="3025">
<tr>
<td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td>
</tr>
</obsgroup>
<obsgroup groupingConceptId="3025">
<tr>
<td><obs conceptId="1197" /></td><td><obs conceptId="3031" /></td><td><obs conceptId="2977" /></td><td><obs conceptId="2978" /></td>
</tr>
</obsgroup>
</table></td>
</tr>

<tr>
<td align="center" ><table border="1" cellspacing="0" cellpadding="3" width="95%">
<tr >
<td style="font-weight:bold">Vitamin A</td><td style="font-weight:bold">Fè</td><td style="font-weight:bold">Albendazol</td><td>Gwosès</td><td><obs conceptId="5272" /></td>
</tr>

<tr>

<td><obs conceptId="2231" /></td>
<td><obs conceptId="2971" /></td>
<td><obs conceptId="941" /></td><td>Kantite semèn gwosès</td><td><obs conceptId="1279" /></td>

</tr>
<tr>

<td><obs conceptId="2231" /></td>

<td><obs conceptId="2971" /></td>
<td><obs conceptId="941" /></td><td>swen avan nesans</td><td><obs conceptId="2992" /></td>
</tr>
<tr>
<td colspan="3"> </td><td>Swen apre nesans</td><td><obs conceptId="2993" /></td>
</tr>
<tr>
<td>metod planifikasyon familyal</td><td><obs conceptId="374" /></td><td></td><td>Alètman</td><td><obs conceptId="5632" /></td>
</tr>

</table></td>
</tr>
</table>
<center><encounterProvider role="Provider" /><submit /></center>
</htmlform>

HAS-Haiti Lab Form

<htmlform>
    <macros>
        lightgrey=#e0e0e0
        lightblue=#95ADCA
        darkblue=#4444ff
    </macros>
<div style="background-color: $lightblue"><b><center>LABORATORY FORM ENTRY</center></b></div>
<br></br>
<center>Encounter Date <encounterDate default="today" />  Location <encounterLocation default="15" order="15" />  <obs conceptId="2933" labelText="Payment" />  <obs conceptId="1827" labelText="Ward" /></center>
<table border="1" width="95%"  cellspacing="6" cellpadding="6" bgcolor="whitesmoke" align="center">
<tr>
<td>
<table border="1" cellspacing="0" align="center" width="95%">
<tr>
<td colspan="10" align="center" bgcolor="#95ADCA"><b>CHIMIE</b></td>
</tr>

<tr style="font-weight:bold">
<td>Test name</td><td>Result</td><td>Ref-m</td><td>Ref-f</td><td>Test name</td><td>Result</td><td>Ref-m</td><td>Ref-f</td>
</tr>

<tr style="font-weight:bold">
<td colspan="4">Tests Hepatiques</td><td colspan="4"> Tests lipidiques</td>
</tr>

<tr>
<td>Bilirubin Total</td><td><obs conceptId="2840"/>mg/dl</td><td>0.2-1.3</td><td>0.2-1.3</td><td>Cholesterol</td><td><obs conceptId="2890"/>mg/dl</td><td>0.8-1.5</td><td>0.7-1.2</td>
</tr>

<tr>
<td>Bilirubin Neonatal</td><td><obs conceptId="1371" />mg/dl</td><td>1.0-10.5</td><td>1.0-10.5</td><td >Triglycerides</td><td><obs conceptId="1009" />mg/dl</td><td> inf. à150</td><td>inf. à 150</td>
</tr>

<tr>
<td>ALT/GPT</td><td><obs conceptId="2842" />U/l</td><td>21-72</td><td>12-43</td><td>HDL Cholesterol</td><td><obs conceptId="2848" />mg/dl</td><td>inf. à 40</td><td>inf. à 40</td>
</tr>

<tr>
<td>AST/GOT</td><td><obs conceptId="2841"  />U/l</td><td>17-59</td><td>14-36</td><td colspan="4">Pancreas</td>
</tr>

<tr>
<td>GGT</td><td><obs conceptId="1370" />U/l</td><td>15-73</td><td>9-52</td><td>Amylase</td><td><obs conceptId="1299" />U/l</td><td>30-110</td><td>30-110</td>
</tr>

<tr>
<td>ALK Phosphatase</td><td><obs conceptId="785" />U/l</td><td>38-126</td><td>38-126</td><td>Lipase</td><td><obs conceptId="1013" />U/l</td><td>23-300</td><td>23-300</td>
</tr>

<tr style="font-weight:bold">
<td colspan="4">Function Renal</td><td colspan="4">Proteine</td>
</tr>

<tr>
<td>Urea Nitrogen/BUN</td><td><obs conceptId="2889" />mg/dl</td><td>9-20</td><td>7-17</td><td>Albumin</td><td><obs conceptId="2928" />g/dl</td><td>35-50</td><td>35-50</td>
</tr>

<tr>
<td>Creatinine</td><td><obs conceptId="2888" />mg/dl</td><td>0.8-1.5</td><td>0.7-1.2</td><td>Total Protein</td><td><obs conceptId="717" />g/dl</td><td>63-82</td><td>63-82</td>
</tr>

<tr>
<td>Uric Acid</td><td><obs conceptId="1373" />mg/dl</td><td>3.5-8.5</td><td>2.5-6.2</td><td>TP/Albumin Quotient</td><td><obs conceptId="3009" /></td><td></td><td></td>
</tr>

<tr style="font-weight:bold">
<td colspan="4" >Electrolyte /Oligo-Element</td><td colspan="4">Cardio Risk</td>
</tr>

<tr>
<td>Sodium</td><td><obs conceptId="2843" />mmol</td><td>137-145</td><td>137-145</td><td>CK</td><td><obs conceptId="1011" />U/l</td><td>55-175</td><td>30-135</td>
</tr>
<tr>
<td>Potassium</td><td><obs conceptId="2844" />mmol/l</td><td>3.5-5.1</td><td>3.5-5.1</td><td>CKMB</td><td><obs conceptId="1378" />U/l</td><td></td><td></td>
</tr>

<tr>
<td>Cloride</td><td><obs conceptId="2845" />mmol/l</td><td>98-107</td><td>98-107</td><td colspan="5"></td>
</tr>

<tr>
<td>Calcium</td><td><obs conceptId="1379" />mg/dl</td><td>8.4-10.2</td><td>8.4-10.2</td><td colspan="5"></td>
</tr>

<tr>
<td>Magnesium</td><td><obs conceptId="1387" />mg/dl</td><td>1.6-2.3</td><td>1.6-2.3</td><td>Fer/fe</td><td><obs conceptId="2850" />Umol/</td><td>8.8-32.24</td><td>6.0-30.4</td>
</tr>

<tr>
<td>Co2</td><td><obs conceptId="2846" />mmol/l</td><td>22-30</td><td>22-30</td><td>HB Glycolysé</td><td><obs conceptId="1852" />%</td><td></td><td></td>
</tr>

