interface/forms/ankleinjury/view.php

   1 <!-- Ankle Injury View Form created by Nikolai Vitsyn by 2004/02/19 -->
   2 <?php
   3 include_once("../../globals.php");
   4 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   5 ?>
   6 <html><head>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_ankleinjury", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?echo $rootdir?>/forms/ankleinjury/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  15 <span class="title">Ankle Evaluation Form</span><br></br>
  16
  17 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  18 <br>
  19 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl"; ?>" class="link">[Don't Save Changes]</a>
  20 <br></br>
  21
  22 <span class=text>Date of Injury: </span><input type=entry name="ankle_date_of_injuary" value="<?echo stripslashes($obj{"ankle_date_of_injuary"});?>" >
  23 <td align="right">Work related?:</td>
  24 <td><input type=checkbox name="ankle_work_related" <?if ($obj{"ankle_work_related"} == "on")
  25 echo "checked";;?>><span class=text></span><br></td>
  26
  27 <table >
  28 <tr>
  29 <td align="right">Foot:</td>
  30 <td><input type=radio name="ankle_foot" value="Left" <?if ($obj{"ankle_foot"} == "Left")
  31 {echo "checked";};?>><span class=text></span><br></td>
  32 <td align="right">Left:</td>
  33 <td><input type=radio name="ankle_foot" value="Right" <?if ($obj{"ankle_foot"} == "Right")
  34 {echo "checked";};?>><span class=text></span><br></td>
  35 <td align="right">Right:</td>
  36 </tr>
  37 </table>
  38
  39 <table >
  40 <tr>
  41 <td align="right">Severity of Pain:</td>
  42 <td align="right">1:</td>
  43 <td><input type=radio name="ankle_severity_of_pain" value="1" <?if ($obj{"ankle_severity_of_pain"} == "1")
  44 {echo "checked";};?>><span class=text></span><br></td>
  45
  46 <td align="right">2:</td>
  47 <td><input type=radio name="ankle_severity_of_pain" value="2" <?if ($obj{"ankle_severity_of_pain"} == "2")
  48 {echo "checked";};?>><span class=text></span><br></td>
  49
  50 <td align="right">3:</td>
  51 <td><input type=radio name="ankle_severity_of_pain" value="3" <?if ($obj{"ankle_severity_of_pain"} == "3")
  52 {echo "checked";};?>><span class=text></span><br></td>
  53 </tr>
  54 </table>
  55
  56 <table><tr>
  57 <td align="right">Significant Swelling:</td>
  58 <td><input type=checkbox name="ankle_significant_swelling" <?if ($obj{"ankle_significant_swelling"} == "on")
  59 {echo "checked";};?>><span class=text></span><br>
  60 </tr>
  61 </table>
  62
  63
  64 <table >
  65 <tr>
  66 <td align="right">Onset of Swelling:</td>
  67 <td><input type=radio name="ankle_onset_of_swelling" value="within minutes" <?if ($obj{"ankle_onset_of_swelling"} == "within minutes")
  68 {echo "checked";};?>><span class=text></span><br></td>
  69 <td align="right">within minutes:</td>
  70 <td><input type=radio name="ankle_onset_of_swelling" value="within hours" <?if ($obj{"ankle_onset_of_swelling"} == "within hours")
  71 {echo "checked";};?>><span class=text></span><br></td>
  72 <td align="right">within hours:</td>
  73 </tr>
  74 </table>
  75
  76 <span class="text">How did Injury Occur?:</span></br>
  77 <textarea name="ankle_how_did_injury_occur" cols ="67" rows="4"  wrap="virtual name">
  78 <?echo stripslashes($obj{"ankle_how_did_injury_occur"});?></textarea>
  79 <br>
  80
  81 <table><th colspan="5">Ottawa Ankle Rules</th>
  82 <tr>
