Clinical Visit Form

JSON File: ct_clinical_visit.json

Questions	Concepts

Questions	Concepts
Patient Details
Encounter date ␣␣-␣␣-␣␣␣␣ 📆	163137 Encounter start date/time
Encounter Provider
Role
Encounter Location
Scheduled visit (boolean) 🔘 Yes 🔘 No	1246 Scheduled visit 1065 Yes 1066 No
Visit type 🔘 Express pharmacy pickup without clinician visit 🔘 Follow-up Visit, Regular	164181 Visit type 166446 Express pharmacy pickup without clinician visit 160523 Follow-up visit, regular
Population Category 🔘 General population 🔘 Key population 🔘 Priority population	166432 Study population type 166430 General population 166431 Target population 167143 Priority Population
Key Population Type 🔘 Intravenous drug user 🔘 Man who has sex with men 🔘 Prisoners 🔘 Sex worker 🔘 Transgender Persons	166433 Target population type 157351 Intravenous drug user 160578 Male who has sex with men 162277 In prison 160579 Sex worker 166415 Transgender status
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	166433 Target population type 166043 Late adolescent/young adulthood period 160580 Client of sex worker 159674 Fisherman 162198 Long-distance truck driver 169409 Migrant worker 166514 Non-intravenous drug user 164100 Refugee 169461 Uniformed services 5622 Other
Complaints and History of Complaints
History of Presenting Complaints (obsGroup)	1727 Signs and symptoms
History of Presenting Complaints	1390 History of present illness
Chiel Complaint ☑️ Abdominal pain ☑️ Back pain ☑️ Chest pain ☑️ Cough ☑️ Chills ☑️ Confusion ☑️ Convulsions ☑️ Depression ☑️ Diarrhea ☑️ Discharge from Penis ☑️ Dizziness and Giddiness ☑️ Ear Problem ☑️ Epigastric pain ☑️ Excessive Sweating ☑️ Facial Pain ☑️ Fever ☑️ Flank Pain ☑️ Headache ☑️ Hearing Loss ☑️ Itching ☑️ Leg Pain ☑️ Loss of Appetite ☑️ Memory Loss ☑️ Lethargy ☑️ Mouth ulceration ☑️ Muscle pain ☑️ Nausea ☑️ Neck Pain ☑️ Night sweats ☑️ Numbness of Foot ☑️ Pain in Eye ☑️ Pain in Joint ☑️ Pain in pelvis ☑️ Pain in Scrotum ☑️ Pain of Breast ☑️ Painful Mouth ☑️ Rash ☑️ Red eye ☑️ Rectal discharge ☑️ Rhinitis ☑️ Seizure ☑️ Shortness of breath ☑️ Shoulder Pain ☑️ Sore throat ☑️ Swallowing Painful ☑️ Swollen Feet ☑️ Tremor ☑️ Urinary symptoms ☑️ Vaginal bleeding ☑️ Vaginal discharge ☑️ Vision difficulties ☑️ Vomiting ☑️ Weight loss	5219 Chief complaint 151 Abdominal pain 141631 Dysfunctional Uterine Bleeding 121543 Anxiety 148035 Back pain 840 Hematuria 117671 Hematochezia 131021 Pain of breast 120749 Chest pain 871 Chills 120345 Confusion 143264 Cough 113054 Convulsions 144576 Coma 106 Acute Coryza 143129 Crying Infant 119574 Delirium 119537 Depression 142412 Diarrhea 122496 Dyspnea 118789 Dysphagia 142247 Discharge from Penis 141830 Dizziness and Giddiness 141585 Ear Problem 141128 Epigastric pain 131040 Pain in Eye 140941 Excessive Sweating 114399 Facial Pain 162626 Intense fatigue and general weakness 140070 Flank Pain 140238 Fever 135462 Lymphogranuloma venereum 139084 Headache 117698 Hearing Loss 116214 Hypotension 879 Pruritus 116558 Pain in Joint 114395 Leg pain 116334 Lethargy 135595 Loss of Appetite 135488 Lymphadenopathy 121657 