{"id":2,"date":"2025-08-14T03:01:39","date_gmt":"2025-08-14T03:01:39","guid":{"rendered":"https:\/\/maxcare.casethemes.net\/?page_id=2"},"modified":"2026-03-16T05:17:21","modified_gmt":"2026-03-16T05:17:21","slug":"clinical-information-form","status":"publish","type":"page","link":"http:\/\/klipworld.com.my\/lfm\/clinical-information-form\/","title":{"rendered":"Clinical Information Form"},"content":{"rendered":"\r\n<table class=\"widefat\">\r\n<tbody>\r\n<tr>\r\n<td><code>        <div class=\"lfm-form-container clinical-form\">\n            <form id=\"lfm-clinical-information-form\" class=\"lfm-form\" method=\"post\" enctype=\"multipart\/form-data\">\n                <div class=\"form-header\">\n                    <h2>LFM Clinical Information Form for Funding Application<\/h2>\n                    <p class=\"form-note\"><em>*To be filled up by the referring Physician<\/em><\/p>\n                <\/div>\n                \n                <!-- Patient Demographics -->\n                <fieldset class=\"form-section\">\n                    <legend>Patient Demographics<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"patient_name_clinical\">Patient's Full Name <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"patient_name_clinical\" name=\"patient_name_clinical\" required \n                                   class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"ic_number\">I.C. Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"ic_number\" name=\"ic_number\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\" required class=\"lfm-input ic-mask\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"age\">Age <span class=\"required\">*<\/span><\/label>\n                            <input type=\"number\" id=\"age\" name=\"age\" min=\"0\" max=\"150\" required \n                                   class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"gender\">Gender<\/label>\n                            <select id=\"gender\" name=\"gender\" class=\"lfm-input\">\n                                <option value=\"\">Select Gender<\/option>\n                                <option value=\"male\">Male<\/option>\n                                <option value=\"female\">Female<\/option>\n                            <\/select>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"address_clinical\">Address <span class=\"required\">*<\/span><\/label>\n                        <textarea id=\"address_clinical\" name=\"address_clinical\" rows=\"3\" required \n                                  class=\"lfm-input\"><\/textarea>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"tel_no\">Telephone No. <span class=\"required\">*<\/span><\/label>\n                            <input type=\"tel\" id=\"tel_no\" name=\"tel_no\" required \n                                   placeholder=\"012-3456789\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"hospital_reg_no\">Hospital Registration No. <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"hospital_reg_no\" name=\"hospital_reg_no\" required \n                                   class=\"lfm-input\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Diagnosis -->\n                <fieldset class=\"form-section\">\n                    <legend>Diagnosis<\/legend>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"primary_diagnosis\">Primary Diagnosis <span class=\"required\">*<\/span><\/label>\n                        <textarea id=\"primary_diagnosis\" name=\"primary_diagnosis\" rows=\"3\" required \n                                  class=\"lfm-input\" placeholder=\"Primary respiratory diagnosis\"><\/textarea>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"other_diagnosis\">Other Diagnosis (Comorbidities)<\/label>\n                        <textarea id=\"other_diagnosis\" name=\"other_diagnosis\" rows=\"2\" \n                                  class=\"lfm-input\" placeholder=\"Other relevant medical conditions\"><\/textarea>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"diagnosis_date\">Date of Diagnosis<\/label>\n                        <input type=\"date\" id=\"diagnosis_date\" name=\"diagnosis_date\" class=\"lfm-input\">\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Clinical Investigations -->\n                <fieldset class=\"form-section\">\n                    <legend>Clinical Investigations<\/legend>\n                    \n                    <div class=\"investigation-group\">\n                        <h4>Lung Function Test<\/h4>\n                        <div class=\"form-row\">\n                            <div class=\"form-group third\">\n                                <label for=\"fev1\">FEV1 (L)<\/label>\n                                <input type=\"number\" step=\"0.01\" id=\"fev1\" name=\"fev1\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"fvc\">FVC (L)<\/label>\n                                <input type=\"number\" step=\"0.01\" id=\"fvc\" name=\"fvc\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"fev1_fvc_ratio\">FEV1\/FVC Ratio (%)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"fev1_fvc_ratio\" name=\"fev1_fvc_ratio\" \n                                       class=\"lfm-input\" placeholder=\"Percentage\">\n                            <\/div>\n                        <\/div>\n                        \n                        <div class=\"form-row\">\n                            <div class=\"form-group half\">\n                                <label for=\"lft_date\">Test Date<\/label>\n                                <input type=\"date\" id=\"lft_date\" name=\"lft_date\" class=\"lfm-input\">\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"investigation-group\">\n                        <h4>Blood Gas (Arterial)<\/h4>\n                        <div class=\"form-row\">\n                            <div class=\"form-group third\">\n                                <label for=\"ph\">pH<\/label>\n                                <input type=\"number\" step=\"0.01\" id=\"ph\" name=\"ph\" \n                                       class=\"lfm-input\" placeholder=\"7.35-7.45\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"pco2\">pCO2 (mmHg)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"pco2\" name=\"pco2\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"po2\">pO2 (mmHg)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"po2\" name=\"po2\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                        <\/div>\n                        \n                        <div class=\"form-row\">\n                            <div class=\"form-group third\">\n                                <label for=\"hco3\">HCO3 (mmol\/L)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"hco3\" name=\"hco3\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"be\">BE (mmol\/L)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"be\" name=\"be\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                            \n                            <div class=\"form-group third\">\n                                <label for=\"spo2\">SpO2 (%)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"spo2\" name=\"spo2\" \n                                       class=\"lfm-input\" placeholder=\"Value\">\n                            <\/div>\n                        <\/div>\n                        \n                        <div class=\"form-row\">\n                            <div class=\"form-group half\">\n                                <label for=\"blood_gas_date\">Test Date<\/label>\n                                <input type=\"date\" id=\"blood_gas_date\" name=\"blood_gas_date\" class=\"lfm-input\">\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"investigation-group\">\n                        <h4>Sleep Study (Polysomnography)<\/h4>\n                        <div class=\"form-row\">\n                            <div class=\"form-group half\">\n                                <label for=\"sleep_study_date\">Date of Sleep Study<\/label>\n                                <input type=\"date\" id=\"sleep_study_date\" name=\"sleep_study_date\" \n                                       class=\"lfm-input\">\n                            <\/div>\n                        <\/div>\n                        \n                        <div class=\"form-row\">\n                            <div class=\"form-group half\">\n                                <label for=\"ahi\">AHI (events\/hour)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"ahi\" name=\"ahi\" \n                                       class=\"lfm-input\" placeholder=\"Apnea-Hypopnea Index\">\n                            <\/div>\n                            \n                            <div class=\"form-group half\">\n                                <label for=\"odi\">ODI (events\/hour)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"odi\" name=\"odi\" \n                                       class=\"lfm-input\" placeholder=\"Oxygen Desaturation Index\">\n                            <\/div>\n                        <\/div>\n                        \n                        <div class=\"form-row\">\n                            <div class=\"form-group half\">\n                                <label for=\"lowest_spo2\">Lowest SpO2 (%)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"lowest_spo2\" name=\"lowest_spo2\" \n                                       class=\"lfm-input\" placeholder=\"Lowest recorded\">\n                            <\/div>\n                            \n                            <div class=\"form-group half\">\n                                <label for=\"time_spo2_below_88\">Time SpO2 below 88% (minutes)<\/label>\n                                <input type=\"number\" step=\"0.1\" id=\"time_spo2_below_88\" name=\"time_spo2_below_88\" \n                                       class=\"lfm-input\" placeholder=\"Duration\">\n                            <\/div>\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Indication -->\n                <fieldset class=\"form-section\">\n                    <legend>Indication for Ventilatory\/Oxygen Support<\/legend>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"indication\">Clinical Indication <span class=\"required\">*<\/span><\/label>\n                        <textarea id=\"indication\" name=\"indication\" rows=\"4\" required \n                                  class=\"lfm-input\" placeholder=\"Detailed reason for equipment request\"><\/textarea>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"equipment_type\">Type of Equipment Applied <span class=\"required\">*<\/span><\/label>\n                            <select id=\"equipment_type\" name=\"equipment_type\" required class=\"lfm-input\">\n                                <option value=\"\">Select equipment type<\/option>\n                                <option value=\"CPAP\">CPAP (Continuous Positive Airway Pressure)<\/option>\n                                <option value=\"BPAP\">BPAP (Bi-level Positive Airway Pressure)<\/option>\n                                <option value=\"Oxygen Concentrator\">Oxygen Concentrator<\/option>\n                                <option value=\"Portable Oxygen\">Portable Oxygen Concentrator<\/option>\n                                <option value=\"Multiple\">Multiple Devices<\/option>\n                            <\/select>\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"other_equipment\">If Multiple\/Specify<\/label>\n                            <input type=\"text\" id=\"other_equipment\" name=\"other_equipment\" \n                                   class=\"lfm-input\" placeholder=\"Please specify\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label>Duration of Support Required <span class=\"required\">*<\/span><\/label>\n                        <div class=\"radio-group\">\n                            <label><input type=\"radio\" name=\"duration_support\" value=\"24_hours\" required> 24 Hours<\/label>\n                            <label><input type=\"radio\" name=\"duration_support\" value=\"sleep_part_day\"> Sleep & Part of the Day<\/label>\n                            <label><input type=\"radio\" name=\"duration_support\" value=\"during_sleep\"> During Sleep Only<\/label>\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"oxygen_prescription\">Oxygen Prescription (if applicable)<\/label>\n                            <input type=\"text\" id=\"oxygen_prescription\" name=\"oxygen_prescription\" \n                                   class=\"lfm-input\" placeholder=\"e.g., 2L\/min, 24 hours\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Physician Information -->\n                <fieldset class=\"form-section\">\n                    <legend>Referring Physician Information<\/legend>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"physician_name\">Name of Referring Physician <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"physician_name\" name=\"physician_name\" required \n                                   class=\"lfm-input\" placeholder=\"Dr. ...