SECTION 1: PATIENT IDENTIFICATION

CuraLink Patient Number @error('curalink_patient_number')

@enderror

Date Registered @error('registration_date')

@enderror

Registration Health Worker @error('registration_health_worker_id')

@enderror

Household Family * @error('family_id')

@enderror

Full Display Name * @error('name')

@enderror

National Registration Card (NRC) Number @error('national_id')

@enderror

First Name @error('first_name')

@enderror

First Surname (1er Apellido) @error('first_surname')

@enderror

Second Surname (2do Apellido) @error('second_surname')

@enderror

Gender * @error('gender')

@enderror

Date of Birth * @error('date_of_birth')

@enderror

Nationality @error('nationality')

@enderror

Phone Number @error('phone')

@enderror

Country of Birth @error('birthplace_country_id')

@enderror

Province of Birth @error('birthplace_province_id')

@enderror

Municipality of Birth @error('birthplace_municipality')

@enderror

Residential Address

Full Address Line @error('residential_address')

@enderror

Province @error('province_id')

@enderror

District @error('district_id')

@enderror

Constituency @error('constituency_id')

@enderror

Ward @error('ward_id')

@enderror

Community / Village @error('village_id')

@enderror

Skin Color @error('skin_color')

@enderror

Marital Status @error('marital_status')

@enderror

Education Level @error('educational_level')

@enderror

Occupation @error('occupation')

@enderror

Workplace Name @error('workplace_name')

@enderror

SECTION 2: FAMILY AND SOCIAL CONTEXT

Relationship to Head of Household @error('relationship_to_head')

@enderror

Primary Caregiver @error('primary_caregiver')

@enderror

Social Support @error('social_support')

@enderror

Lives With

@foreach(['Parents', 'Spouse', 'Children', 'Extended family', 'Alone'] as $rel)

lives_with ?? [])) ? 'checked' : '' }}> {{ $rel }}

@endforeach

PARENT DETAILS

Father Information

Father Full Name @error('father_name')

@enderror

Is Father Alive? @error('father_alive')

@enderror

Mother Information

Mother Full Name @error('mother_name')

@enderror

Is Mother Alive? @error('mother_alive')

@enderror

SECTION 3: PERSONAL MEDICAL HISTORY

Pre-existing Diseases

@foreach(['Hypertension', 'Diabetes Mellitus', 'HIV', 'Tuberculosis', 'Asthma', 'Epilepsy', 'Heart Disease', 'Stroke', 'Cancer', 'Kidney Disease', 'Sickle Cell Disease', 'Mental Health Condition'] as $disease)

medical_history_diseases ?? [])) ? 'checked' : '' }}> {{ $disease }}

@endforeach

Diagnosis Date

Details / Clinical Presentation

Current Treatment Protocol

SECTION 4: SURGICAL HISTORY

Previous Surgeries

@php $surgeries = old('surgical_history', $patient->surgical_history ?? []); @endphp @forelse($surgeries as $idx => $surg) @empty @endforelse

Procedure / Operation	Year	Hospital	Complications

SECTION 5: ALLERGIES

Drug Allergies

Food Allergies

Other Allergies

Reaction / Severity

SECTION 6: MEDICATION HISTORY

Current Medications

@php $meds = old('current_medications', $patient->current_medications ?? []); @endphp @forelse($meds as $idx => $med) @empty @endforelse

Medication Name	Dose	Frequency	Reason

Medication Adherence

Reason for poor adherence (if applicable)

SECTION 7: IMMUNIZATION HISTORY (Esquema de Vacunación)

Childhood Vaccination

@foreach(['BCG', 'Polio', 'Pentavalent', 'PCV', 'Rotavirus', 'Measles'] as $vacc)

immunization_history ?? [])) ? 'checked' : '' }}> {{ $vacc }}

@endforeach

Adult Vaccination

@foreach(['COVID-19', 'Tetanus', 'Hepatitis B'] as $vacc)

immunization_history ?? [])) ? 'checked' : '' }}> {{ $vacc }}

@endforeach

SECTION 8: REPRODUCTIVE HEALTH (FEMALE)

is_pregnant ?? 0) ? 'checked' : '' }}> Patient is Currently Pregnant

Age at Menarche

Menstrual Cycle

Last Menstrual Period (LMP)

