Clinical Visit Form
JSON File: ct_clinical_visit.json
Questions | Concepts |
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Patient Details |
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Encounter date ␣␣-␣␣-␣␣␣␣ 📆 | |
Encounter Provider |
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Role |
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Encounter Location |
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Scheduled visit (boolean) 🔘 Yes 🔘 No | |
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular | |
Population Category 🔘 General population 🔘 Key population 🔘 Priority population | |
Key Population Type 🔘 Intravenous drug user 🔘 Man who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons | |
Priority Population Type 🔽 Adolescent Girls & Young Women 🔽 Client of sex worker 🔽 Fisher Folk 🔽 Long-distance truck driver 🔽 Migrant Workers 🔽 Non-intravenous drug user 🔽 Refugee 🔽 Uniformed Forces 🔽 Other | |
Complaints and History of Complaints |
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History of Presenting Complaints (obsGroup) | |
History of Presenting Complaints | |
Chiel Complaint | |
Specify other complaints __________________________________ | |
Onset Date ␣␣-␣␣-␣␣␣␣ 📆 | |
Duration (Days) __________________________________ | |
Chief complaint (text) __________________________________ | |
Past Medication History |
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Past medical & Surgical history narrative __________________________________ | |
Current TPT/ TB Treatment |
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Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown | |
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown | |
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown | |
Allergies & Adverse Drug Reactions |
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AAllergies | workspace-launcher |
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown | |
Medicine Causing Reaction | |
Reaction ☑️ Anaphylaxis ☑️ Angioedema ☑️ Anaemia ☑️ Arrhythmia ☑️ Bronchospasm ☑️ Cough ☑️ Diarrhea ☑️ Dystonia ☑️ Flu-Like Syndrome ☑️ Flushing ☑️ Fever ☑️ GI ☑️ Nausea ☑️ Hypertension ☑️ Hives ☑️ Headache ☑️ Hepatotoxicity ☑️ Hyperuricemia ☑️ Itching ☑️ Mental status change ☑️ Musculoskeletal pain ☑️ Optic Neuritis ☑️ Shortness of breath ☑️ Rash ☑️ Tendon Rupture ☑️ Visual Disturbances ☑️ Vomiting ☑️ Unknown ☑️ Other | 160646 Reaction (to an allergen)
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Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening | |
Date of Onset | |
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution | |
Family History |
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Family History Narrative __________________________________ | |
Sexual History |
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Sexually active? 🔘 Yes 🔘 No 🔘 Currently not sexually active | |
Sex without a condom 🔘 Yes 🔘 No 🔘 Unknown | |
Recent history of a Sexually Transmitted Infection 🔘 Yes 🔘 No 🔘 Unknown | |
Reproductive History |
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LMP ␣␣-␣␣-␣␣␣␣ 📆 | |
Is client pregnant? 🔘 Yes 🔘 No 🔘 Unknown | |
Expected Date of Delivery (EDD) ␣␣-␣␣-␣␣␣␣ 📆 | |
Wants (more) children in the near future? 🔘 Yes 🔘 No 🔘 Unknown | |
Family planning status 🔘 On Family Planning 🔘 Not using Family Planning 🔘 Wants Family Planning | |
Current/Desired Family Planning Method (s) 🔽 Condoms 🔽 Diaphragm 🔽 Emergency contraceptive pills 🔽 Female condom 🔽 Female sterilization 🔽 Hysterectomy 🔽 Implantable contraceptive 🔽 Injectable contraceptives 🔽 Intrauterine device 🔽 Lactational amenorrhea 🔽 Levonorgestrel 🔽 Male condom 🔽 Medroxyprogesterone acetate 🔽 Natural family planning 🔽 Norplant (implantable contraceptive) 🔽 Oral contraception 🔽 Sexual abstinence 🔽 Tubal ligation procedure 🔽 Vasectomy 🔽 Other non-coded | |
Current/Desired Family Planning Method (s) ☑️ Condoms ☑️ Vasectomy | |
Social History |
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History of Substance Use (Alcohol, Tobacco, Drugs) 🔘 Never 🔘 Current/Past use | |
Do you smoke cigarettes 🔘 Never smoker 🔘 Unknown if ever smoked 🔘 Smoker 🔘 Former smoker | |
Number of years smoked | |
Number of cigarette per day | |
Alcohol use 🔘 Never 🔘 Currently 🔘 In the past | |
Duration in Years*** | |
Substances abused***** ☑️ None ☑️ Barbiturate abuse ☑️ Cannabis Abuse ☑️ Cocaine abuse ☑️ Inhalant abuse ☑️ Khat abuse ☑️ Narcotic abuse ☑️ Opioid abuse | |
History of Recent Travel? 🔘 Yes 🔘 No | |
Subjective narrative***CC | 61675c28-e628-4173-bc65-d5e0df78a6da |
Immunization History |
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Immunizations | workspace-launcher |
Objective History |
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General examination findings ☑️ Normal ☑️ Cyanosis ☑️ Dehydration ☑️ Finger Clubbing ☑️ Jaundice ☑️ Lethargic ☑️ Lymph Node Axillary ☑️ Lymph Nodes Inguinal ☑️ Oral thrush ☑️ Oedema ☑️ Wasting ☑️ Nasal Flaring ☑️ Pallor | |
General Examination Notes | |
Systemic Examination |
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Physical exam outcome 🔘 Normal 🔘 Abnormal | |
Reviews of System ☑️ Abdominal ☑️ Cardiovascular ☑️ Central Nervous System ☑️ Head, Ear, Eye, Nose & Throat ☑️ Genitourinary ☑️ Musculoskeletal ☑️ Respiratory ☑️ Skin | |
Abdomen findings ☑️ Abdominal distension ☑️ Abdominal mass ☑️ Splenomegaly ☑️ Hepatomegaly ☑️ Abdominal tenderness |