{"id":575,"date":"2026-01-27T16:10:19","date_gmt":"2026-01-27T13:10:19","guid":{"rendered":"https:\/\/sandbox.kazikasi.digital\/utulivu\/?page_id=575"},"modified":"2026-01-27T16:11:44","modified_gmt":"2026-01-27T13:11:44","slug":"1st-visit-details-form","status":"publish","type":"page","link":"https:\/\/sandbox.kazikasi.digital\/utulivu\/1st-visit-details-form\/","title":{"rendered":"1st Visit Details Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/utulivu\/wp-json\/wp\/v2\/pages\/575#gf_6' data-formid='6' novalidate><input id=\"gpnf_session_hash_6\" type=\"hidden\" name=\"gpnf_session_hash\" value=\"efad6b9b7913\">\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>3<\/span><span class='gf_step_page_name'> &#8211; Patient Details<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_orange' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_orange percentbar_33' style='width:33%;'><span>33%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_6_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_53\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_53'>Select Patient<\/label><div class='ginput_container ginput_container_select'><select disabled='disabled' name='input_53' id='input_6_53' class='large gfield_select'     aria-invalid=\"false\" ><option value='931' selected='selected'>Oyier Owiye #REG000473<\/option><option value='933' >Yolanda Masinde #REG000474<\/option><option value='960' >Hefziba Amba #REG000494<\/option><option value='963' >Hamilton Ogunda #REG000509<\/option><option value='968' >Ayabonga Mxotwe #REG000549<\/option><option value='972' >Mlemba Mtalitinya #REG000560<\/option><option value='978' >Editha Joseph #REG000579<\/option><option value='982' >Husseni Athumani #REG000590<\/option><option value='1012' >Felister McDonald #REG000595<\/option><option value='1014' >Grender McDonald #REG000597<\/option><option value='1019' >Grender McDonald #REG000602<\/option><option value='1032' >Amba Oyugi #REG000624<\/option><option value='1046' >Ahmed Msita #REG000630<\/option><\/select><input type=\"hidden\" id=\"gwro_hidden_capture_6_53\" name=\"gwro_hidden_capture_6_53\" value=\"931\" class=\"gf-default-disabled\" \/><\/div><\/div><div id=\"field_6_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_59'>Patient Entry ID<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_59' id='input_6_59' type='text' value='931' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_57\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_57'>Doctor on Duty<\/label><div class='ginput_container ginput_container_select'><select disabled='disabled' name='input_57' id='input_6_57' class='large gfield_select'     aria-invalid=\"false\" ><option value='38' selected='selected'>Demo Doctor<\/option><option value='8' >Gideon Mwanza<\/option><\/select><input type=\"hidden\" id=\"gwro_hidden_capture_6_57\" name=\"gwro_hidden_capture_6_57\" value=\"38\" class=\"gf-default-disabled\" \/><\/div><\/div><div id=\"field_6_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_107'>Old Entry ID<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_107' id='input_6_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_105'>Name of Patient<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_105' id='input_6_105' type='text' value='Oyier Owiye' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_58\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_58'>Registration Number<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_58' id='input_6_58' type='text' value='REG000473' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_45\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_45'>Temperature (\u00b0C)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_45' id='input_6_45' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_46\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_46'>Pulse (bpm)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_46' id='input_6_46' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_50\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_50'>Height (cm)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_50' id='input_6_50' type='number' step='any'   value='100' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_47\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_47'>Systolic (mmHg)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_47' id='input_6_47' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_48\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_48'>Diastolic (mmHg)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_48' id='input_6_48' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_49\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_49'>Spo2 (%)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_49' id='input_6_49' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_51\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_51'>Weight (kg)<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_51' id='input_6_51' type='number' step='any'   value='10' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-quarter field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_64'>BMI<\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_64' id='input_6_64' type='text' value='10' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_66'>Chief Complaint<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_6_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_67\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_67'>General Examination<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_67' id='input_6_67' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_70\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_70'>Preliminary Diagnosis<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_70' id='input_6_70' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_113\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_113'>History<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_6_113' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_6_115\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_115'>Plan of Action<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_115' id='input_6_115' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_6_102\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Send to Lab\/Procedure<\/legend><div class='ginput_container ginput_container_consent'><input name='input_102.1' id='input_6_102_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_102_1' >Get Laboratory\/Procedure Details for Patient<\/label><input type='hidden' name='input_102.2' value='Get Laboratory\/Procedure Details for Patient' class='gform_hidden' \/><input type='hidden' name='input_102.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_6_109\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Send to Pharmacy<\/legend><div class='ginput_container ginput_container_consent'><input name='input_109.1' id='input_6_109_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_6_109_1' >Get Drug Treatment Directly<\/label><input type='hidden' name='input_109.2' value='Get Drug Treatment Directly' class='gform_hidden' \/><input type='hidden' name='input_109.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_6_75' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' data-js='page-field-id-75' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_74\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_74'>Select Test\/Procedure 1<\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_6_74' class='large gfield_select'     aria-invalid=\"false\" ><option value='1093' selected='selected'>AMOXYLINE CAPSULE<\/option><option value='1094' >AMPICLOX CAPSULES<\/option><option value='1095' >AMPICLOX SYRUP 100mls<\/option><option value='1096' >ARTEFAN 20\/120<\/option><option value='1097' >AZUMA 500mg<\/option><option value='1098' >PIROXICAM TAB<\/option><option value='1099' >CAPTOPRIL TABS<\/option><option value='1100' >CEFALEXINE CAPSULES 250mg<\/option><option value='1101' >CEFALEXINE SYRUP 100mls<\/option><option value='1102' >CEFTRIAXONE IV<\/option><option value='1103' >CETRIZINE TABS<\/option><option value='1104' >CIPRO TABS 500mg<\/option><option value='1105' >DICLOFENAC IV<\/option><option value='1106' >DOXY CAPS<\/option><option value='1107' >FERROLIC TABS<\/option><option value='1108' >FOLIC ACID 5mg<\/option><option value='1109' >HYDROCOTISONE INJ<\/option><option value='1110' >INFUSSION DNS 500mls<\/option><option value='1111' >INFUSSION LR 500mls<\/option><option value='1112' >INFUSSION NS 500mls<\/option><option value='1113' >SKIN DERM CREAM<\/option><option value='1114' >IV ARTESUNATE 60mg<\/option><option value='1115' >IV PANTOPRAZOLE 40mg<\/option><option value='1116' >LORATADINE 10mg TABS<\/option><option value='1117' >LOSARTAN H TABS<\/option><option value='1118' >METRONIDAZOLE GEL<\/option><option