<tr>
<td>Amonia</td><td><obs conceptId="2847" />Umol/l</td><td>9-30</td><td>9-30</td><td>Glucose2</td><td><obs conceptId="887" />mg/dl</td><td>70-110</td><td>70-110</td>
</tr>
</table></td>
</tr>
<tr>
<td>
<table border="1" cellspacing="0" align="center"  width="95%">
<tr>
<td colspan="8" align="center" bgcolor="#95ADCA"><b>HEMATOLOGIE</b></td>
</tr>

<tr>
<td>Hematocrite</td><td><obs conceptId="1015" />%</td><td colspan="2" style="font-weight:bold"> Morphologie<obs conceptId="1374" style="checkbox" /></td><td colspan="2" style="font-weight:bold">Differential <obs conceptId="1026" style="checkbox" />%</td>
</tr>

<tr>
<td>Platelets</td><td><obs conceptId="729" />x10^9/1</td><td>Anisocytocis</td><td><obs conceptId="2894" /></td><td>Neurophilis Band</td><td><obs conceptId="2910" /></td>
</tr>

<tr>
<td>Reticulocytes</td><td><obs conceptId="1327" />%</td><td>Microcytosis</td><td><obs conceptId="2895" /></td><td>Neutrophilis Seg</td><td><obs conceptId="2911" /></td>
</tr>

<tr>
<td>Temps de saignement</td><td><obs conceptId="1384" />sec</td><td>Anisochromasie</td><td><obs conceptId="2905" /></td><td>Eosinophils</td><td><obs conceptId="1024" /></td>
</tr>

<tr>
<td>Temps de Coagulation</td><td><obs conceptId="2909" />sec</td><td>Polychromasie</td><td><obs conceptId="2901" /></td><td>Basophils</td><td><obs conceptId="1025" /></td>
</tr>

<tr>
<td>PT/INR</td><td><obs conceptId="2999" />sec</td><td>Macrocytosis</td><td><obs conceptId="2896" /></td><td>Monocytes</td><td><obs conceptId="1023" /></td>
</tr>
<tr>
<td>Vitesse sedimentaion</td><td><obs conceptId="1878" /></td><td>Spherocytes</td><td><obs conceptId="2904"/></td><td>Lymphocytes</td><td><obs conceptId="1021" /></td>
</tr>

<tr>
<td>Sickling Test</td><td><obs conceptId="1369" /></td><td>Poikilocytose</td><td><obs conceptId="2898" /></td><td>Normoblast</td><td><obs conceptId="3010" /></td>
</tr>

<tr>
<td>CD4</td><td><obs conceptId="5497" /></td><td>Hypochromasie</td><td><obs conceptId="2900" /></td><td>Myeloblastes</td><td><obs conceptId="1730" /></td>
</tr>

<tr>
<td>Malaria Smear</td><td><obs conceptId="32" /></td><td>Basophils stipling </td><td><obs conceptId="2902" /></td><td>Myelocytes</td><td><obs conceptId="3028" /></td>
</tr>

<tr>
<td>Proteine-c Reactive</td><td><obs conceptId="6232" />mg/l</td><td>Target Cells</td><td><obs conceptId="2903" /></td><td>Promyelocytes</td><td><obs conceptId="3029" /></td>
</tr>

<tr>
<td>Hemoglobine</td><td><obs conceptId="21" />g/dl</td><td>Ovalo/Elliptocytose</td><td><obs conceptId="2897" /></td><td>Metamyelocytes</td><td><obs conceptId="3030" /></td>
</tr>

<tr>
<td>WBC/globule blanc</td><td><obs conceptId="678" /></td><td>Megalocyte</td><td><obs conceptId="3211" /></td><td>NRBC/100 WBC</td><td><obs conceptId="2912" /></td>
</tr>

<tr>
<td>WBC Corrected</td><td><obs conceptId="6131" /></td><td></td><td></td><td>Plasma Cell</td><td><obs conceptId="1002" /></td>
</tr>

<tr>
<td colspan="4"></td><td>Atyp. Cells</td><td><obs conceptId="1328" /></td>
</tr>
</table>
</td>
</tr>   
<tr>
<td>
<table border="1" cellspacing="0" align="center" width="95%">
<tr>
<td colspan="6" align="center" bgcolor="#95ADCA" cellspacing="2"><b>ANALYSE URINE</b></td>
</tr>
<tr style="font-weight:bold">
<td>MACROSCOPIC<obs conceptId="2995" style="checkbox" /></td><td>RESULTAT</td><td>MICROSCOPIC<obs conceptId="2994" style="checkbox" /></td><td>RESULTAT</td>
</tr>

<tr>
<td>Sang</td><td><obs conceptId="3063"/></td><td>WBC</td><td><obs conceptId="2922" /></td>
</tr>

<tr>
<td>Urobilinogen</td><td><obs conceptId="3011" />mg/dl</td><td>RBC</td><td><obs conceptId="2923" /></td>
</tr>

<tr>
<td>Bilirubin</td><td><obs conceptId="2919" /></td><td>Epithelial cells</td><td><obs conceptId="666" /></td>
</tr>

<tr>
<td>Protein</td><td><obs conceptId="2887" />mgdl</td><td>Bacteria</td><td><obs conceptId="724" /></td>
</tr>

<tr>
<td>Nitrite</td><td><obs conceptId="2921" /></td><td>Mucus Threads</td><td><obs conceptId="2925" /></td>
</tr>

<tr>
<td>Ketone</td><td><obs conceptId="2885" /></td><td>Amphorous po4/urates</td><td><obs conceptId="2924" /></td>
</tr>

<tr>
<td>Sucre</td><td><obs conceptId="2916" />mg/dl</td><td>Cast/hyalin</td><td><obs conceptId="2926" /></td>
</tr>
<tr>

<td>pH</td><td><obs conceptId="2917" /></td><td>Casts wachs</td><td><obs conceptId="6132" /></td>
</tr>

<tr>
<td>Gravité specifique</td><td><obs conceptId="2920" /></td><td>Crystals </td><td><obs conceptId="2927" /></td>
</tr>

<tr>
<td>Urine Pregnancy Test</td><td><obs conceptId="45" /></td><td>Proteinurie</td><td><obs conceptId="1383" /></td>
</tr>
</table>
</td>
</tr>   
<tr>
<td>
<table border="1" width="95%" cellspacing="0" align="center">
<tr>
<td colspan="8" align="center" bgcolor="#95ADCA"><b>EXAMEN DE SEL</b></td>
</tr>

<tr style="font-weight:bold">
<td colspan="4">Ova and Parasites<obs conceptId="2996" style="checkbox" /></td><td colspan="2">Stool Guaiac Test<obs conceptId="1372" style="checkbox"/></td>
</tr>

<tr>
<td>E. Coli</td><td><obs conceptId="709" /></td><td>Ascaris Ova</td><td><obs conceptId="716" /></td><td>Blood</td><td><obs conceptId="2918" /></td>
</tr>

<tr>
<td></td><td></td><td>Hookworm</td><td><obs conceptId="2934" /></td><td>Fat</td><td><obs conceptId="2938" /></td>
</tr>

