{
    "fields": {
        "last_menstrual_period": {
            "label": "Last Menstrual Period:",
            "type": "date",
            "dateFormat": "yy-mm-dd",
            "datepicker": {
                "hideIfNoPrevNextType": true,
                "yearRange": "2010:+10",
                "changeMonth": true,
                "changeYear": true
            }
        },
        "menstrual_history": {
            "label": "Menstrual History:",
            "type": "select"
        },
        "number_pregnancy": {
            "label": "Total Number of Pregnancies",
            "type": "select"
        },
        "number_full_term_delivery": {
            "label": "Number of Full Term Deliveries",
            "type": "select"
        },
        "number_pre_term_delivery": {
            "label": "Number of Preterm Deliveries",
            "type": "select"
        },
        "number_miscarriage_or_abortion": {
            "label": "Number of Miscarriages or Abortions",
            "type": "select"
        },
        "number_live_birth": {
            "label": "Number of Live Births",
            "type": "select"
        },
        "pregnancy_complication": {
            "label": "Pregnancy Complications, Check All That Apply:",
            "type": "checkbox"
        },
        "pregnancy_complication_other": {
            "label": "If Other Pregnancy Complication, Describe:"
        },
        "marital_status": {
            "label": "Marital Status:",
            "type": "select"
        },
        "contraception_previous": {
            "label": "Previous Contraception:",
            "type": "select"
        },
        "contraception_current": {
            "label": "Current Contraception:",
            "type": "select"
        },
        "contraception_source": {
            "label": "Source of Contraception",
            "type": "select"
        },
        "fertility_desire": {
            "label": "Fertility Desires:",
            "type": "select"
        },
        "hiv_risk": {
            "label": "HIV Risks:",
            "type": "select"
        },
        "hiv_status": {
            "label": "HIV Status",
            "type": "select"
        },
        "hiv_tested": {
            "label": "Tested for HIV?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_partner_test": {
            "label": "Partner tested for HIV?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_positive_test": {
            "label": "Tested positive for HIV?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_partner_positive_test": {
            "label": "Partner tested positive for HIV?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_counseling": {
            "label": "HIV counseling given?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_partner_counseling": {
            "label": "HIV counseling given to partner?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "hiv_discordant": {
            "label": "HIV discordant couple?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "referred_ctc": {
            "label": "Referred to CTC?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "post_test_counseling": {
            "label": "Post-test HIV counseling given?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "implant_removed": {
            "label": "Implant removed?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "contraception_after_miscarriage": {
            "label": "Contraception given after recent miscarriage?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "delivery_in_42_days": {
            "label": "Delivery within 42 days?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "contraception_in_42_days": {
            "label": "Contraception given within 42 days of delivery?",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "contraception_dispensed": {
            "label": "Contraception Dispensed:",
            "type": "select"
        },
        "quantity_pills_dispensed": {
            "label": "Quantity of Pills Dispensed:",
            "type": "select"
        },
        "quantity_condoms_dispensed": {
            "label": "Quantity of Condoms Dispensed:",
            "type": "select"
        },
        "quantity_depo_provera": {
            "label": "Dose of Depo Provera:",
            "type": "select"
        },
        "condom_education": {
            "label": "Condom Use Education Preformed",
            "type": "radio",
            "enum": [
                "Yes",
                "No"
            ],
            "removeDefaultNone": true
        },
        "cervical_symptom": {
            "label": "Cervical Symptoms:",
            "type": "checkbox"
        },
        "breast_symptom": {
            "label": "Breast Symptoms:",
            "type": "checkbox"
        }
    }
}