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neuro_visit.html
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neuro_visit.html
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<htmlform formUuid="179ea08c-f66f-4b77-80a9-a5269a75ef49" formName="Neuro Visit" formEncounterType="4d0b20e6-9bb1-4504-bb76-24486387ca7f" formVersion="1.0">
<style>
.background {
background-color: #888;
}
table.neuro {
border-collapse: collapse;
background-color: #000;
}
table.neuro > tbody > tr > td, table.neuro > tbody > tr > th {
border: 0;
vertical-align: baseline;
padding: 2px;
text-align: left;
background-color: #F3F9FF;
}
div.inline {
display: inline;
}
table.neuroIneer {
border-collapse: collapse;
background-color: #000;
}
table.neuroIneer > tbody > tr > td, table.neuroIneer > tbody > tr > th {
border: 0;
vertical-align: baseline;
padding: 2px;
text-align: left;
background-color: #F3F9FF;
}
</style>
<script type="text/javascript">
jq(function () {
jq('input[type="checkbox"]').on('change', function() {
jq(this).siblings('input[type="checkbox"]').prop('checked', false);
});
});
</script>
<h2>Neuro Visit Form</h2>
<div class="background">
<br />
<table class="neuro">
<tbody>
<tr>
<td>Date:<encounterDate id="encounterDate" showTime="false" default="now" /></td>
<td>Location:<encounterLocation default="24" /></td>
<td>Examiner: <encounterProvider default="currentUser" /></td>
</tr>
<tr>
<td>
Spinal Sensory Level:
<obs conceptId="164189AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
</td>
<td><obs conceptId="160594AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="5141AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Rt" style="checkbox" /></td>
<td><obs conceptId="160594AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="5139AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Lt" style="checkbox" /></td>
</tr>
<tr>
<td colspan="3">Visit Type:<br />
<obs conceptId="164181AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptIds="164180AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160530AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Initial,Follow Up" style="radio" answerSeparator="" required="true" />
</td>
</tr>
</tbody>
</table>
<br />
<table class="neuro">
<tbody>
<repeat>
<template>
<tr>
<td>
Diagnosis: <obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Diagnosis" style="autocomplete" />
</td>
<td>
<obs conceptId="159946AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159943AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Primary" style="checkbox" />
<obs conceptId="159946AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159944AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Secondary" style="checkbox" />
</td>
</tr>
</template>
<render n="1" concept="Diagnosis"/>
<render n="2" concept="Diagnosis"/>
<render n="3" concept="Diagnosis"/>
</repeat>
</tbody>
</table>
<br />
<table class="neuro">
<tbody>
<tr>
<obsgroup groupingConceptId="1727AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA">
<td><obs conceptId="1728AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="140238AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Fever" style="checkbox" /></td>
<td><obs conceptId="1728AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="206AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Seizure" style="checkbox" /></td>
<td><obs conceptId="1728AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="122983AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Vomiting" style="checkbox" /></td>
</obsgroup>
</tr>
<tr>
<td colspan="3">
Other Diagnoses:<obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Diagnosis" style="autocomplete" />
</td>
</tr>
</tbody>
</table>
<table class="neuro">
<tbody>
<tr>
<td colspan="2">Urine Continence status:<obs conceptId="163272AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="163270AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,163269AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,163271AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,111636AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1175AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Normal,Continent with CIC,Continent with CIC and meds,Incontinent (urine),N/A,Unknown"/></td>
<td>CIC:<br />
<obs conceptId="164192AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164192AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
<obs conceptId="164192AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Unknown" style="checkbox" />
</td>
</tr>
<tr>
<td>
CIC New:<br />
<span>
<obs conceptId="164193AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164193AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
<obs conceptId="164193AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Unknown" style="checkbox" />
</span>
Bowel Management:<br />
<span>
<obs conceptId="164194AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164194AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
<obs conceptId="164194AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Unknown" style="checkbox" />
</span>
Bmgmt Visit New:<br />
<span>
<obs conceptId="164195AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164195AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
<obs conceptId="164195AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Unknown" style="checkbox" />
</span>
</td>
<td colspan="2">
<table class="neuroIneer">
<tbody>
<tr>
<td>
Currently taking medication:<br />
<obsgroup groupingConceptId="160741AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA">
<obs conceptId="159367AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="159367AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
</obsgroup>
</td>
</tr>
<tr id="medication-history">
<td>Medication History:<br />
<repeat>
<template>
<obsgroup groupingConceptId="160741AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA">
<obs conceptId="1282AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Drug" style="autocomplete" />
</obsgroup>
</template>
<render n="1" concept="Drug"/>
<render n="2" concept="Drug"/>
<render n="3" concept="Drug"/>
</repeat>
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td id="current-medication" colspan="3">Current medication:
<table class="neuroIneer">
<tbody>
<tr>
<th style="background-color: #888">Drug</th>
<th style="background-color: #888; text-align: center">Dose</th>
<th style="background-color: #888; text-align: center">Units</th>
<th style="background-color: #888; text-align: center">Frequency</th>
<th style="background-color: #888; text-align: center">Duration</th>
<th style="background-color: #888; text-align: center">Duration units</th>
</tr>
<repeat>
<template>
<obsgroup groupingConceptId="1442AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA">
<tr>
<td><obs conceptId="1282AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Drug" style="autocomplete" /></td>
<td><obs conceptId="1443AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
<td><obs conceptId="1444AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" size="5" /></td>
<td>
<obs conceptId="160855AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="160862AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160863AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160864AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160865AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160858AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160866AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,160870AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerLabels="Once daily,Once daily at bedtime,Once daily in the evening,Once daily in the morning,Twice daily,Thrice daily,Four times daily"