<tr>
<td>E. nana</td><td><obs conceptId="2940" /></td><td>Trichirus</td><td><obs conceptId="2935" /></td><td>Mucus</td><td><obs conceptId="2939" /></td>
</tr>

<tr>
<td>I Butschili</td><td><obs conceptId="2941" /></td><td>Taenia Ova</td><td><obs conceptId="2936" /></td><td></td><td></td>
</tr>

<tr>
<td>Giardia</td><td><obs conceptId="1797" /></td><td>Hymenolepsis</td><td><obs conceptId="2937" /></td><td></td><td></td>
</tr>

<tr>
<td>Trichomonas</td><td><obs conceptId="684" /></td><td></td><td></td><td></td><td></td>
</tr>
</table>
</td>
</tr>   
<tr>
<td>
<table  align="center" cellspacing="0" border="1" width="50%">
<tr>
<td   colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> SEROLOGIE BANQUE DE SANG
</td>
</tr>   

<tr>
<td>Groupe Sanguin </td><td><obs conceptId="300" /></td><td>Cross-Match</td><td><obs conceptId="3033" /></td>
</tr>   
</table>
</td>
</tr>   
<tr>
<td>
<table  align="center" cellspacing="0" border="1" width="95%">
<tr>
<td   colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> SEROLOGIE
</td>
</tr>

<tr><td>Hepatite B</td><td><obs conceptId="1844" /></td><td>Vidal Test</td><td><obs conceptId="306" /></td></tr>

<tr><td>ASO</td><td><obs conceptId="1874" /></td><td>Cryptococose</td><td><obs conceptId="1219" /></td></tr>

<tr>
<td colspan="2">Syphilis <obs conceptId="223" style="no_yes" /></td><td>HIV <obs conceptId="1040" /></td><td></td>
</tr>
</table>
 </td>
</tr>   
<tr>
<td>
<table  align="center" cellspacing="0" border="1" width="95%">
<tr>
<td   colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> LIQUIDE CORPORELLE
</td>
</tr>
<tr>
<td >Liquide cerebrospinale  <obs conceptId="1377" style="checkbox" /></td><td>Pleural<obs conceptId="2011" style="checkbox" /></td><td>Ascitique <obs conceptId="1917" style="checkbox" /></td><td></td>
</tr>
<tr>
<td>Cell count : Globule Blanc</td><td><obs conceptId="3060" />mm3</td><td>Protein</td><td><obs conceptId="3016" />mg/dl</td>
</tr>
<tr>
<td>Globue rouge</td><td><obs conceptId="1879" />mm3</td><td>Sucre</td><td><obs conceptId="3062" />mg/dl</td>
</tr>
<tr>
<td>Differentiel:Lymphs</td><td><obs conceptId="3061" />%</td><td></td><td></td>
</tr>
<tr>
<td>Polys</td><td><obs conceptId="1022" />%</td><td>Other</td><td><obs conceptId="1939" /></td>
</tr>
<tr><td colspan="2">Cytologie<obs conceptId="3000" style="checkbox" /></td><td colspan="2">Chimie <obs conceptId="3001" style="checkbox" /></td></tr>

</table>
</td>
</tr>   
<tr>
<td>
<table  align="center" cellspacing="0" border="1" width="95%">
<tr>
<td   colspan="4" align="center" bgcolor="#95ADCA" style="font-weight:bold"> BACTERIOLOGIE / BACILLOSCOPIE
</td>
</tr>
<tr>
<td colspan="2">TB crachat <obs conceptId="6130" /></td><td>Culture</td><td><obs conceptId="2870" /></td>
</tr>

<tr>
<td colspan="4">Gram Stain <obs conceptId="1382"  size="100"/></td>
</tr>
</table>
</td>
</tr>
<tr><td align="center">Remarque <obs conceptId="1602" size="150" /></td></tr>                
</table>
<center><encounterProvider role="Hospital Provider"/>
<submit /></center>
</htmlform>

HAS-Haiti Dispensary Form

<htmlform>
    <macros>
        lightgrey=#e0e0e0
        lightblue=#95ADCA
        darkblue=#4444ff
    </macros>
    <div style="background-color: $lightblue" align="center"><b>FOM KONSILTASYON DISPANSE

</b></div><BR/>
    <center>Location <encounterLocation order="1,2,4,5,8,9"/>   
    Date <encounterDate /></center>


<table  bgcolor="#f9f9f9" border="1" width="80%" cellspacing="4" cellpadding="6" align="center">
 <tr>
<td>
<table border="1" cellspacing="0" width="95%" align="center">
<tr>
<td>KOB <obs conceptId="1719" />goud</td>
<td>TMP <obs conceptId="5088" /></td>
<td>TA <obs conceptId="5085" /> / <obs conceptId="5086" /></td>
<td>PWA <obs conceptId="5089" />kg</td>
</tr>
</table>
</td>
</tr>

