<%@ include file="/includes.jsp"%>
<style type="text/css">
@import url(../emdt/printForm.css);
</style>
<%@ include file="printstyles.css"%>
<tiles:importAttribute />
<div class="container">
	<input type="hidden" value="false" id="unsaveButtonId">
	<div class="sectionSubPageTop">

		<h2>Triage Assessment</h2>
		<div class="fieldSet2Column" style="text-align: left;">
			<p>
				This triage tool is based on the <b>UKONS (Oncology Nursing
					Society) 24 Hour Helpline, Rapid Assessment and Access Tool Kit</b> and
				incorporates World Health Organisation Toxicity Assessment Criteria
				and the National Cancer Institute Common Terminology Criteria for
				Adverse Events Version 4.0 Published: May 28, 2009 (v4.03: June 14,
				2010).
			</p>
			<p>For further details of the grading system please refer to the
				guidance notes through following the link below.</p>

		</div>
		<div class="fieldSet2Column">
			<span class="inputLabel"><a
				href="../emdt/tiles/forms/ChemoG1/TriageAssessment/Triage%20Toolkit%20UKons%20Nov%202016.pdf"
				target="_blank">Instructions for Triage Assessment <img
					src="../emdt/images/16x16/pdf.gif"
					title="Click to open instructions" alt="PDF" />
			</a></span>
		</div>
		<div class="fieldSet2Column">
			<hr />
		</div>
		<div>
			<div class="fieldSetLeftColumn">
				<span class="inputLabel">Patient Treatment Stage:</span>
			</div>
			<div class="fieldSetRightColumn">
				<span class="inputControl"> <tiles:insertTemplate
						template='../../printFieldRenderer.jsp'>
						<tiles:putAttribute name="fieldOptionsMapName"
							value="Chemo_Patient_Treatment_Stage" />
						<tiles:putAttribute name="fieldInputType" value="5" />
						<tiles:putAttribute name="fieldName" value="TAFP1PatStage" />
					</tiles:insertTemplate>

				</span>
			</div>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>

		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Cycle nbr:</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="Chemo_Cycle_Nbr" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFP1PatCycle" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Day nbr:</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="Chemo_Day_Nbr" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFP1PatDay" />
				</tiles:insertTemplate> <%--
			<webapp:namedList id="nl_Chemo_Day_Nbr" domain="EMDT" name="Chemo_Day_Nbr" /> <smvc:select disabled="${readOnly}" path="value[TAFP1PatDay]"
					styleId="TAFP1PatDay">
					<option value="" />
					<emdt:optionsMap name="nl_Chemo_Day_Nbr" property='pairIterator' label="second" value="first" />
				</smvc:select>
				 --%>
			</span>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
			<h2>Patient Details</h2>
		</div>


		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Patient Name</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF1PatientName" />
				</tiles:insertTemplate></span>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">DOB</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF2PatientDOB" />
				</tiles:insertTemplate>
			</span>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
			<h2>Patient History</h2>
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Diagnosis</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF3Diagnosis" />
					<tiles:putAttribute name="colWidth" value="20" />
					<tiles:putAttribute name="colHeight" value="4" />
					<tiles:putAttribute name="fieldType" value="101" />
				</tiles:insertTemplate></span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Gender</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="SexCode" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF4Gender" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Consultant</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapDomain"
						value="${consultationNoteForm.view.form.getField('TAF5Consultant').optionsMapDomain}" />
					<tiles:putAttribute name="fieldOptionsMapName"
						value="${consultationNoteForm.view.form.getField('TAF5Consultant').optionsMapName}" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF5Consultant" />
				</tiles:insertTemplate>
			</span>

		</div>

		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
			<h2>Enquiry Details</h2>
		</div>


