<htmlform>
<!-- Autogenerated example form (template from 01-Nov-2010 -->
<macros>
paperFormId = (Fill this in)
headerColor =#009d8e
fontOnHeaderColor = white
</macros>
<style>
.section {
border: 1px solid $headerColor;
padding: 2px;
text-align: left;
margin-bottom: 1em;
}
.sectionHeader {
background-color: $headerColor;
color: $fontOnHeaderColor;
display: block;
padding: 2px;
font-weight: bold;
}
table.baseline-aligned td {
vertical-align: baseline;
}
</style>
<span style="float:right">Paper Form ID: $paperFormId</span>
<h2>Amani Antenatal History (v1.0)</h2>
<section headerLabel="1. Encounter Details">
<table class="baseline-aligned">
<tr>
<td>Date:</td>
<td>
<encounterDate default="today"/>
</td>
</tr>
<tr>
<td>Location:</td>
<td>
<encounterLocation/>
</td>
</tr>
<tr>
<td>Provider:</td>
<td>
<encounterProvider/>
</td>
</tr>
<tr>
<td>Patient Name:</td>
<td>
<lookup class="value" expression="patient.personName"/>
</td>
</tr>
</table>
</section>
<section headerLabel="2. Antenatal History">
<table border="1" cellspacing="0" class="baseline-aligned">
<tr>
<td>
<table border="1" cellspacing="0">
<tr>
<td>
<table>
<tr>
<td>
<b>Reason For Visit:</b>
</td>
<td>
<obs conceptId="1433" style="radio" answerConceptIds="1435,1434,5622" answerLabels="Planning Pregnancy<br \/ >, Currently Pregnant<br \/ >, Other"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Antenatal Visits #:</b>
</td>
<td>
<obs conceptId="1425"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>If Pregnant, was
<br />pregnancy intended?</b>
</td>
<td>
<obs conceptId="1426" style="radio" answerConceptIds="1065,1066,1067" answerLabels="Yes<br \/ >, No<br \/ >, Unknown"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Last Menstrual Period:</b>
</td>
<td>
<obs conceptId="1427"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Date of Delivery:</b>
</td>
<td>
<obs conceptId="1596"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Blood Type:</b>
</td>
<td>
<obs conceptId="1426" style="radio" answerConceptIds="152674, 152675, 152676, 152677, 152678,152679, 152680,152681" answerLabels="A+, A-<br \/ >, B+, B-<br \/ >, 0+, 0-<br \/ >,AB+, AB-<br \/ >"/>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td>
<table border="1" cellspacing="0">
<tr>
<td>
<table>
<tr>
<td>
<b>High-Risk Sex:</b>
</td>
<td>
<obs conceptId="1355" style="yes_no"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>HIV Test:</b>
</td>
<td>
<obs conceptId="1356" style="yes_no" dateLabel="<br \/ >Date:"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Partner's HIV Status:</b>
</td>
<td>
<obs conceptId="1436" style="radio" answerConceptIds="664,703,1067" answerLabels="Negative<br \/ >, Positive<br \/ >, Unknown"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>STI Treatment:</b>
</td>
<td>
<obs conceptId="1428"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>RPR/VDRL:</b>
</td>
<td>
<obs conceptId="299" style="radio" answerConceptIds="1228, 1229" answerLabels="Reactive<br \/ >, NR"/>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td>
<table>
<tr>
<td>
<b>Last Tetnus:</b>
</td>
<td>
<obs conceptId="1428"/>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td>
<b>Recent Contraceptive Use:</b>
<br/>
<obs conceptId="1635" answerConceptId="1107" answerLabel="None" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="780" answerLabel="Oral Contraception" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="190" answerLabel="Condoms" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="5277" answerLabel="Natural Planning / Rhythm" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="5278" answerLabel="Diaphragm" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="1378" answerLabel="Depo-Provera" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="1359" answerLabel="Norplant" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="1388" answerLabel="Surgery" style="checkbox"/>
<br/>
<obs conceptId="1635" answerConceptId="5622" answerLabel="Other" style="checkbox"/>
<br/>
</td>
</tr>
</table>
</td>
<td>
<table>
<tr>
<td>
<b>Previous Complications:</b>
<br/>
<obs conceptId="1430" answerConceptId="113859" answerLabel="Hypertension" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="1431" answerLabel="Low Birth Weight Baby" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="119481" answerLabel="Diabetes Mellitus" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="48" answerLabel="Miscarriage" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="1171" answerLabel="Cesarean Section" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="228" answerLabel="Antepartum Hemorrhage" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="230" answerLabel="Postpartum Hemorrhage" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="130" answerLabel="Puerperal Sepsis" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="113602" answerLabel="Prolonged Labor" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="127847" answerLabel="Recto-vaginal Fistula" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="49" answerLabel="Vesico-vaginal Fistula" style="checkbox"/>
<br/>
<obs conceptId="1430" answerConceptId="5622" answerLabel="Other" style="checkbox"/>
<br/>
</td>
</tr>
</table>
</td>
</tr>
</table>
</section>
<submit/>
</htmlform>
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