<tr>
<td>
<table border="1" cellspacing="0" width="95%" align="center">
<tr><td colspan="3" bgcolor="#95ADCA" align="center"><b>DYAGNOSTIK</b></td></tr>
<tr>
<td>TIP VIZIT</td>
<td>TIP DYAGNOSTIK</td>
<td>KOD DYAGNOSTIK</td>
</tr>
<repeat>
<template>
<includeIf velocityTest="(($patient.gender == 'F') || ($patient.gender)) &&  ($patient.gender != 'M')">
<obsgroup groupingConceptId="2629">
<tr>
<td><obs conceptId="3100" /></td>
<td><obs conceptId="3104" /></td>
<td><obs conceptId="2879" answerConceptIds="3125,114,3149,1799,3159,3165,3178,3185,10,3126,43,3137,3138,1899,3139,3140,3141,891,1903,3142,3143,3144,3145,3146,117,3147,3148,1905,5334,3150,1910,212,16,1797,3151,3152,3153,3154,1801,29,1913,3155,3156,151,3157,3158,140,1970,3160,3161,892,3162,63,1965,3163,1998,3164,134,128,166,1981,1798,3166,3167,3168,6103,3170,3179,1927,1920,3182,3183,3177,123,141,3176,3184,3186,3,3187,3188,3189,1796,3190,903,3191,3192,3175,1949,1945,1942,1800,3171,3172,3173,3174,3127,3128,2014,5995,3129,3130,127,3131,3132,3133,3134,3136" answerLabels="1-INFECTIVE OTITIS EXTERNA UNSPECIFIED (3125)
,2-UNSPECIFIED OTITIS MEDIA (114)
,3-ACUTE TONSILLITIS (3149)
,4-DIPHTHERIA UNSPECIFIED (1799)
,5-ACUTE NASOPHARYNGITIS (COMMON COLD) (3159)
,6-ACUTE LARYNGITIS (3165)
,7-ACUTE SINUSITIS (3178)
,8-OTHER DISEASES OF UPPER RESPIRATORY TRACT (3185)
,9-ACUTE BRONCHITIS (10)
,10-UNSPECIFIED CHRONIC BRONCHITIS (3126)
,11-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED (43)
,12-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED GRAVE PNEUMONIA (3137)
,13-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED TRES GRAVE (3138)
,14-ASTHMA LEGER (1899)
,15-ASTHMA CRISE SEVERE (3139)
,16-UNSPECIFIED PULMONARY TUBERCULOSIS SUSPICION (3140)
,17-UNSPECIFIED PULMONARY TUBERCULOSIS  EN TRAITEMENT (3141)
,18-WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS) (891)
,19-UNSPECIFIED PLEURAL EFFUSION (1903)
,20-OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED (3142)
,21-ACUTE PERICARDITIS UNSPECIFIED (3143)
,23-HEART FAILURE UNSPECIFIED (3144)
,24-PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) (3145)
,25-VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED (3146)
,26-OTHER AND UNSPECIFIED CONJUNCTIVITIS (117)
,27-CONJUNCTIVAL XEROSIS (3147)
,28-UNSPECIFIED DISORDER OF EYE AND ADNEXA (3148)
,29-ESOPHAGITIS (1905)
,30-CANDIDIASIS OF MOUTH (5334)
,31-PERIAPICAL ABSCESS WITHOUT SINUS (3150)
,32-UNSPECIFIED GASTRITIS AND GASTRODUODENITIS DYSPEPSIA PEPTICULCERS ETC. (1910)
,33-GASTRIC ULCER (212)
,34-DIARRHEA OF PRESUMED INFECTIOUS ORIGIN DIARRHEAL DISEASES (16)
,35-GIARDIASIS (1797)
,36-SHIGELLOSIS UNSPECIFIED (3151)
,37-AMEBIASIS UNSPECIFIED (3152)
,38-VOLUME DEPLETION DISORDER DEGREE A (3153)
,39-VOLUME DEPLETION DISORDER DEGREE B (3154)
,40-VOLUME DEPLETION DISORDER DEGREE C (1801)
,41-HEPATITIS UNSPECIFIED (29)
,42-UNSPECIFIED PERITONITIS (1913)
,43-UNSPECIFIED HEMORRHOIDS WITHOUT MENTION OF COMPLICATION (3155)
,44-HERNIA OF OTHER SPECIFIED SITES WITHOUT MENTION OF OBSTRUCTION ORGANGRENE (3156)
,45-ABDOMINAL PAIN (151)
,46-INTESTINAL PARASITISM UNSPECIFIED (3157)
,47-OTHER DISORDERS OF INTESTINE (3158)
,48-SCABIES (140)
,49-PRURIGO (1970)
,50-UNSPECIFIED URTICARIA (3160)
,51-TOXOCARIASIS (3161)
,52-VARICELLA WITHOUT MENTION OF COMPLICATION (892)
,53-OTHER AND UNSPECIFIED MYCOSES (3162)
,54-MEASLES WITHOUT MENTION OF COMPLICATION MEASLES (63)
,55-IMPETIGO (1965)
,56-PITYRIASIS VERSICOLOR (3163)
,57-ANTHRAX UNSPECIFIED (1998)
,58-ULCER OF LOWER LIMBS EXCEPT DECUBITUS ULCER (3164)
,59-CELLULITIS AND ABSCESS OF UNSPECIFIED SITES (134)
,60-OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) WITHOUT MENTION OF COMPLICATION (128)
,61-DOG BITE (166)
,62-FRACTURE OF UNSPECIFIED BONE CLOSED (1981)
,63-CONTUSION OF UNSPECIFIED SITE (1798)
,64-UNSPECIFIED SITE OF SPRAIN AND STRAIN (3166)
,65-PYOGENIC ARTHRITIS (3167)
,67-UNSPECIFIED ARTHROPATHY (3168)
,68-OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED (6103)
,69-SCIATICA (3170)
,70-LUMBAGO (3179)
,71-NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY (1927)
,72-CYSTITIS UNSPECIFIED (1920)
,73-URINARY CALCULUS UNSPECIFIED (3182)
,74-ACUTE PYELONEPHRITIS (3183)
,75-RETENTION OF URINE (3177)
,76-UNSPECIFIED MALARIA (123)
,77-TYPHOID FEVER TYPHOID FEVER (141)
,78-RELAPSING FEVER (3176)
,79-HB-S DISEASE WITH MENTION OF CRISIS ANEMIA (3184)
,80-SICKLE-CELL ANEMIA  (3186)
,81-ANEMIA UNSPECIFIED (3)
,82-MALNUTRITION OF MILD DEGREE MALNUTRITION (3187)
,83-MALNUTRITION OF MODERATE DEGREE MALNUTRITION (3188)
,84-OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION (3189)
,85-KWASHIORKOR MALNUTRITION (1796)
,86-ACQUIRED IMMUNODEFICIENCY SYNDROME UNSPECIFIED SUSPICION SEXUALLY TRANSMITTED DISEASE AND  HIV INFECTION (3190)
,88-ESSENTIAL HYPERTENSION (903)
,89-MILD OR UNSPECIFIED PRE-ECLAMPSIA COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3191)
,90-ECLAMPSIA COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3192)
,91-OTHERS (CANCER HYPERTHYROID ETC.) (3175)
,92-MENINGITIS UNSPECIFIED (1949)
,93-EPILEPSY UNSPECIFIED (1945)
,94-HYSTERIA UNSPECIFIED (1942)
,95-COMA (1800)
,96-CONCUSSION UNSPECIFIED (3171)
,97-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL I (3172)
,98-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL II (3173)
,99-PREGNANCY EXAMINATION OR TEST PREGNANCY UNCONFIRMED PRENATAL III (3174)
,100-LATENT SYPHILIS UNSPECIFIED SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3127)
,101-UNSPECIFIED ABORTION COMPLICATION OF PREGNANCY DELIVERY AND PUERPERIUM (3128)
,102-CHANCROID PLUS CHANCRE (2014)
,103-URETHRAL DISCHARGE (5995)
,104-OTHER ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITHOUT MENTION OF ABSCESS (3129)
,105-OTHER VENEREAL DISEASES SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3130)
,106-DYSMENORRHEA (127)
,108-UNSPECIFIED DISORDERS OF MENSTRUSTION (3131)
,109-HYDROCELE UNSPECIFIED (3132)
,110-UNSPECIFIED SYMPTOM ASSOCIATED WITH FEMALE GENITAL ORGANS (3133)
,111-UNATTENDED DEATH (3134)
,113-CHILD DELIVERY (3136)
"/></td>