\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"physician_ic\">I.C. Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"text\" id=\"physician_ic\" name=\"physician_ic\" \n                                   pattern=\"[0-9]{6}-[0-9]{2}-[0-9]{4}\" \n                                   placeholder=\"000000-00-0000\" \n                                   maxlength=\"14\" required class=\"lfm-input ic-mask\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"physician_phone\">Phone Number <span class=\"required\">*<\/span><\/label>\n                            <input type=\"tel\" id=\"physician_phone\" name=\"physician_phone\" required \n                                   placeholder=\"012-3456789\" class=\"lfm-input\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"physician_email\">Email <span class=\"required\">*<\/span><\/label>\n                            <input type=\"email\" id=\"physician_email\" name=\"physician_email\" required \n                                   placeholder=\"doctor@hospital.com\" class=\"lfm-input\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"physician_facility\">Healthcare Facility<\/label>\n                            <input type=\"text\" id=\"physician_facility\" name=\"physician_facility\" \n                                   class=\"lfm-input\" placeholder=\"Hospital\/Clinic name\">\n                        <\/div>\n                        \n                        <div class=\"form-group half\">\n                            <label for=\"physician_specialty\">Specialty<\/label>\n                            <input type=\"text\" id=\"physician_specialty\" name=\"physician_specialty\" \n                                   class=\"lfm-input\" placeholder=\"e.g., Respiratory Medicine\">\n                        <\/div>\n                    <\/div>\n                    \n                    <div class=\"form-row\">\n                        <div class=\"form-group half\">\n                            <label for=\"physician_signature_date\">Date <span class=\"required\">*<\/span><\/label>\n                            <input type=\"date\" id=\"physician_signature_date\" name=\"physician_signature_date\" \n                                   required class=\"lfm-input\" value=\"2026-08-03\">\n                        <\/div>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Medical Report -->\n                <fieldset class=\"form-section\">\n                    <legend>Medical Report Submission<\/legend>\n                    \n                    <div class=\"form-note\">\n                        <p>Please submit a summary of applicant's medical report. The medical report must be signed or verified by the respiratory consultant in charge.<\/p>\n                    <\/div>\n                    \n                    <div class=\"form-group\">\n                        <label for=\"medical_report\">Upload Medical Report (PDF only) <span class=\"required\">*<\/span><\/label>\n                        <input type=\"file\" id=\"medical_report\" name=\"medical_report\" \n                               accept=\".pdf,application\/pdf\" required class=\"lfm-file-input\">\n                        <small>Maximum file size: <span id=\"max-file-size\">5MB<\/span><\/small>\n                        <div id=\"file-error\" class=\"error-message\" style=\"display:none;\"><\/div>\n                    <\/div>\n                    \n                    <div class=\"form-group checkbox-group\">\n                        <label>\n                            <input type=\"checkbox\" name=\"confirm_medical_report\" value=\"1\" required>\n                            I confirm that the medical report is complete, accurate, and verified by the respiratory consultant <span class=\"required\">*<\/span>\n                        <\/label>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Certification -->\n                <fieldset class=\"form-section\">\n                    <legend>Certification<\/legend>\n                    \n                    <div class=\"form-group checkbox-group\">\n                        <label>\n                            <input type=\"checkbox\" name=\"certify_information\" value=\"1\" required>\n                            I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge <span class=\"required\">*<\/span>\n                        <\/label>\n                    <\/div>\n                    \n                    <div class=\"form-group checkbox-group\">\n                        <label>\n                            <input type=\"checkbox\" name=\"consent_share\" value=\"1\">\n                            I consent to the sharing of this information with relevant healthcare providers for the purpose of patient care\n                        <\/label>\n                    <\/div>\n                <\/fieldset>\n                \n                <!-- Form Actions -->\n                <div class=\"form-actions\">\n                    <button type=\"submit\" class=\"submit-button\">\n                        <span class=\"button-text\">Submit Clinical Information<\/span>\n                        <span class=\"loading-spinner\" style=\"display: none;\">Submitting...<\/span>\n                    <\/button>\n                <\/div>\n                \n                <div id=\"clinical-form-message\" class=\"form-message\"><\/div>\n            <\/form>\n        <\/div>\n        <\/code><\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-2","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/2","targetHints":{"allow":["GET"]}}],"collection":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/comments?post=2"}],"version-history":[{"count":2,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/2\/revisions"}],"predecessor-version":[{"id":6522,"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/pages\/2\/revisions\/6522"}],"wp:attachment":[{"href":"http:\/\/klipworld.com.my\/lfm\/wp-json\/wp\/v2\/media?parent=2"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}