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<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>

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