</tr></obsgroup>
</includeIf>

<includeIf velocityTest="$patient.gender == 'M' ">
<obsgroup groupingConceptId="2629">
<tr>
<td><obs conceptId="3100" /></td>
<td><obs conceptId="3104" /></td>
<td><obs conceptId="2879" answerConceptIds="3125,114,3149,1799,3159,3165,3178,3185,10,3126,43,3137,3138,1899,3139,3140,3141,891,1903,3142,3143,3144,3145,3146,117,3147,3148,1905,5334,3150,1910,212,16,1797,3151,3152,3153,3154,1801,29,1913,3155,3156,151,3157,3158,140,1970,3160,3161,892,3162,63,1965,3163,1998,3164,134,128,166,1981,1798,3166,3167,3168,6103,3170,3179,1927,1920,3182,3183,3177,123,141,3176,3184,3186,3,3187,3188,3189,1796,3190,903,3175,1949,1945,1942,1800,3171,3127,2014,5995,3129,3130,3132,3134" answerLabels="1-INFECTIVE OTITIS EXTERNA UNSPECIFIED (3125)
,2-UNSPECIFIED OTITIS MEDIA (114)
,3-ACUTE TONSILLITIS (3149)
,4-DIPHTHERIA UNSPECIFIED (1799)
,5-ACUTE NASOPHARYNGITIS (COMMON COLD) (3159)
,6-ACUTE LARYNGITIS (3165)
,7-ACUTE SINUSITIS (3178)
,8-OTHER DISEASES OF UPPER RESPIRATORY TRACT (3185)
,9-ACUTE BRONCHITIS (10)
,10-UNSPECIFIED CHRONIC BRONCHITIS (3126)
,11-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED (43)
,12-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED GRAVE PNEUMONIA (3137)
,13-BRONCHOPNEUMONIA ORGANISM UNSPECIFIED TRES GRAVE (3138)
,14-ASTHMA LEGER (1899)
,15-ASTHMA CRISE SEVERE (3139)
,16-UNSPECIFIED PULMONARY TUBERCULOSIS SUSPICION (3140)
,17-UNSPECIFIED PULMONARY TUBERCULOSIS  EN TRAITEMENT (3141)
,18-WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS) (891)
,19-UNSPECIFIED PLEURAL EFFUSION (1903)
,20-OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED (3142)
,21-ACUTE PERICARDITIS UNSPECIFIED (3143)
,23-HEART FAILURE UNSPECIFIED (3144)
,24-PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) (3145)
,25-VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED (3146)
,26-OTHER AND UNSPECIFIED CONJUNCTIVITIS (117)
,27-CONJUNCTIVAL XEROSIS (3147)
,28-UNSPECIFIED DISORDER OF EYE AND ADNEXA (3148)
,29-ESOPHAGITIS (1905)
,30-CANDIDIASIS OF MOUTH (5334)
,31-PERIAPICAL ABSCESS WITHOUT SINUS (3150)
,32-UNSPECIFIED GASTRITIS AND GASTRODUODENITIS DYSPEPSIA PEPTICULCERS ETC. (1910)
,33-GASTRIC ULCER (212)
,34-DIARRHEA OF PRESUMED INFECTIOUS ORIGIN DIARRHEAL DISEASES (16)
,35-GIARDIASIS (1797)
,36-SHIGELLOSIS UNSPECIFIED (3151)
,37-AMEBIASIS UNSPECIFIED (3152)
,38-VOLUME DEPLETION DISORDER DEGREE A (3153)
,39-VOLUME DEPLETION DISORDER DEGREE B (3154)
,40-VOLUME DEPLETION DISORDER DEGREE C (1801)
,41-HEPATITIS UNSPECIFIED (29)
,42-UNSPECIFIED PERITONITIS (1913)
,43-UNSPECIFIED HEMORRHOIDS WITHOUT MENTION OF COMPLICATION (3155)
,44-HERNIA OF OTHER SPECIFIED SITES WITHOUT MENTION OF OBSTRUCTION ORGANGRENE (3156)
,45-ABDOMINAL PAIN (151)
,46-INTESTINAL PARASITISM UNSPECIFIED (3157)
,47-OTHER DISORDERS OF INTESTINE (3158)
,48-SCABIES (140)
,49-PRURIGO (1970)
,50-UNSPECIFIED URTICARIA (3160)
,51-TOXOCARIASIS (3161)
,52-VARICELLA WITHOUT MENTION OF COMPLICATION (892)
,53-OTHER AND UNSPECIFIED MYCOSES (3162)
,54-MEASLES WITHOUT MENTION OF COMPLICATION MEASLES (63)
,55-IMPETIGO (1965)
,56-PITYRIASIS VERSICOLOR (3163)
,57-ANTHRAX UNSPECIFIED (1998)
,58-ULCER OF LOWER LIMBS EXCEPT DECUBITUS ULCER (3164)
,59-CELLULITIS AND ABSCESS OF UNSPECIFIED SITES (134)
,60-OPEN WOUND(S) (MULTIPLE) OF UNSPECIFIED SITE(S) WITHOUT MENTION OF COMPLICATION (128)
,61-DOG BITE (166)
,62-FRACTURE OF UNSPECIFIED BONE CLOSED (1981)
,63-CONTUSION OF UNSPECIFIED SITE (1798)
,64-UNSPECIFIED SITE OF SPRAIN AND STRAIN (3166)
,65-PYOGENIC ARTHRITIS (3167)
,67-UNSPECIFIED ARTHROPATHY (3168)
,68-OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED (6103)
,69-SCIATICA (3170)
,70-LUMBAGO (3179)
,71-NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY (1927)
,72-CYSTITIS UNSPECIFIED (1920)
,73-URINARY CALCULUS UNSPECIFIED (3182)
,74-ACUTE PYELONEPHRITIS (3183)
,75-RETENTION OF URINE (3177)
,76-UNSPECIFIED MALARIA (123)
,77-TYPHOID FEVER TYPHOID FEVER (141)
,78-RELAPSING FEVER (3176)
,79-HB-S DISEASE WITH MENTION OF CRISIS ANEMIA (3184)
,80-SICKLE-CELL ANEMIA (3186)
,81-ANEMIA UNSPECIFIED (3)
,82-MALNUTRITION OF MILD DEGREE MALNUTRITION (3187)
,83-MALNUTRITION OF MODERATE DEGREE MALNUTRITION (3188)
,84-OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION (3189)
,85-KWASHIORKOR MALNUTRITION (1796)
,86-ACQUIRED IMMUNODEFICIENCY SYNDROME UNSPECIFIED SUSPICION SEXUALLY TRANSMITTED DISEASE AND  HIV INFECTION (3190)
,88-ESSENTIAL HYPERTENSION (903)
,91-OTHERS (CANCER HYPERTHYROID ETC.) (3175)
,92-MENINGITIS UNSPECIFIED (1949)
,93-EPILEPSY UNSPECIFIED (1945)
,94-HYSTERIA UNSPECIFIED (1942)
,95-COMA (1800)
,96-CONCUSSION UNSPECIFIED (3171)
,100-LATENT SYPHILIS UNSPECIFIED SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3127)
,102-CHANCROID PLUS CHANCRE (2014)
,103-URETHRAL DISCHARGE (5995)
,104-OTHER ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITHOUT MENTION OF ABSCESS (3129)
,105-OTHER VENEREAL DISEASES SEXUALLY TRANSMITTED DISEASE AND HIV INFECTION (3130)
,109-HYDROCELE UNSPECIFIED (3132)
,111-UNATTENDED DEATH (3134)
"/></td>