/>
</td>
<td><obs conceptId="159368AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
<td>
<obs conceptId="1732AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="1822AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1072AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1073AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1074AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerLabels="Hours,Days,Weeks,Months" />
</td>
</tr>
</obsgroup>
</template>
<render n="1" concept="Drug"/>
<render n="2" concept="Drug"/>
<render n="3" concept="Drug"/>
</repeat>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>
<br />
<table class="neuro">
<tbody>
<tr>
<td>
Stool Pattern:<obs conceptId="162654AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="1115AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,996AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,117208AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1175AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Normal,Constipated,Incontinent(stool),NA" />
</td>
<td colspan="2">
Maternal use of Folate during pregnancy: <br />
<table class="neuro">
<tbody>
<tr>
<td colspan="2">
<obs conceptId="164196AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164196AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
</td>
</tr>
</tbody>
</table>
</td>
</tr>
<tr>
<td>
Development Review :<obs conceptId="1189AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="162056AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,162061AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,162062AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,162063AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1175AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Smiling,Sitting,Standing,Walking,N/A" />
</td>
<td>
Braces :<obs conceptId="164201AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
</td>
<td>
Devices:<obs conceptId="164204AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
</td>
</tr>
<tr>
<td>
Speech:<obs conceptId="164209AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
</td>
<td>School:<obs conceptId="1712AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
<td>HC(cm):<obs conceptId="5314AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
</tr>
</tbody>
</table>
<br />
<table class="neuro">
<tbody>
<tr>
<td>
Frontanelle:<obs conceptId="162505AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="162507AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,162506AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1836AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Sunken,Flat,Full,Unknown"/>
</td>
<td>
Sight:<obs conceptId="164213AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="147215AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,135566AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,163344AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,112710AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,163345AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Blind,Decreased vision,Sunset,Squint,Normal vision,Unknown" />
</td>
<td>LE:<br />
<obs conceptId="164519AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="159533AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,140077AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,130802AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,126247AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerLabels="Normal strength,Flaccid Paraplegia,Paresis of Lower Extremity,Spastic Paraplegia,Unknown" />
</td>
</tr>
<tr>
<td>Shunt OK:<br />
<obs conceptId="164214AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="164214AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
</td>
<td>Surgical wound status:<obs conceptId="164215AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
<td>Scoliosis:<br />
<obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="113125AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="162334AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
</td>
</tr>
</tbody>
</table>
<br />
<table class="neuro">
<tbody>
<tr>
<td>
Decubitus ulcers:<br />
<obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="119656AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox" />
<obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="162334AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox" />
</td>
<td>Decubitus Ulcer Location:<obs conceptId="164216AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="129183AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,129184AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,129187AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,129188AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,142889AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,142890AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,155862AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="Lower Back,Heel,Buttock,Upper Back,Hip,Ankle,Sacrum,Unknown" />
</td>
<td>Other Signs: <obs conceptId="6042AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerClasses="Diagnosis" style="autocomplete"/></td>
</tr>
<tr>
<td>Date of Last Labs:
<obs conceptId="160753AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"/>
</td>
<td>Labs OK?:<obs conceptId="164217AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
<td>Issues: <obs conceptId="160531AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" /></td>
</tr>
<tr>
<td>
Health status:<br />
<obs conceptId="159640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159405AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Overall well" style="checkbox" />
<obs conceptId="159640AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="159407AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Not overall well" style="checkbox" />
</td>
<td>Next Clinic Date:<obs conceptId="5096AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" allowFutureDates="true"/></td>
<td>
Place:<obs conceptId="1763AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
SSI:<obs conceptId="1729AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA"
answerConceptIds="1107AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,164218AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,164219AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,164220AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA,1067AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabels="None,Superficial,Deep Incisional,Organ space,Unknown" />
</td>
</tr>
<tr>
<td>
Neuro OR Needed?:<br />
<obs conceptId="164258AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1065AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="Yes" style="checkbox"/>
<obs conceptId="164258AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerConceptId="1066AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" answerLabel="No" style="checkbox"/>
</td>
<td>Neuro OR Date:<obs conceptId="160753AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" allowFutureDates="true" /></td>
<td>Neuro OR Done?:<obs conceptId="9b66006e-8f03-43a8-bcd0-ab8d4e38557a" /></td>
</tr>
<tr>
<td>
Physical exam:<obs conceptId="1391AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA" />
</td>
<td></td>
<td></td>
</tr>
</tbody>
</table>
<br />
</div>
<submit submitClass="confirm right" submitCode="uicommons.saveForm"/>
<ifMode mode="VIEW" include="false">
<button class="cancel"><uimessage code="uicommons.cancelForm"/></button>
</ifMode>
</htmlform>