Memory Loss 111721 Mouth ulceration 131015 Painful Mouth 133028 Muscle Cramp, Nocturnal 133632 Muscle pain 121 Myalgia 5978 Nausea 133469 Neck Pain 133027 Night sweats 132653 Numbness of Foot 162628 Unexplained bleeding 125225 Swallowing painful 131034 Pain in pelvis 5953 Vision difficulties 512 Rash 127777 Red eye 6017 Refusal to feed 113224 Rhinitis 131032 Pain in Scrotum 206 Seizure 126535 Shoulder Pain 112989 Shock 158843 Sore throat 141597Dyssomnia 125198 Swollen Feet 112200 Tremor 160208 Urinary symptoms 157498 Limb weakness 832 Weight loss 123396 Vaginal discharge 122983 Vomiting 111525 Vertigo 5622 Other
Specify other complaints __________________________________	160531 Chief complaint (text)
Onset Date ␣␣-␣␣-␣␣␣␣ 📆	1730 Sign/symptom start date
Duration (Days) __________________________________	1731 Sign/symptom duration
Chief complaint (text) __________________________________	160531 Chief complaint (text)
Past Medication History
Past medical & Surgical history narrative __________________________________	165095 General patient note
Current TPT/ TB Treatment
Currently on treatment for tuberculosis 🔘 Yes 🔘 No 🔘 Unknown	159798 Currently on tuberculosis treatment 1065 Yes 1066 No 1067 Unknown
Currently on tuberculosis prophylaxis treatment (TPT) 🔘 Yes 🔘 No 🔘 Unknown	166449 Currently taking tuberculosis prophylaxis 1065 Yes 1066 No 1067 Unknown
Previously completed Tuberculosis preventive treatment 🔘 Yes 🔘 No 🔘 Unknown	166463 Completed course of tuberculosis prophylaxis 1065 Yes 1066 No 1067 Unknown
Allergies & Adverse Drug Reactions
AAllergies	workspace-launcher
Patient reports adverse drug reaction(s)? 🔘 Yes 🔘 No 🔘 Unknown	1512 Allergy to drug 1065 Yes 1066 No 1067 Unknown
Medicine Causing Reaction	1193 Current drugs used
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) 148888 Anaphylaxis 148787 Angioedema 121629 Anaemia 120148 Arrhythmia 108 Bronchospasm 143264 Cough 142412 Diarrhea 118773 Dystonia 137162 Influenza-like symptoms 140039 Flushing 140238 Fever 5978 Nausea 139581 GI upset ***** 117399 Hypertension 111061 Hives 139084 Headache 159098 Hepatotoxicity 138111 Hyperuricaemia 879 Pruritus 121677 Mental status change 159347 Musculoskeletal pain 114736 Optic Neuritis 141600 Shortness of breath 512 Rash 113180 Rupture of Achilles tendon 123074 Visual disturbance 122983 Vomiting 1067 Unknown 5622 Other**
Severity 🔘 Not graded 🔘 Mild 🔘 Moderate 🔘 Severe 🔘 Life-threatening	162760 Severity of adverse reaction 1067 Unknown 1498 Mild 1499 Moderate 1500 Severe 162819 Fatal
Date of Onset	160753 Date of event
Action taken 🔘 Continue drug 🔘 Dose adjusted 🔘 Discontinued 🔘 Substitution	1255 Antiretroviral plan 1257 Continue regimen 981 Dosing change 1260 Stop all 1259 Change regimen
Family History
Family History Narrative __________________________________	160618 Family history comment
Sexual History
Sexually active? 🔘 Yes 🔘 No 🔘 Currently not sexually active	160109 Sexually active 1065 Yes 1066 No 160573 Currently not sexually active
Sex without a condom 🔘 Yes 🔘 No 🔘 Unknown	166658 Had sex without condom 1065 Yes 1066 No 1067 Unknown