value='1119' >METRONIDAZOLE SYRUP 100mls<\/option><option value='1120' >METRONIDAZOLE TABS<\/option><option value='1121' >METOCLOPRAMIDE INJ<\/option><option value='1122' >NIFEDIPINE TABS<\/option><option value='1123' >OMEPRAZOLE CAPS<\/option><option value='1124' >ORS<\/option><option value='1125' >PANTOPRAZOLE TABS 40mls<\/option><option value='1126' >PARACETAMOL TAB<\/option><option value='1127' >PARACETAMOL SYRUP 100mls<\/option><option value='1128' >RECEL GEL 100mls<\/option><option value='1129' >RECEL GEL SYRUP 180mls<\/option><option value='1130' >SUCRAFIL O GEL 100mls<\/option><option value='1131' >VITA CARE 200mls SUSPENSION<\/option><option value='1132' >CLOTRIMAZOLE CREAM<\/option><option value='1133' >MUPIROCIN CREAM<\/option><option value='1134' >VITAMIN B COMPLEX<\/option><option value='1135' >MULTIVITAMIN SYRUP<\/option><option value='1136' >BISACODLY<\/option><option value='1137' >IV CEFTRIAXON\/SALBACTUM<\/option><option value='1138' >WOODWARD SYRUP<\/option><option value='1139' >ALBENDAZOLE TAB<\/option><option value='1140' >MEBENDAZOLE<\/option><option value='1141' >VIVIAN TAB<\/option><option value='1142' >IBUPROFEN TAB<\/option><option value='1143' >MELOXICAM TAB<\/option><option value='1144' >TRAMADOL CAP<\/option><option value='1145' >PARACETAMOL INJ<\/option><option value='1146' >PREDINISOLONE TAB<\/option><option value='1147' >CETRIZEN TAB<\/option><option value='1148' >ALLUPRINOL TAB<\/option><option value='1149' >DOMPERIDONE TAB<\/option><option value='1150' >DICLOPER TAB<\/option><option value='1151' >BETROZOLE SYRUP<\/option><option value='1152' >COUPHY SYRUP<\/option><option value='1153' >ESOMEPRAZOLE<\/option><option value='1154' >GENTAMYCINE INJ<\/option><option value='1155' >SILDENAFIL CITRATE TAB<\/option><option value='1156' >AMOCLAV SYRUP<\/option><option value='1157' >CEFALEXIN SYRUP<\/option><option value='1158' >NASAL DROP<\/option><option value='1159' >NYSTATIN SYRUP<\/option><option value='1160' >AMOXYLINE SYRUP<\/option><option value='1161' >BBE<\/option><\/select><\/div><\/div><div id=\"field_6_77\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_77'>Cost 1<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_77' id='input_6_77' type='number' step='any'   value='3000' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_6_79\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add Test\/Procedure 2<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_79'><div class='gchoice gchoice_6_79_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_79.1' type='checkbox'  value='Click to Add'  id='choice_6_79_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_79_1' id='label_6_79_1' class='gform-field-label gform-field-label--type-inline'>Click to Add<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_96'>Notes on Test\/Procedure 1<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_6_96' type='text' value='Laboratory Test' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_80\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_80'>Select Test\/Procedure 2<\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_6_80' class='large gfield_select'     aria-invalid=\"false\" ><option value='1093' selected='selected'>AMOXYLINE CAPSULE<\/option><option value='1094' >AMPICLOX CAPSULES<\/option><option value='1095' >AMPICLOX SYRUP 100mls<\/option><option value='1096' >ARTEFAN 20\/120<\/option><option value='1097' >AZUMA 500mg<\/option><option value='1098' >PIROXICAM TAB<\/option><option value='1099' >CAPTOPRIL TABS<\/option><option value='1100' >CEFALEXINE CAPSULES 250mg<\/option><option value='1101' >CEFALEXINE SYRUP 100mls<\/option><option value='1102' >CEFTRIAXONE IV<\/option><option value='1103' >CETRIZINE TABS<\/option><option value='1104' >CIPRO TABS 500mg<\/option><option value='1105' >DICLOFENAC IV<\/option><option value='1106' >DOXY CAPS<\/option><option value='1107' >FERROLIC TABS<\/option><option value='1108' >FOLIC ACID 5mg<\/option><option value='1109' >HYDROCOTISONE INJ<\/option><option value='1110' >INFUSSION DNS 500mls<\/option><option value='1111' >INFUSSION LR 500mls<\/option><option value='1112' >INFUSSION NS 500mls<\/option><option value='1113' >SKIN DERM CREAM<\/option><option value='1114' >IV ARTESUNATE 60mg<\/option><option value='1115' >IV PANTOPRAZOLE 40mg<\/option><option value='1116' >LORATADINE 10mg TABS<\/option><option value='1117' >LOSARTAN H TABS<\/option><option value='1118' >METRONIDAZOLE