		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Enquiry Date</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF6EnquiryDate" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Enquiry Time</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF7EnquiryTime" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Who is calling?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"><tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF8WhoIsCalling" />
				</tiles:insertTemplate> </span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Contact No.</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF9ContactNo" />
				</tiles:insertTemplate></span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Drop in?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="YesNo" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF10DropIn" />
				</tiles:insertTemplate>
			</span>
		</div>
	</div>
	<div class="sectionSubPageTop">
		<h2>Reason for Call</h2>
		<div class="fieldSet2Column">
			<span class="inputLabel">Reason for call (in patients own
				words)</span>
		</div>
		<div class="fieldSet2Column">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF11ReasonForCall" />
					<tiles:putAttribute name="colWidth" value="80" />
					<tiles:putAttribute name="colHeight" value="1" />
					<tiles:putAttribute name="fieldType" value="101" />
				</tiles:insertTemplate></span>
		</div>
	</div>
	<div class="sectionSubPageTop">
		<h2>Active Treatment Details</h2>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Is the patient on active treatment?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_Active_Tmnt" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF12ActiveTmnt" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">State Regimen</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF13StateRegimen" />
				</tiles:insertTemplate></span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Are they part of a clinical trial?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="YesNo" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF14ClinTrial" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel"> When did the patient last receive
				treatment? </span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_Last_Tmnt" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF15LastTmnt" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">What is the patient's temperature? </span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF16PatientTemp" />
				</tiles:insertTemplate><sup>o</sup>C <%-- this is to create a degree symbol - PDF does not like &deg; etc --%>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Does the patient have a central line?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="YesNo" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF17CentralLine" />
				</tiles:insertTemplate>
			</span>
		</div>
	</div>
	<div class="sectionSubPageTop">
		<div class="fieldSet2Column">
			<!-- spacer -->
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<b>Symptom</b>
			</div>
			<div class="sym_mid_col">
				<b>Severity</b>
			</div>
			<div class="sym_right_col">
				<b>Comment</b>
			</div>
		</div>


		<%-- define lists to be used repeatedly below --%>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Fever (and receiving chemo)</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFFeverChemo" />
				</tiles:insertTemplate>

			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtFeverChemo" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Chest Pain</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFChest" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtChest" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Performance Status</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFPerfStat" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtPerf" />
				</tiles:insertTemplate>
			</div>
		</div>


		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Nausea</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFNausea" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtNaus" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Vomiting</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFVomiting" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtVom" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Oral / stomatitis</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFOralStom" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtOralStom" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Diarrhoea</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFDiarrhoea" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtDiar" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Constipation</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFConstipation" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtCons" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Fever (not receiving chemo)</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFFeverNoChemo" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtFeverNoChemo" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Infection</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFInfection" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtInfection" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Palmar - plantar syndrome</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFPalmar" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtPalmar" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Fatigue</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFFatigue" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtFatig" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Anorexia</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFAnorexia" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtAnor" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Dyspnoea / shortness of breath</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFDyspnoea" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtDysp" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Rash</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFRash" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtRash" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Neurosensory / motor</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFNeuro" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtNeur" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Bleeding</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFBleeding" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtBleed" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Pain</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFPain" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtPain" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Bruising</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFBruising" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtBruising" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Extravasation</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFExtravasation" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtExtravasation" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Urinary disorder</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFUrin" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtUrin" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Ocular/Eye problems</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFEye" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtEye" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">Other (please state)</span>
			</div>
			<div class="sym_mid_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="TAF_green_amber_red" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAFOther" />
				</tiles:insertTemplate>
			</div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFCmtOther" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="sym_container clearfix">
			<div class="sym_left_col">
				<span class="sym_label">State other symptom</span>
			</div>
			<div class="sym_mid_col"></div>
			<div class="sym_right_col">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldInputType" value="1" />
					<tiles:putAttribute name="fieldName" value="TAFOtherSymptom" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer -->
			<div
				style="margin-left: auto; margin-right: auto; font-weight: bold; clear: both;">
				<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAFAssessmentGrading" />
				</tiles:insertTemplate>
			</div>
		</div>

		<div class="fieldSet2Column">
			<!-- spacer -->
		</div>

	</div>



	<div class="sectionSubPageTop">
		<div class="fieldSet2Column">
			<h2>Medical History / Medication</h2>