Pregnancy History

Number of Pregnancies (Gravida)

Number of Births (Para)

Number of Abortions

Number of Living Children

Contraception (Current Method)

ANC Visits Count (if applicable)

ANC Gestational Age (weeks)

ANC Risk Factors

SECTION 8: REPRODUCTIVE HEALTH (MALE)

Fertility Concerns

Sexual Health Concerns

SECTION 9: LIFESTYLE ASSESSMENT

Tobacco Use

Status

Type

Duration (years)

Quantity per day

Alcohol Use Frequency

Physical Activity Level

Nutrition & Anthropometry Assessment

Height (cm)

Weight (kg)

BMI (Auto-calculated)

Waist Circumference (cm)

Diet Pattern

Fruit Intake

Vegetable Intake

Sugar Intake

Salt Intake

Staple Foods

@foreach(['Nshima', 'Rice', 'Potatoes', 'Bread', 'Cassava'] as $food)

staple_foods ?? [])) ? 'checked' : '' }}> {{ $food }}

@endforeach

SECTION 10: OCCUPATIONAL & ENVIRONMENTAL HISTORY

Occupational Risks

@foreach(['Mining exposure', 'Agricultural chemicals', 'Dust exposure', 'Heavy labour', 'Radiation exposure', 'Other'] as $risk)

occupational_risks ?? [])) ? 'checked' : '' }}> {{ $risk }}

@endforeach

Environmental Risks

@foreach(['Unsafe water', 'Poor sanitation', 'Indoor air pollution', 'Flooding', 'Vector exposure'] as $risk)

environmental_risks ?? [])) ? 'checked' : '' }}> {{ $risk }}

@endforeach

SECTION 11: FAMILY HISTORY (Antecedentes Familiares)

Family History of Illnesses

@php $famHistory = old('family_history', $patient->family_history ?? []); @endphp @forelse($famHistory as $idx => $hist) @empty @endforelse

Disease / Condition	Relationship	Age of Onset

SECTION 12: PHYSICAL EXAMINATION (Baseline)

@php $pe = old('physical_examination', $patient->physical_examination ?? []); @endphp

Examination Date

Healthcare Worker

Vital Signs

Blood Pressure

Heart Rate

Resp. Rate

Temperature

SpO2

General Examination

Appearance

Nutrition Status

Hydration

System Examination Findings

@foreach(['Cardiovascular', 'Respiratory', 'Neurological', 'Musculoskeletal', 'Abdominal', 'Skin'] as $sys)

{{ $sys }} Findings

@endforeach

SECTION 13: SCREENING RECORD

@php $scr = old('screening_record', $patient->screening_record ?? []); @endphp

Non-Communicable Disease Screening

Blood Pressure

Blood Glucose

Cholesterol

Cancer Screening

Infectious Disease Screening

HIV Status / Date

TB Screening Status

Malaria History

STI / Hepatitis

SECTION 14: DISPENSARY CLASSIFICATION

Patient Category * @error('dispensary_group')

@enderror

Group 2 Risk Factors @foreach(['Tobacco', 'Alcohol', 'Obesity', 'Family history', 'Poor lifestyle', 'Occupational risk'] as $rf)

dispensary_risk_factors ?? [])) ? 'checked' : '' }}> {{ $rf }}

@endforeach

Group 3: Chronic Conditions

Group 4: Disability Condition

Group 4: Support Required

Removal Reason @error('removal_reason')

@enderror

Risk Factors Summary

SECTION 15: HEALTH PROBLEM LIST

@php $probs = old('health_problem_list', $patient->health_problem_list ?? []); @endphp @forelse($probs as $idx => $prob) @empty @endforelse

Problem / Diagnosis	Date Identified	Status

SECTION 16: INDIVIDUAL CARE PLAN

@php $plan = old('individual_care_plan', $patient->individual_care_plan ?? []); @endphp

Preventive Care Checklist

@foreach(['Lifestyle counselling', 'Screening', 'Vaccination', 'Health education', 'Family planning', 'Mental health support'] as $pc)

@endforeach

Treatment Plan

Diagnosis

Medication

Follow-up schedule

Referral History

Referred To

Reason for Referral

Referral Outcome