GEL<\/option><option value='1119' >METRONIDAZOLE SYRUP 100mls<\/option><option value='1120' >METRONIDAZOLE TABS<\/option><option value='1121' >METOCLOPRAMIDE INJ<\/option><option value='1122' >NIFEDIPINE TABS<\/option><option value='1123' >OMEPRAZOLE CAPS<\/option><option value='1124' >ORS<\/option><option value='1125' >PANTOPRAZOLE TABS 40mls<\/option><option value='1126' >PARACETAMOL TAB<\/option><option value='1127' >PARACETAMOL SYRUP 100mls<\/option><option value='1128' >RECEL GEL 100mls<\/option><option value='1129' >RECEL GEL SYRUP 180mls<\/option><option value='1130' >SUCRAFIL O GEL 100mls<\/option><option value='1131' >VITA CARE 200mls SUSPENSION<\/option><option value='1132' >CLOTRIMAZOLE CREAM<\/option><option value='1133' >MUPIROCIN CREAM<\/option><option value='1134' >VITAMIN B COMPLEX<\/option><option value='1135' >MULTIVITAMIN SYRUP<\/option><option value='1136' >BISACODLY<\/option><option value='1137' >IV CEFTRIAXON\/SALBACTUM<\/option><option value='1138' >WOODWARD SYRUP<\/option><option value='1139' >ALBENDAZOLE TAB<\/option><option value='1140' >MEBENDAZOLE<\/option><option value='1141' >VIVIAN TAB<\/option><option value='1142' >IBUPROFEN TAB<\/option><option value='1143' >MELOXICAM TAB<\/option><option value='1144' >TRAMADOL CAP<\/option><option value='1145' >PARACETAMOL INJ<\/option><option value='1146' >PREDINISOLONE TAB<\/option><option value='1147' >CETRIZEN TAB<\/option><option value='1148' >ALLUPRINOL TAB<\/option><option value='1149' >DOMPERIDONE TAB<\/option><option value='1150' >DICLOPER TAB<\/option><option value='1151' >BETROZOLE SYRUP<\/option><option value='1152' >COUPHY SYRUP<\/option><option value='1153' >ESOMEPRAZOLE<\/option><option value='1154' >GENTAMYCINE INJ<\/option><option value='1155' >SILDENAFIL CITRATE TAB<\/option><option value='1156' >AMOCLAV SYRUP<\/option><option value='1157' >CEFALEXIN SYRUP<\/option><option value='1158' >NASAL DROP<\/option><option value='1159' >NYSTATIN SYRUP<\/option><option value='1160' >AMOXYLINE SYRUP<\/option><option value='1161' >BBE<\/option><\/select><\/div><\/div><div id=\"field_6_82\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_82'>Cost 2<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_82' id='input_6_82' type='number' step='any'   value='3000' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_6_83\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add Test\/Procedure 3<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_83'><div class='gchoice gchoice_6_83_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_83.1' type='checkbox'  value='Click to Add'  id='choice_6_83_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_83_1' id='label_6_83_1' class='gform-field-label gform-field-label--type-inline'>Click to Add<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_97'>Notes on Test\/Procedure 1<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_6_97' type='text' value='Laboratory Test' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_84\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_84'>Select Test\/Procedure 3<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_6_84' class='large gfield_select'     aria-invalid=\"false\" ><option value='1093' selected='selected'>AMOXYLINE CAPSULE<\/option><option value='1094' >AMPICLOX CAPSULES<\/option><option value='1095' >AMPICLOX SYRUP 100mls<\/option><option value='1096' >ARTEFAN 20\/120<\/option><option value='1097' >AZUMA 500mg<\/option><option value='1098' >PIROXICAM TAB<\/option><option value='1099' >CAPTOPRIL TABS<\/option><option value='1100' >CEFALEXINE CAPSULES 250mg<\/option><option value='1101' >CEFALEXINE SYRUP 100mls<\/option><option value='1102' >CEFTRIAXONE IV<\/option><option value='1103' >CETRIZINE TABS<\/option><option value='1104' >CIPRO TABS 500mg<\/option><option value='1105' >DICLOFENAC IV<\/option><option value='1106' >DOXY CAPS<\/option><option value='1107' >FERROLIC TABS<\/option><option value='1108' >FOLIC ACID 5mg<\/option><option value='1109' >HYDROCOTISONE INJ<\/option><option value='1110' >INFUSSION DNS 500mls<\/option><option value='1111' >INFUSSION LR 500mls<\/option><option value='1112' >INFUSSION NS 500mls<\/option><option value='1113' >SKIN DERM CREAM<\/option><option value='1114' >IV ARTESUNATE 60mg<\/option><option value='1115' >IV PANTOPRAZOLE 40mg<\/option><option value='1116' >LORATADINE 10mg TABS<\/option><option value='1117' >LOSARTAN H