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> </tr></obsgroup> </includeIf> </template> <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 Form
<htmlform>
<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' )
$relationship.personB.personName
#end
#end
#end
\#end
"/>
</td>
</tr>
</table>
</td><td align="center" valign="middle">
<img src="http://intranet.hashaiti.org:81/image/HASlogo_circle_black_small_whitebackground.gif" />
<br />
<lookup complexExpression="
<img src="[http://intranet.hashaiti.org:81/frontdesk/barre_code.php?string=$]{patient.getPatientIdentifier(1)}"/>
" />
</td>
</tr>
</table>
<table border="1" width="800px" cellspacing="0" align="center" cellpadding="1">
<tr>
<td valign="middle" style="width:220px"><br/><b>Services: </b><br/><br/></td><td style="width:256px">
<obs conceptId="1827" required="true" answerConceptIds="1691,2037,6206,2034,3036,2036,1542,2035,1692,6196,6194" answerLabels="ADULT.ISOLATION,ADULT.SURGERY (GENERAL),CHOLERA,INTERNAL.MEDICINE,MALNUTRITION,OBGYN,OBSERVATION,PEDIATRIC.GENERAL,PEDITRIC.ISOLATION,PEDIATRIC.NEONATAL,PEDIATRIC.SURGERY" />
</td><td ></td>
</tr>
<tr><td><b>Durée de l'hospitalisation:</b><br/>(Duration of Hospitalization)</td><td><b>Du</b> (From)<encounterDate default="today" /></td><td><b>Au</b> (To)<obs conceptId="1829" /></td></tr>
<tr ><td valign="top"><b>Diagnostics(s)<br/></b>(Diagnosis)</td><td colspan="3" >
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="1" size="80" /><br/>
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="2" size="80"/><br/>
<obs conceptId="6042" answerClasses="Diagnosis" style="autocomplete" labelText="3" size="80" /><br/>
<obs 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 conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="1" size="80"/><br/>
<br/>
<obs conceptId="6193" answerClasses="Procedure" style="autocomplete" labelText="2" size="80"/><br/>
<obs conceptId="2630" size="80" labelText="Non-Coded"/>
</td></tr>
<tr><td valign="top"><b>Transféré à </b><br/>(Tranferred to)</td><td colspan="2"><obs conceptId="1285" /></td></tr>
<tr><td valign="top"><b>Condition à L'éxeat</b><br/>(Status at Discharge)</td><td colspan="3"><obs conceptId="2044" style="radio"/></td></tr>
<tr><td><b>Rendez vous:</b><br/>(Return Visit)</td><td><b>Date de Rendez-vous</b><br/><obs conceptId="5096" allowFutureDates="true" /> </td><td><b> Lieu </b>(Place)<br/><obs conceptId="2639" answers="HAS,Dispensaire HAS,Dispensaire non HAS,HIV/TB Clinic" /></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="Provider"/>
<submit />
</td>
</tr>
</table>
</htmlform>
Files of HTML forms for using with the Metadata Sharing Module (includes necessary concepts, etc)
(Please note the specific OpenMRS version. Due to changes in the OpenMRS data model, metadata sharing packages created on OpenMRS 1.6.x will most likely not be importable in OpenMRS 1.7.x. Also, due to a slight change made in HTML Form Entry 1.7.2, forms exported using HTML Form Entry 1.7.0 or 1.7.1 will not be importable using HTML Form Entry 1.7.2+, or vice versa).
Hospital Albert Schweitzer Haiti LAB HTML Form (OpenMRS 1.7.1 Build 17223, HTML Form Entry 1.7.2, Metadata Sharing 0.8.1.8)
Hospital Albert Schweitzer Haiti Hosptial Admission HTML Form (OpenMRS 1.7.1 Build 17223, HTML Form Entry 1.7.2, Metadata Sharing 0.8.1.8)
Partners In Health HIV-exposed infant clinic visit (example) (OpenMRS 1.6.3 dev Build 17073, HTML Formentry 1.7.2, Metadata sharing 0.8.1.8)