		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Significant Medical<br />History/Medication
			</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF18SigMedHistory" />
					<tiles:putAttribute name="colWidth" value="40" />
					<tiles:putAttribute name="colHeight" value="1" />
					<tiles:putAttribute name="fieldType" value="101" />
				</tiles:insertTemplate></span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>

		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Action Taken</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF19ActionTaken" />
					<tiles:putAttribute name="colWidth" value="40" />
					<tiles:putAttribute name="colHeight" value="1" />
					<tiles:putAttribute name="fieldType" value="101" />
				</tiles:insertTemplate></span>
		</div>
	</div>
	<div class="sectionSubPageTop">
		<h2>Triage Practitioner</h2>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Triage Practitioner Name</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapDomain"
						value="${consultationNoteForm.view.form.getField('TAF20TriagePractioner').optionsMapDomain}"/>
					<tiles:putAttribute name="fieldOptionsMapName"
						value="${consultationNoteForm.view.form.getField('TAF20TriagePractioner').optionsMapName}"/>
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF20TriagePractioner" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Designation</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapDomain"
						value="${consultationNoteForm.view.form.getField('TAF21TriagePractDesig').optionsMapDomain}"/>
					<tiles:putAttribute name="fieldOptionsMapName"
						value="${consultationNoteForm.view.form.getField('TAF21TriagePractDesig').optionsMapName}"/>
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF21TriagePractDesig" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Date</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF22TriagePractDate" />
				</tiles:insertTemplate>
			</span>
		</div>
	</div>
	<div class="sectionSubPageTop">
		<h2>Follow up Action</h2>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Follow up Action Taken</span>
		</div>
		<div class="fieldSetRightColumn">
			<tiles:insertTemplate template='../../printFieldRenderer.jsp'>
				<tiles:putAttribute name="fieldName" value="TAF23FollowActionTaken" />
				<tiles:putAttribute name="colWidth" value="40" />
				<tiles:putAttribute name="colHeight" value="4" />
				<tiles:putAttribute name="fieldType" value="101" />
			</tiles:insertTemplate>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Consultant team contacted?</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapName" value="YesNo" />
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF24ConsTeamCont" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Date contacted</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF25FUpDateContacted" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>

		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Follow up Name</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapDomain"
						value="${consultationNoteForm.view.form.getField('TAF26FUpName').optionsMapDomain}"/>
					<tiles:putAttribute name="fieldOptionsMapName"
						value="${consultationNoteForm.view.form.getField('TAF26FUpName').optionsMapName}"/>
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF26FUpName" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Designation</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldOptionsMapDomain"
						value="${consultationNoteForm.view.form.getField('TAF27FUpDesig').optionsMapDomain}"/>
					<tiles:putAttribute name="fieldOptionsMapName"
						value="${consultationNoteForm.view.form.getField('TAF27FUpDesig').optionsMapName}"/>
					<tiles:putAttribute name="fieldInputType" value="5" />
					<tiles:putAttribute name="fieldName" value="TAF27FUpDesig" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Date</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"> <tiles:insertTemplate
					template='../../printFieldRenderer.jsp'>
					<tiles:putAttribute name="fieldName" value="TAF28FUpDate" />
				</tiles:insertTemplate>
			</span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>

		<div class="fieldSetLeftColumn">
			<span class="inputLabel">Last updated by:</span>
		</div>
		<div class="fieldSetRightColumn">
			<span class="inputControl"><c:out value="${consultationNoteForm.view.note.modifiedByUser.name}"/></span>
		</div>
		<div class="fieldSet2Column">
			<!-- spacer to fix layout -->
		</div>
		<div>
			<div class="fieldSetLeftColumn">
				<span class="inputLabel">Last updated:</span>
			</div>
			<div class="fieldSetRightColumn">
				<span class="inputControl"><fmt:formatDate value="${consultationNoteForm.view.note.modifiedDate}" pattern="dd MMM yyyy HH:mm" /></span>
			</div>
		</div>

	</div>
</div>