TABS<\/option><option value='1118' >METRONIDAZOLE GEL<\/option><option value='1119' >METRONIDAZOLE SYRUP 100mls<\/option><option value='1120' >METRONIDAZOLE TABS<\/option><option value='1121' >METOCLOPRAMIDE INJ<\/option><option value='1122' >NIFEDIPINE TABS<\/option><option value='1123' >OMEPRAZOLE CAPS<\/option><option value='1124' >ORS<\/option><option value='1125' >PANTOPRAZOLE TABS 40mls<\/option><option value='1126' >PARACETAMOL TAB<\/option><option value='1127' >PARACETAMOL SYRUP 100mls<\/option><option value='1128' >RECEL GEL 100mls<\/option><option value='1129' >RECEL GEL SYRUP 180mls<\/option><option value='1130' >SUCRAFIL O GEL 100mls<\/option><option value='1131' >VITA CARE 200mls SUSPENSION<\/option><option value='1132' >CLOTRIMAZOLE CREAM<\/option><option value='1133' >MUPIROCIN CREAM<\/option><option value='1134' >VITAMIN B COMPLEX<\/option><option value='1135' >MULTIVITAMIN SYRUP<\/option><option value='1136' >BISACODLY<\/option><option value='1137' >IV CEFTRIAXON\/SALBACTUM<\/option><option value='1138' >WOODWARD SYRUP<\/option><option value='1139' >ALBENDAZOLE TAB<\/option><option value='1140' >MEBENDAZOLE<\/option><option value='1141' >VIVIAN TAB<\/option><option value='1142' >IBUPROFEN TAB<\/option><option value='1143' >MELOXICAM TAB<\/option><option value='1144' >TRAMADOL CAP<\/option><option value='1145' >PARACETAMOL INJ<\/option><option value='1146' >PREDINISOLONE TAB<\/option><option value='1147' >CETRIZEN TAB<\/option><option value='1148' >ALLUPRINOL TAB<\/option><option value='1149' >DOMPERIDONE TAB<\/option><option value='1150' >DICLOPER TAB<\/option><option value='1151' >BETROZOLE SYRUP<\/option><option value='1152' >COUPHY SYRUP<\/option><option value='1153' >ESOMEPRAZOLE<\/option><option value='1154' >GENTAMYCINE INJ<\/option><option value='1155' >SILDENAFIL CITRATE TAB<\/option><option value='1156' >AMOCLAV SYRUP<\/option><option value='1157' >CEFALEXIN SYRUP<\/option><option value='1158' >NASAL DROP<\/option><option value='1159' >NYSTATIN SYRUP<\/option><option value='1160' >AMOXYLINE SYRUP<\/option><option value='1161' >BBE<\/option><\/select><\/div><\/div><div id=\"field_6_86\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_86'>Cost 3<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_86' id='input_6_86' type='number' step='any'   value='3000' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_6_87\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add Test\/Procedure 4<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_87'><div class='gchoice gchoice_6_87_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_87.1' type='checkbox'  value='Click to Add'  id='choice_6_87_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_87_1' id='label_6_87_1' class='gform-field-label gform-field-label--type-inline'>Click to Add<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_98\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_98'>Notes on Test\/Procedure 3<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_6_98' type='text' value='Laboratory Test' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_88\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_88'>Select Test\/Procedure 4<\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_6_88' class='large gfield_select'     aria-invalid=\"false\" ><option value='1093' selected='selected'>AMOXYLINE CAPSULE<\/option><option value='1094' >AMPICLOX CAPSULES<\/option><option value='1095' >AMPICLOX SYRUP 100mls<\/option><option value='1096' >ARTEFAN 20\/120<\/option><option value='1097' >AZUMA 500mg<\/option><option value='1098' >PIROXICAM TAB<\/option><option value='1099' >CAPTOPRIL TABS<\/option><option value='1100' >CEFALEXINE CAPSULES 250mg<\/option><option value='1101' >CEFALEXINE SYRUP 100mls<\/option><option value='1102' >CEFTRIAXONE IV<\/option><option value='1103' >CETRIZINE TABS<\/option><option value='1104' >CIPRO TABS 500mg<\/option><option value='1105' >DICLOFENAC IV<\/option><option value='1106' >DOXY CAPS<\/option><option value='1107' >FERROLIC TABS<\/option><option value='1108' >FOLIC ACID 5mg<\/option><option value='1109' >HYDROCOTISONE INJ<\/option><option value='1110' >INFUSSION DNS 500mls<\/option><option value='1111' >INFUSSION LR 500mls<\/option><option value='1112' >INFUSSION NS 500mls<\/option><option value='1113' >SKIN DERM CREAM<\/option><option value='1114' >IV ARTESUNATE 60mg<\/option><option value='1115' >IV PANTOPRAZOLE 