templates/prescription/general_edit.html

   1 <html>
   2 <head>
   3 {literal}
   4  <style type="text/css" title="mystyles" media="all">
   5 <!--
   6 td {
   7         font-size:8pt;
   8         font-family:helvetica;
   9 }
  10 input {
  11         font-size:8pt;
  12         font-family:helvetica;
  13 }
  14 select {
  15         font-size:8pt;
  16         font-family:helvetica;
  17 }
  18 textarea {
  19         font-size:8pt;
  20         font-family:helvetica;
  21 }
  22 -->
  23 </style>
  24 {/literal}
  25 </head>
  26 <body {$STYLE.BOTTOM_BG_LINE}>
  27 <form name="prescribe" method="post" action="{$FORM_ACTION}">
  28 <table CELLSPACING="0" CELLPADDING="3">
  29 <tr>
  30         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Starting Date</td>
  31         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  32                 {html_select_date start_year="-10" end_year="+5" time=$prescription->start_date prefix="start_date_"}
  33         </td>
  34 </tr>
  35 <tr>
  36         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Provider</td>
  37         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  38                 {html_options name="provider_id" options=$prescription->provider->utility_provider_array() selected=$prescription->provider->get_id()}
  39         </td>
  40 </tr>
  41 <tr>
  42         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Patient Name</td>
  43         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >{$prescription->patient->get_name_display()}</td>
  44         <input type="hidden" name="patient_id" value="{$prescription->patient->id}" />
  45 </tr>
  46 <tr>
  47         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Drug</td>
  48         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  49                 <input type="input" size="20" name="drug" value="{$prescription->drug}"/><input class="button" type="BUTTON" onClick="drugPopup=window.open('controller.php?prescription&lookup', 'drugPopup', 'width=400,height=50,menubar=no,titlebar=no,left = 825,top = 400'); drugPopup.opener=self; return true;" value="Drug Lookup"/>
  50         </td>
  51 </tr>
  52 <tr>
  53         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Quantity</td>
  54         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  55                 <input TYPE="TEXT" NAME="quantity" SIZE="2" MAXLENGTH="10" VALUE="{$prescription->quantity}"/>
  56         </td>
  57 </tr>
  58 <tr>
  59         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Medicine Units</td>
  60         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  61                 <input TYPE="TEXT" NAME="size" SIZE="11" MAXLENGTH="10" VALUE="{$prescription->size}"/>
  62                 <select name="unit">{html_options options=$prescription->unit_array selected=$prescription->unit}</select>
  63         </td>
  64 </tr>
  65 <tr>
  66         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Take</td>
  67         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  68                 <input TYPE="TEXT" NAME="dosage" SIZE="11" MAXLENGTH="10" VALUE="{$prescription->dosage}"/> in
  69                 <select name="form">{html_options options=$prescription->form_array selected=$prescription->form}</select>
  70                 <select name="route">{html_options options=$prescription->route_array selected=$prescription->route}</select>
  71                 <select name="interval">{html_options options=$prescription->interval_array selected=$prescription->interval}</select>
  72         </td>
  73 </tr>
  74 <tr>
  75         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Refill</td>
  76         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  77                 {html_options name="refills" options=$prescription->refills_array selected=$prescription->refills}
  78                 <input TYPE="TEXT" NAME="per_refill" SIZE="2" MAXLENGTH="10" VALUE="{$prescription->per_refill}"/> units</td>
  79 </tr>
  80 <tr>
  81         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Substitution</td>
  82         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  83         {html_options name="substitute" options=$prescription->substitute_array selected=$prescription->substitute}
  84         </td>
  85 </tr>
  86 <tr>
  87         <td COLSPAN="1" ALIGN="LEFT" VALIGN="MIDDLE" >Notes</td>
  88         <td COLSPAN="2" ALIGN="LEFT" VALIGN="MIDDLE" >
  89         <textarea name="note" cols="30" rows="3" wrap="virtual">{$prescription->note}</textarea>
  90         </td>
  91 </tr>
  92 <tr>
  93         <td><input type="submit" value="Prescribe" /></td>
  94 </tr>
  95 </table>
  96 <input type="hidden" name="id" value="{$prescription->id}" />
  97 <input type="hidden" name="process" value="{$PROCESS}" />
  98 </form>
  99 </body>
 100 </html>