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</includeIf>
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<render/>
<render/>
<render/>
<render/>
</repeat>

</table>
</td>
</tr>

<tr>
<td>
<table border="1" cellspacing="0" width="95%" align="center">
<tr><td colspan="2"  bgcolor="#95ADCA" align="center"><b>MEDIKAMAN</b></td></tr>
<tr>
<td>PASYAN</td>
<td>KOD MEDIKAMAN</td>
</tr>
<includeIf velocityTest="(($patient.gender == 'F') || ($patient.gender)) &&  ($patient.gender != 'M')">
<repeat>
    <template>
<obsgroup groupingConceptId="3094" >
<tr>
<td><obs conceptId="3092" /></td>
<td><obs conceptId="3093" answerConceptIds="88,2078,6101,2757,2512,2114,2339,2341,2117,3056,3111,2121,2122,2521,446,2321,2440,2495,2303,2085,2427,2125,2128,2327,2406,3118,351,2425,2490,246,3108,3066,3124,3123,3113,2130,2543,190,907,3114,2416,2415,409,2442,2444,2358,2362,3120,3119,3121,2398,323,2486,3122,2340,3117,3115,944,2779,2368" answerLabels="1-ASPIRIN 75MG (88)
,2-ASPIRIN 500MG (2078)
,3-VITAMIN A 200 000IU (6101)
,4-AMINOPHYLLINE 200MG (2757)
,5-AMOXICILLIN 500MG (2512)
,6-CHLORAMPHENIC 250MG CAP (2114)
,7-CHLOROQUINE 100MG (2339)
,8-CHLOROQUINE 250MG (2341)
,10-CIPROFLOXACIN 500MG (2117)
,11-BACTRIM 20/100 (3056)
,12-BACTRIM 80/400 (3111)
,13-DOXYCYCLINE 100MG (2121)
,14-ERYTHROMYCIN 250MG (2122)
,15-HCTZ 50MG (2521)
,16-ALUMINUM HYDROXIDE (446)
,17-METHYLDOPA 250MG (2321)
,18-METRONIDAZOLE 250MG (2440)
,19-MULTIVITAMIN ADULT (2495)
,20-NYSTATIN VAGINAL (2303)
,21-PARACETAMOL 100MG (2085)
,22-PARACETAMOL 500MG (2427)
,23-PEN VK 125MG (2125)
,24-PEN VK 250MG (2128)
,25-PHENOBARBITAL 50MG (2327)
,26-PROPANTHELINE 15MG (2406)
,27-RESPERPINE 0.25 (3118)
,28-ORS PACKETS (351)
,29-FESO4 + ACID FOLIC (2425)
,31-VITAMIN SYRUP (2490)
,32-PIPERAZINE SYRUP (246)
,33-COUGH SYRUP (3108)
,34-BICILLIN 2.4 MIL.UNT (3066)
,35-WATER FOR INJ. 5ML (3124)
,36-WATER FOR INJ. 10ML (3123)
,37-LIDOCAINE 2% 10ML (3113)
,38-PROCAINE PENICILLIN (2130)
,39-CONCEPTROL TABLETS (2543)
,40-CONDOMS (190)
,41-MEDROXYPROGESTERONE (907)
,42-LOFEMINAL CYCLES (3114)
,43-NORPLANT INSERTS (2416)
,44-OVERETTE CYCLES (2415)
,45-BENZYL BENZOATE 25% (409)
,46-BETADINE SOLUTION (2442)
,47-CHLORHEXIDINE SOLN. (2444)
,48-DESENEX CREAM (2358)
,49-EMUL-O-BALM (2362)
,50-SET SUTURE (3120)
,51-SET PANSEMENT (3119)
,52-SULFADIAZINE 500MG (3121)
,53-TETRACYCLINE OPHT (2398)
,54-GENTIAN VIOLET 1% (323)
,55-ACID FOLIC 5MG (2486)
,56-TYLENOL SYRUP (3122)
,57-CHLOROQUINE SYRUP (2340)
,58-PARACETAMOL 120MG (3117)
,59-NORMAL SALINE (3115)
,60-ANTACID (944)
,61-OXYGENE 3% (2779)
,63-NEOMYCIN (2368)
" />
</includeIf>

<includeIf velocityTest="$patient.gender == 'M' ">
<repeat>
    <template>
<obsgroup groupingConceptId="3094" >
<tr>
<td><obs conceptId="3092" /></td>
<td><obs conceptId="3093" answerConceptIds="88,2078,6101,2757,2512,2114,2339,2341,2117,3056,3111,2121,2122,2521,446,2321,2440,2495,2085,2427,2125,2128,2327,2406,3118,351,2425,2490,246,3108,3066,3124,3123,3113,2130,190,409,2442,2444,2358,2362,3120,3119,3121,2398,323,2486,3122,2340,3117,3115,944,2779,2368" answerLabels="1-ASPIRIN 75MG (88)
,2-ASPIRIN 500MG (2078)
,3-VITAMIN A 200 000IU (6101)
,4-AMINOPHYLLINE 200MG (2757)
,5-AMOXICILLIN 500MG (2512)
,6-CHLORAMPHENIC 250MG CAP (2114)
,7-CHLOROQUINE 100MG (2339)
,8-CHLOROQUINE 250MG (2341)
,10-CIPROFLOXACIN 500MG (2117)
,11-BACTRIM 20/100 (3056)
,12-BACTRIM 80/400 (3111)
,13-DOXYCYCLINE 100MG (2121)
,14-ERYTHROMYCIN 250MG (2122)
,15-HCTZ 50MG (2521)
,16-ALUMINUM HYDROXIDE (446)
,17-METHYLDOPA 250MG (2321)
,18-METRONIDAZOLE 250MG (2440)
,19-MULTIVITAMIN ADULT (2495)
,21-PARACETAMOL 100MG (2085)
,22-PARACETAMOL 500MG (2427)
,23-PEN VK 125MG (2125)
,24-PEN VK 250MG (2128)
,25-PHENOBARBITAL 50MG (2327)
,26-PROPANTHELINE 15MG (2406)
,27-RESPERPINE 0.25 (3118)
,28-ORS PACKETS (351)
,29-FESO4 + ACID FOLIC (2425)
,31-VITAMIN SYRUP (2490)
,32-PIPERAZINE SYRUP (246)
,33-COUGH SYRUP (3108)
,34-BICILLIN 2.4 MIL.UNT (3066)
,35-WATER FOR INJ. 5ML (3124)
,36-WATER FOR INJ. 10ML (3123)
,37-LIDOCAINE 2% 10ML (3113)
,38-PROCAINE PENICILLIN (2130)
,40-CONDOMS (190)
,45-BENZYL BENZOATE 25% (409)
,46-BETADINE SOLUTION (2442)
,47-CHLORHEXIDINE SOLN. (2444)
,48-DESENEX CREAM (2358)
,49-EMUL-O-BALM (2362)
,50-SET SUTURE (3120)
,51-SET PANSEMENT (3119)
,52-SULFADIAZINE 500MG (3121)
,53-TETRACYCLINE OPHT (2398)
,54-GENTIAN VIOLET 1% (323)
,55-ACID FOLIC 5MG (2486)
,56-TYLENOL SYRUP (3122)
,57-CHLOROQUINE SYRUP (2340)
,58-PARACETAMOL 120MG (3117)
,59-NORMAL SALINE (3115)
,60-ANTACID (944)
,61-OXYGENE 3% (2779)
,63-NEOMYCIN (2368)
" />
</includeIf>