40mg<\/option><option value='1116' >LORATADINE 10mg TABS<\/option><option value='1117' >LOSARTAN H TABS<\/option><option value='1118' >METRONIDAZOLE GEL<\/option><option value='1119' >METRONIDAZOLE SYRUP 100mls<\/option><option value='1120' >METRONIDAZOLE TABS<\/option><option value='1121' >METOCLOPRAMIDE INJ<\/option><option value='1122' >NIFEDIPINE TABS<\/option><option value='1123' >OMEPRAZOLE CAPS<\/option><option value='1124' >ORS<\/option><option value='1125' >PANTOPRAZOLE TABS 40mls<\/option><option value='1126' >PARACETAMOL TAB<\/option><option value='1127' >PARACETAMOL SYRUP 100mls<\/option><option value='1128' >RECEL GEL 100mls<\/option><option value='1129' >RECEL GEL SYRUP 180mls<\/option><option value='1130' >SUCRAFIL O GEL 100mls<\/option><option value='1131' >VITA CARE 200mls SUSPENSION<\/option><option value='1132' >CLOTRIMAZOLE CREAM<\/option><option value='1133' >MUPIROCIN CREAM<\/option><option value='1134' >VITAMIN B COMPLEX<\/option><option value='1135' >MULTIVITAMIN SYRUP<\/option><option value='1136' >BISACODLY<\/option><option value='1137' >IV CEFTRIAXON\/SALBACTUM<\/option><option value='1138' >WOODWARD SYRUP<\/option><option value='1139' >ALBENDAZOLE TAB<\/option><option value='1140' >MEBENDAZOLE<\/option><option value='1141' >VIVIAN TAB<\/option><option value='1142' >IBUPROFEN TAB<\/option><option value='1143' >MELOXICAM TAB<\/option><option value='1144' >TRAMADOL CAP<\/option><option value='1145' >PARACETAMOL INJ<\/option><option value='1146' >PREDINISOLONE TAB<\/option><option value='1147' >CETRIZEN TAB<\/option><option value='1148' >ALLUPRINOL TAB<\/option><option value='1149' >DOMPERIDONE TAB<\/option><option value='1150' >DICLOPER TAB<\/option><option value='1151' >BETROZOLE SYRUP<\/option><option value='1152' >COUPHY SYRUP<\/option><option value='1153' >ESOMEPRAZOLE<\/option><option value='1154' >GENTAMYCINE INJ<\/option><option value='1155' >SILDENAFIL CITRATE TAB<\/option><option value='1156' >AMOCLAV SYRUP<\/option><option value='1157' >CEFALEXIN SYRUP<\/option><option value='1158' >NASAL DROP<\/option><option value='1159' >NYSTATIN SYRUP<\/option><option value='1160' >AMOXYLINE SYRUP<\/option><option value='1161' >BBE<\/option><\/select><\/div><\/div><div id=\"field_6_90\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_90'>Cost 4<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_90' id='input_6_90' type='number' step='any'   value='3000' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_6_91\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Add Test\/Procedure 4<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_91'><div class='gchoice gchoice_6_91_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_91.1' type='checkbox'  value='Click to Add'  id='choice_6_91_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_91_1' id='label_6_91_1' class='gform-field-label gform-field-label--type-inline'>Click to Add<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_99'>Notes on Test\/Procedure 4<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_6_99' type='text' value='Laboratory Test' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_92\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_92'>Select Test\/Procedure 5<\/label><div class='ginput_container ginput_container_select'><select disabled=\"true\" name='input_92' id='input_6_92' class='large gfield_select'     aria-invalid=\"false\" ><option disabled=\"true\" selected value='' >&ndash; No Results &ndash;<\/option><\/select><\/div><\/div><div id=\"field_6_94\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_94'>Cost 5<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_94' id='input_6_94' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_6_100\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_100'>Notes on Test\/Procedure 5<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_6_100' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_6_106\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_6_106'>Summary of Lab\/Procedure Recommendations<\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_6_106-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/sandbox.kazikasi.digital\/utulivu\/wp-includes\/css\/dashicons.min.css?ver=7.0' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/sandbox.kazikasi.digital\/utulivu\/wp-includes\/css\/editor.min.css?ver=7.0' media='all' \/>\n<div