{
    "fields": {
        "due_date": {
            "label": "Expected Due Date:",
            "type": "date",
            "dateFormat": "yy-mm-dd",
            "datepicker": {
                "hideIfNoPrevNextType": true,
                "yearRange": "2010:+10",
                "changeMonth": true,
                "changeYear": true
            }
        },
        "number_pregnancy": {
            "label": "Pregnancy Number:",
            "type": "select"
        },
        "current_gestationalage_weeks": {
            "label": "Approximate Estimated Gestational Age (weeks):",
            "type": "select"
        },
        "date_gestationalage": {
            "type": "hidden"
        },
        "symptom": {
            "label": "Symptoms:",
            "type": "checkbox"
        },
        "other_symptom": {
            "label": "If Other Symptoms, Please Describe:"
        },
        "patient_weight": {
            "label": "Patient Weight in Kg:",
            "type": "number"
        },
        "fundal_height": {
            "label": "Fundal Height (cm):",
            "type": "select"
        },
        "cervical_dilation": {
            "label": "Cervical Dilation (cm):",
            "type": "select"
        },
        "fetal_station": {
            "label": "Fetal Station:",
            "type": "select"
        },
        "hemoglobin": {
            "label": "Hemoglobin (g/dl):",
            "type": "number"
        },
        "fetal_movement": {
            "label": "Fetal Movement:",
            "type": "select"
        },
        "fetal_heart_rate": {
            "label": "Fetal Heart Rate:",
            "type": "select"
        },
        "hiv_status": {
            "label": "Result if tested for HIV on first visit",
            "type": "select"
        },
        "treatment_given": {
            "label": "If any treatment given, please describe:",
            "type": "textarea"
        },
        "notes": {
            "label": "Other Application Notes:",
            "type": "textarea"
        },
        "admission": {
            "label": "Admission required today?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "in_labor": {
            "label": "Laboring Now?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_status_prior_firstvisit": {
            "label": "HIV Status prior to first visit",
            "type": "select"
        },
        "tested_hiv_firstvisit": {
            "label": "Tested for HIV on first visit?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "second_hiv_test": {
            "label": "Tested positive by second HIV test?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "refer_ctc": {
            "label": "Referred to CTC?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_hiv": {
            "label": "Partner tested for HIV in clinic?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_positive": {
            "label": "Partner tested positive for HIV?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "discordant_couple": {
            "label": "Discordant couple?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "combo_drugs": {
            "label": "Patient recieved PMCTC combo drugs?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "art_drugs": {
            "label": "Patient using ART?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "ctx_given": {
            "label": "Patient given CTX?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "counsel_feeding": {
            "label": "Counseled on how to feed the baby?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "syphillus_test": {
            "label": "Tested for Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "syphillus_status": {
            "label": "Infected with Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "syphillus_treatment": {
            "label": "Being treated for Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_std": {
            "label": "Partner infected with STD",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_std_treatment": {
            "label": "Partner being treated for STD",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_syphillus_test": {
            "label": "Partner infected with Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_syphillus_status": {
            "label": "Partner infected with Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "partner_syphillus_treatment": {
            "label": "Partner being treated for Syphillus",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "malaria_test": {
            "label": "Tested for malaria?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "malar_pos": {
            "label": "Tested positive for malaria?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "bednet_voucher": {
            "label": "Given voucher for free bednet?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "ipt1": {
            "label": "Given IPT1?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "ipt2": {
            "label": "Given IPT2?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "bp_systolic": {
            "label": "BP Systolic",
            "type": "number"
        },
        "bp_diastolic": {
            "label": "BP Diastolic",
            "type": "number"
        },
        "anemia_severe": {
            "label": "Severe Anemia (>8.5g/dl)",
            "type": "select"
        },
        "tt2plus_vaccine": {
            "label": "Received vaccination of TT2+",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "referral": {
            "label": "Referral?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "referred_ctc": {
            "label": "Mother Referred To CTC?",
            "type": "radio",
            "enum": [
                "Yes",
                "No",
                "Unknown"
            ],
            "removeDefaultNone": true
        }
    }
}