  83 <td align="right">Bone Tenderness:</td>
  84 <td align="right">Medial malleolus:</td>
  85 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Medial malleolus" <?if ($obj{"ankle_ottawa_bone_tenderness"} == "Medial malleolus")
  86 {echo "checked";};?>><span class=text></span><br></td>
  87 <td align="right">Lateral malleolus:</td>
  88 <td><input type=radio name="ankle_ottawa_bone_tenderness"  value="Lateral malleolus" <?if ($obj{"ankle_ottawa_bone_tenderness"} == "Lateral malleolus")
  89 {echo "checked";};?>><span class=text></span><br></td>
  90 <td align="right">Base of fifth (5th) Metarsal:</td>
  91 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Base of fifth (5th) Metarsal" <?if ($obj{"ankle_ottawa_bone_tenderness"} == "Base of fifth (5th) Metarsal")
  92 {echo "checked";};?>><span class=text></span><br></td>
  93 <td align="right">At the Navicular:</td>
  94 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="At the Navicular" <?if ($obj{"ankle_ottawa_bone_tenderness"} == "At the Navicular")
  95 {echo "checked";};?>><span class=text></span><br></td>
  96 </tr>
  97 </table>
  98
  99 <table >
 100 <tr>
 101 <td align="right">Able to Bear Weight four (4) steps:</td>
 102 <td align="right">Yes:</td>
 103 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="Yes" <?if ($obj{"ankle_able_to_bear_weight_steps"} == "Yes")
 104 {echo "checked";};?>><span class=text></span><br></td>
 105 <td align="right">No:</td>
 106 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="No" <?if ($obj{"ankle_able_to_bear_weight_steps"} == "No")
 107 {echo "checked";};?>><span class=text></span><br></td>
 108 </tr>
 109 </table>
 110
 111 <table>
 112 <tr><th>X-Ray Interpretation:</th> <th>Additional X-RAY Notes:</th></tr>
 113 <tr>
 114 <td>
 115 <input type=entry name="ankle_x_ray_interpretation" value="<?echo
 116 stripslashes($obj{"ankle_x_ray_interpretation"});?>" size="50">
 117 </td>
 118 <td rowspan=2>
 119 <textarea name="ankle_additional_x_ray_notes" cols ="30" rows="1" wrap="virtual name">
 120 <?echo stripslashes($obj{"ankle_additional_x_ray_notes"});?></textarea>
 121 <td>
 122 </tr>
 123 </table>
 124
 125 <table>
 126 <tr><th>Diagnosis:</th><th>Additional Diagnosis:</th></tr>
 127 <tr>
 128 <td><input type=entry name="ankle_diagnosis1" value="<?echo
 129 stripslashes($obj{"ankle_diagnosis1"});?>" size="50">
 130 </td>
 131 <td rowspan=2>
 132 <textarea name="ankle_additional_diagnisis" rows="2" cols="30" wrap="virtual name">
 133 <?echo stripslashes($obj{"ankle_additional_diagnisis"});?></textarea>
 134 </td>
 135
 136 <tr>
 137 <td><input type=entry name="ankle_diagnosis2" value="<?echo
 138 stripslashes($obj{"ankle_diagnosis2"});?>" size="50"></td>
 139 </tr>
 140 <td><input type=entry name="ankle_diagnosis3" value="<?echo
 141 stripslashes($obj{"ankle_diagnosis3"});?>" size="50"></td>
 142 </tr>
 143 <td><input type=entry name="ankle_diagnosis4" value="<?echo
 144 stripslashes($obj{"ankle_diagnosis4"});?>" size="50"></td>
 145 </tr>
 146 </table>
 147
 148 <table><tr><th>Plan:</th><tr>
 149 <tr><td>
 150 <textarea name="ankle_plan" rows="4" cols="67" wrap="virtual name">
 151 <?echo stripslashes($obj{"ankle_plan"});?></textarea>
 152 </td></tr></table>
 153
 154 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
 155 <br>
 156 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl"; ?>" class="link">[Don't Save Changes]</a>
 157 </form>
 158 <?php
 159 formFooter();
 160 ?>