</td>
</tr>
</obsgroup>
</template>

<render/>
<render/>
<render/>
<render/>

</repeat>

<tr>
<td colspan="2"><font color="#f9f9f9">.</font></td>
<tr>
<td>DAT RANDEVOU <obs conceptId="5096" allowFutureDates="true"/></td>
<td>DAT REFERAL <obs conceptId="3097" allowFutureDates="true"/></td>
</tr>
</tr>
</table>
</td>
</tr>
</table>
<CENTER>MOUN KI SIYEN <encounterProvider role="Health Agent"/>                   
<submit/></CENTER>
</htmlform>

HAS-Haiti Hospital Admission/Discharge Form

<htmlform>
<script type="text/javascript">
$j(function() {
     getField('transfertoward.value').change(function() {
              if( getValue('transfertoward.value') == getValue('ward.value') ) {
                    setValue('transfertoward.value', '');
              }
     });
});
</script>

<script type="text/javascript">
$j(function() {
      getField('dischargeDate.value').change(function() {
             if ( getValue('encounterDate.value') > getValue('dischargeDate.value')) {
                   window.alert('Dat dichaj ou antre pa kapab avan dat admisyon an.\nThe discharge date you entered is before the admission date.')
             }
     });
});
</script>


<script type="text/javascript">
<!-- Error Checking before Form Submit -->
beforeSubmit.push(function() {
    var error = false;
    <!-- Clear the previous errors -->
    setValue('returnDate.error', '');
    setValue('returnPlace.error', '');
    setValue('dischargeDate.error', '');
    setValue('procedureOne.error', '');
    setValue('procedureTwo.error', '');
    setValue('diagOne.error', '');
    setValue('diagTwo.error', '');
    setValue('diagThree.error', '');
    setValue('diagFour.error', '');
    setValue('transfertoward.error', '');

    <!-- For Admission/Discharge Dates -->
    if ( (getValue('dischargeDate.value') != '') &amp;&amp; (getValue('dischargeDate.value') &lt; getValue('encounterDate.value'))) {
        getField('dischargeDate.error').html('Dat dichaj ou antre a pa kapab avan dat admisyon an.\nThe discharge date cannot be before the admission date.').show();
        error=true;
    }

    <!-- For Return Visit Date -->
    if ( (getValue('returnDate.value') != '') &amp;&amp; (getValue('dischargeDate.value') &gt; getValue('returnDate.value'))) {
        getField('returnDate.error').html('Dat randevou ou antre a pa kapab avan dat dichaj la.\nThe return visit date cannot be before the discharge date.').show();
        error=true;
    }

    <!-- For abandon with Follow-up Date -->
    if ( (getValue('abandon.value') == 'true') &amp;&amp; (getValue('returnDate.value') != '') ) {
        getField('returnDate.error').html('Ou pa kapab antre dat randevou si pasyan an sove.\nYou cannot enter a return visit date if the patient left without authorization.').show();
        error=true;
    }

    <!-- For Abandon with Follow-up Place -->
    if ( (getValue('abandon.value') == 'true') &amp;&amp; (getValue('returnPlace.value') != '') ) {
        getField('returnPlace.error').html('Ou pa kapab antre ki kote yo bay pasyan an randevou si li sove.\nYou cannot enter a return visit location if the patient left without authorization.').show();
        error=true;
    }

    <!-- For status=died with Follow-up Date -->
    if ( (getValue('status.value') == '159') &amp;&amp; (getValue('returnDate.value') != '') ) {
        getField('returnDate.error').html('Ou pa kapab antre dat randevou si pasyan an mouri.\nYou cannot enter a return visit date if the patient died.').show();
        error=true;
    }

    <!-- For status=died with Follow-up Place -->
    if ( (getValue('status.value') == '159') &amp;&amp; (getValue('returnPlace.value') != '') ) {
        getField('returnPlace.error').html('Ou pa kapab antre ki kote yo bay pasyan an randevou si li mouri.\nYou cannot enter a return visit location if the patient died.').show();
        error=true;
    }

    <!-- For Abandon with Transfer -->
    if ( (getValue('abandon.value') == 'true') &amp;&amp; (getValue('transfertoward.value') != '') ) {
        getField('transfertoward.error').html('Ou pa kapab antre nan ki wòd yo tranfere pasyan an  si li sove.\nYou cannot enter a transfer ward if the patient left without authorization.').show();
        error=true;
    }

    <!-- For Both Procedures the Same -->
    if ( ( (getValue('procedureOne.value') != '') &amp;&amp; (getValue('procedureTwo.value') != '') ) &amp;&amp; (getValue('procedureOne.value') == getValue('procedureTwo.value'))) {
        getField('procedureTwo.error').html('Ou pa kapab genyen yon menm pwosedi de (2) fwa.\nYou cannot have the same procedure twice').show();
        error=true;
    }

    <!-- For Diagnosis Two Same -->
    if ( (getValue('diagTwo.value') != '') &amp;&amp;
        ( getValue('diagTwo.value') == getValue('diagOne.value') ||
          getValue('diagTwo.value') == getValue('diagThree.value') ||
          getValue('diagTwo.value') == getValue('diagFour.value') ) ) {
        getField('diagTwo.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show();
        error=true;
    }

    <!-- For Diagnosis Three Same -->
    if ( (getValue('diagThree.value') != '') &amp;&amp;
        ( getValue('diagThree.value') == getValue('diagOne.value') ||
          getValue('diagThree.value') == getValue('diagTwo.value') ||
          getValue('diagThree.value') == getValue('diagFour.value') ) ) {
        getField('diagThree.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show();
        error=true;
    }
    
    <!-- For Diagnosis Four Same -->
    if ( (getValue('diagFour.value') != '') &amp;&amp;
        ( getValue('diagFour.value') == getValue('diagOne.value') ||
          getValue('diagFour.value') == getValue('diagTwo.value') ||
          getValue('diagFour.value') == getValue('diagThree.value') ) ) {
        getField('diagFour.error').html('Ou pa kapab genyen yon menm diagnosis de (2) fwa.\nYou cannot have the same diagnosis twice').show();
        error=true;
    }

    if (error == true) {
          return false;
    }
    return true;
});
</script>

    <macros>
        lightgrey=#e0e0e0
        lightblue=#95ADCA
        darkblue=#4444ff
    </macros>

<div style="background-color: $lightblue"><b><center>Hospital Admission Form</center></b></div>
 
