interface/forms/example/print.php

   1 <?php
   2 /*
   3  * Sports Physical Form created by Jason Morrill: January 2009
   4  */
   5
   6 include_once("../../globals.php");
   7 include_once("$srcdir/api.inc");
   8
   9 /** CHANGE THIS - name of the database table associated with this form **/
  10 $table_name = "form_example";
  11
  12 /** CHANGE THIS name to the name of your form **/
  13 $form_name = "My Example Form";
  14
  15 /** CHANGE THIS to match the folder you created for this form **/
  16 $form_folder = "example";
  17
  18 formHeader("Form: ".$form_name);
  19 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
  20
  21 /* load the saved record */
  22 $record = formFetch($table_name, $_GET["id"]);
  23
  24 /* remove the time-of-day from the date fields */
  25 if ($record['form_date'] != "") {
  26     $dateparts = split(" ", $record['form_date']);
  27     $record['form_date'] = $dateparts[0];
  28 }
  29 if ($record['dob'] != "") {
  30     $dateparts = split(" ", $record['dob']);
  31     $record['dob'] = $dateparts[0];
  32 }
  33 if ($record['sig_date'] != "") {
  34     $dateparts = split(" ", $record['sig_date']);
  35     $record['sig_date'] = $dateparts[0];
  36 }
  37 ?>
  38
  39 <html><head>
  40 <?php html_header_show();?>
  41
  42 <!-- supporting javascript code -->
  43 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery.js"></script>
  44 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/textformat.js"></script>
  45
  46 <!-- page styles -->
  47 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  48 <link rel="stylesheet" href="../../forms/<?php echo $form_folder; ?>/style.css" type="text/css">
  49
  50 </head>
  51
  52 <body class="body_top">
  53
  54 Printed on <?php echo date("F d, Y", time()); ?>
  55
  56 <form method=post action="">
  57 <span class="title"><?php xl($form_name,'e'); ?></span><br>
  58
  59 <!-- container for the main body of the form -->
  60 <div id="print_form_container">
  61
  62 <div id="print_general">
  63 <table>
  64 <tr><td>
  65 Date:
  66    <input type='text' size='10' name='form_date' id='form_date'
  67     value='<?php echo stripslashes($record['form_date']);?>'
  68     title='<?php xl('yyyy-mm-dd','e'); ?>'
  69     />
  70 </td></tr>
  71 <tr><td>
  72 Name: <input id="name" name="name" type="text" size="50" maxlength="250" value="<?php echo stripslashes($record['name']);?>">
  73 Date of Birth:
  74    <input type='text' size='10' name='dob' id='dob'
  75     value='<?php echo stripslashes($record['dob']);?>'
  76     title='<?php xl('yyyy-mm-dd Date of Birth','e'); ?>'
  77     />
  78 </td></tr>
  79 <tr><td>
  80 Phone: <input name="phone" id="phone" type="text" size="15" maxlength="15" value="<?php echo stripslashes($record['phone']);?>">
  81 </td></tr>
  82 <tr><td>
  83 Address: <input name="address" id="address" type="text" size="80" maxlength="250" value="<?php echo stripslashes($record['address']);?>">
  84 </td></tr>
  85 </table>
  86 </div>
  87
  88 <div id="print_bottom">
  89 Use this space to express notes <br>
  90 <textarea name="notes" id="notes" cols="80" rows="4"><?php echo stripslashes($record['notes']);?></textarea>
  91 <br><br>
  92 <div style="text-align:right;">
  93 Signature?
  94 <input type="radio" id="sig" name="sig" value="y" <?php if ($record["sig"] == 'y') echo "CHECKED"; ?>>Yes
  95 /
  96 <input type="radio" id="sig" name="sig" value="n" <?php if ($record["sig"] == 'n') echo "CHECKED"; ?>>No
  97 &nbsp;&nbsp;
  98 Date of signature:
  99    <input type='text' size='10' name='sig_date' id='sig_date'
 100     value='<?php echo stripslashes($record['sig_date']);?>'
 101     title='<?php xl('yyyy-mm-dd','e'); ?>' />
 102 </div>
 103 </div>
 104
 105 </div> <!-- end form_container -->
 106
 107 </form>
 108
 109 </body>
 110
 111 <script language="javascript">
 112 window.print();
 113 window.close();
 114 </script>
 115
 116 </html>