id=\"wp-input_6_106-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_106\" id=\"input_6_106\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/div><div id=\"field_6_101\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_101'>Grand Total (Tshs)<\/label><div class='ginput_container ginput_container_number'><input name='input_101' id='input_6_101' type='text' step='any'   value='' class='large gform-text-input-reset'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_6_111' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_6_111' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' data-js='page-field-id-111' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_6_112\" class=\"gfield gfield--type-form gfield--input-type-form gform-theme__no-reset--children gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_112'>Enter Drug\/Pharmacy Details<\/label><div class=\"gpnf-nested-entries-container ginput_container\">\n\n\t<table class=\"gpnf-nested-entries\">\n\n\t\t<thead>\n\t\t<tr>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-1\">\n\t\t\t\t\tName of Drug\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-3\">\n\t\t\t\t\tStock Level\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-4\">\n\t\t\t\t\tStatus\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-11\">\n\t\t\t\t\tFrequency\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-10\">\n\t\t\t\t\tRoute\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-14\">\n\t\t\t\t\tPackage\t\t\t\t<\/th>\n\t\t\t\t\t\t\t<th class=\"gpnf-field-12\">\n\t\t\t\t\tDuration (Days)\t\t\t\t<\/th>\n\t\t\t\t\t\t<th class=\"gpnf-row-actions\"><span class=\"screen-reader-text\">Actions<\/span><\/th>\n\t\t<\/tr>\n\t\t<\/thead>\n\n\t\t<tbody data-bind=\"visible: entries().length, foreach: entries\">\n\t\t<tr data-bind=\"attr: { 'data-entryid': id }\">\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f1.label, attr: { 'data-value': f1.label }\"\n\t\t\t\t\tdata-heading=\"Name of Drug\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f3.label, attr: { 'data-value': f3.label }\"\n\t\t\t\t\tdata-heading=\"Stock Level\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f4.label, attr: { 'data-value': f4.label }\"\n\t\t\t\t\tdata-heading=\"Status\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f11.label, attr: { 'data-value': f11.label }\"\n\t\t\t\t\tdata-heading=\"Frequency\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f10.label, attr: { 'data-value': f10.label }\"\n\t\t\t\t\tdata-heading=\"Route\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f14.label, attr: { 'data-value': f14.label }\"\n\t\t\t\t\tdata-heading=\"Package\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t\t<td class=\"gpnf-field\"\n\t\t\t\t\tdata-bind=\"html: f12.label, attr: { 'data-value': f12.label }\"\n\t\t\t\t\tdata-heading=\"Duration (Days)\"\n\t\t\t\t>&nbsp;<\/td>\n\t\t\t\t\t\t<td class=\"gpnf-row-actions\" style=\"display: none;\" data-bind=\"visible: true\">\n\t\t\t\t<ul>\n\t\t\t\t\t<li class=\"edit\"><button type=\"button\" class=\"edit-button gform-theme-button--secondary\" data-bind=\"click: $parent.editEntry, attr: { 'aria-label': 'Edit Drug {0} where Name of Drug is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Edit<\/button><\/li>\n\t\t\t\t\t\t\t\t\t\t<li class=\"delete\"><button type=\"button\" class=\"delete-button gform-theme-button--simple gform-theme-button--size-md\" data-bind=\"click: $parent.deleteEntry, attr: { 'aria-label': 'Delete Drug {0} where Name of Drug is {1}.'.gformFormat( $index() + 1, f1.label ) }\">Delete<\/button><\/li>\n\t\t\t\t<\/ul>\n\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t\t<tbody data-bind=\"visible: entries().length <= 0\">\n\t\t<tr class=\"gpnf-no-entries\" data-bind=\"visible: entries().length <= 0\" style=\"display: none;\">\n\t\t\t<td colspan=\"8\">\n\t\t\t\tThere are no <span>Drugs.<\/span>\t\t\t<\/td>\n\t\t<\/tr>\n\t\t<\/tbody>\n\n\t<\/table>\n\n\t<button type=\"button\" class=\"gpnf-add-entry\"\n\t\t        data-formid=\"6\"\n\t\t        data-nestedformid=\"19\"\n\t\t\t\tdata-bind=\"attr: { disabled: isMaxed }, css: { 'gf-default-disabled': isMaxed }\"\n\t\t\t\t>\n\t\t\t\tAdd Drug\n\t\t\t<\/button>\t\n\t\t\t<p class=\"gpnf-add-entry-max\" data-bind=\"visible: isMaxed\" style=\"display: none;\">\n\t\t\t\tMaximum number of drugs reached.\n\t\t\t<\/p>\n<\/div>\n<input type=\"hidden\"\n                name=\"input_112\"\n                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