<table border="1" width="800px"  cellspacing="0" align="center" cellpadding="1">
<tr>
<td colspan="3">
<table border="1" width="100%"  valign="middle" cellspacing="0" cellpadding="1" ><tr><td><b>LAST NAME</b></td><td><b>FIRST NAME</b></td><td><b>DATE OF BIRTH</b></td><td><b>DOSSIER #</b> </td></tr>
<tr>
<td><span><lookup expression="patient.personName.familyName"/></span></td>
<td><span><lookup expression="patient.personName.givenName"/></span></td>
<td><span><lookup expression="patient.birthdate"/></span></td>
<td><span><lookup expression="patient.getPatientIdentifier(1)"/></span></td>
</tr>
<tr><td colspan="2"><B>LOCALITY</B></td><td><B>ADDRESS</B></td><td><B>CITY</B></td></tr>
<tr><td colspan="2"><lookup complexExpression="
#set( $locality = 0 )
#set( $locality = $personAttributes.get('Tribe') )
#if( $locality == 0 || $locality == 'no tribe name specified' )
    OUT DISTRICT
#else
    $locality
#end
"/></td>
<td><lookup expression="patient.personAddress.address1"/></td>
<td><lookup expression="patient.personAddress.cityVillage"/></td>
</tr>

<tr><td><B>PATIENT AGE</B></td><td><B>GENDER</B></td><td colspan="2"><B>PARENT (Mother)</B></td></tr>
<tr><td><span> <lookup expression="patient.age"/></span></td>
<td>   <span><lookup expression="patient.gender" codePrefix="gender_"/></span></td>
<td colspan="2"><lookup complexExpression="#foreach ( $relationship in $relationshipList )
    #if( $relationship.relationshipType.bIsToA == 'Parent' )
          #if( !($relationship.personB.patientId == $patient.patientId ))
             #if( $relationship.personB.gender == 'F' )
                   $relationship.personB.personName
             #end
          #end
    #end
#end
"/>
</td>
</tr>

</table>
</td><td align="center" valign="middle">
<img src="http://intranet.hashaiti.org:81/image/HASlogo_circle_black_small_whitebackground.gif"  />
<br />

<lookup complexExpression="
&#60;img src=&#34;http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=${patient.getPatientIdentifier(1)}&#34;/&#62;
" />

</td>
</tr>
</table>
<table border="1" width="800px" cellspacing="0" align="center" cellpadding="1">
<includeIf velocityTest="!(($patient.gender == 'F') || ($patient.gender == 'M')) || (! $patient.age)">
<tr>
<td>
<b><font color='darkorange' size='+2'>ERROR: Unknown gender or date of birth.  Please update patient demographics before filling out this form.<hr></hr>
Erè: Pasyan an pa gen sèks li oubyen dat nesans li antre nan sistèm nan, tanpri ajoute enfòmasyon sa yo avan ou ranpli fòm nan.</font></b>
</td>
</tr>
</includeIf>

<excludeIf velocityTest="!(($patient.gender == 'F') || ($patient.gender == 'M')) || (! $patient.age)">
<tr>
<td valign="middle" style="width:220px"><br/><b>Services: </b><br/><br/>
</td><td style="width:256px">

<includeIf velocityTest="$patient.gender == 'F' ">
<obs id="ward" conceptId="1827" required="true" answerConceptIds="1691,2037,3036,6206,2034,2036,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBGYN,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" />
</includeIf>
<includeIf velocityTest="$patient.gender == 'M' ">
<obs id="ward" conceptId="1827" required="true" answerConceptIds="1691,2037,3036,6206,2034,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" />
</includeIf>

</td><td ></td>
</tr>
<tr><td><b>Durée de l'hospitalisation:</b><br/>(Duration of Hospitalization)</td><td><b>Du</b> (From)<encounterDate id="encounterDate" default="today" disallowMultipleEncountersOnDate="warn" /></td><td><b>Au</b> (To)<obs id="dischargeDate" conceptId="1829" />
</td></tr>

<tr ><td valign="top"><b>Diagnostics(s)<br/></b>(Diagnosis)</td><td colspan="3" >

<obs id="diagOne" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="1" size="80" /><br/>

<obs id="diagTwo" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="2" size="80"/><br/>

<obs id="diagThree" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="3" size="80" /><br/>

<obs id="diagFour" conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="4" size="80" />

</td></tr>

<tr><td valign="top"><b>Traitement ou Procédure</b><br/>(Treatment or Procedure)</td> <td colspan="3"><obs id="procedureOne" conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="1" size="80"/><br/>

<obs id="procedureTwo" conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="2" size="80"/><br/>

</td></tr>
<tr><td valign="top"><b>Transféré à </b><br/>(Tranferred to)</td><td colspan="2">

<includeIf velocityTest="$patient.gender == 'F' ">
<obs id="transfertoward" conceptId="1285" answerConceptIds="1691,2037,3036,6206,2034,2036,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBGYN,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" />
</includeIf>
<includeIf velocityTest="$patient.gender == 'M' ">
<obs id="transfertoward" conceptId="1285" answerConceptIds="1691,2037,3036,6206,2034,1542,2035,1692,6196,6194" answerLabels="ADULT ISOLATION,ADULT SURGERY (GENERAL),ANNEXE (MALNUTRITION),CHOLERA,INTERNAL MEDICINE,OBSERVATION,PEDIATRIC GENERAL,PEDITRIC ISOLATION,PEDIATRIC NEONATAL,PEDIATRIC SURGERY" />
</includeIf>

</td></tr>
<tr><td valign="top"><b>Condition à L'éxeat</b><br/>(Status at Discharge)</td><td colspan="3"><obs id="status" conceptId="2044" style="radio"/></td></tr>

<tr><td valign="top"><b>Patir sans Autorisation</b><br/>(Left without Authorization)</td><td colspan="3"><obs id="abandon" conceptId="6505" style="checkbox" /></td></tr>

<tr><td><b>Rendez vous:</b><br/>(Return Visit)</td><td><b>Date de Rendez-vous</b><br/><obs id="returnDate" conceptId="5096" allowFutureDates="true" />  </td><td><b> Lieu </b>(Place)<br/><obs id="returnPlace" conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic,Autre" /></td>
</tr>

<tr>
<td  colspan="4" align="center"> <b>Lieu</b> (Location) <encounterLocation default="15" order="15" type="hidden" /> <b>Nom du Medecin</b> (Doctor Name)<encounterProvider role="Hospital Provider"/>
<submit submitClass="submitButton"/>
</td>
</tr>     

</excludeIf>
</table>

<script type="text/javascript">
$j(function() {
    $j('.submitButton').click(function(event) {
        if ( getValue('dischargedate.value') ) {
          if (!(getValue('status.value'))) {
             window.alert("Please select the discharge status.");
             event.preventDefault();
          }
        }
    });
});
</script>
</htmlform>
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1 Comment

  1. Caution:

    In order to use the sample forms, you need to make sure that all the concepts referred to in the

    form are in your concept dictionary otherwise the form would not be saved.