contrib/forms/hearingtest/new.php

   1 <?php
   2
   3 /**
   4  * Generated DocBlock
   5  *
   6  * @package OpenEMR
   7  * @link    http://www.open-emr.org
   8  * @author  andres_paglayan <andres_paglayan>
   9  * @author  cornfeed <jdough823@gmail.com>
  10  * @author  fndtn357 <fndtn357@gmail.com>
  11  * @author  sunsetsystems <sunsetsystems>
  12  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  13  * @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
  14  * @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
  15  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  16  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  17  */
  18
  19 ?>
  20 <!-- Form generated from formsWiz  -->
  21 <?php
  22 require_once("../../globals.php");
  23 require_once("$srcdir/api.inc.php");
  24
  25 use OpenEMR\Core\Header;
  26
  27 formHeader("Form: hearingtest");
  28 ?>
  29 <html><head>
  30     <?php Header::setupHeader(); ?>
  31 </head>
  32 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  33 <form method=post action="<?php echo $rootdir;?>/forms/hearingtest/save.php?mode=new" name="my_form">
  34 <span class="title">Hearing Test</span><br /><br />
  35 <input type=checkbox name='with_hearing_aid'  ><span class=text>With hearing Aid?</span><br />
  36 <table>
  37 <tr>
  38 <td>
  39 <span class=text>Right Ear 250: </span><input type="text" name="right_ear_250" value="" ><br />
  40 <span class=text>Right Ear 500: </span><input type="text" name="right_ear_500" value="" ><br />
  41 <span class=text>Right Ear 1000: </span><input type="text" name="right_ear_1000" value="" ><br />
  42 <span class=text>Right Ear 2000: </span><input type="text" name="right_ear_2000" value="" ><br />
  43 <span class=text>Right Ear 3000: </span><input type="text" name="right_ear_3000" value="" ><br />
  44 <span class=text>Right Ear 4000: </span><input type="text" name="right_ear_4000" value="" ><br />
  45 <span class=text>Right Ear 5000: </span><input type="text" name="right_ear_5000" value="" ><br />
  46 <span class=text>Right Ear 6000: </span><input type="text" name="right_ear_6000" value="" ><br />
  47 </td>
  48 <td>
  49 <span class=text>Left Ear 250: </span><input type="text" name="left_ear_250" value="" ><br />
  50 <span class=text>Left Ear 500: </span><input type="text" name="left_ear_500" value="" ><br />
  51 <span class=text>Left Ear 1000: </span><input type="text" name="left_ear_1000" value="" ><br />
  52 <span class=text>Left Ear 2000: </span><input type="text" name="left_ear_2000" value="" ><br />
  53 <span class=text>Left Ear 3000: </span><input type="text" name="left_ear_3000" value="" ><br />
  54 <span class=text>Left Ear 4000: </span><input type="text" name="left_ear_4000" value="" ><br />
  55 <span class=text>Left Ear 5000: </span><input type="text" name="left_ear_5000" value="" ><br />
  56 <span class=text>Left Ear 6000: </span><input type="text" name="left_ear_6000" value="" ><br />
  57 </td>
  58 </tr>
  59 </table>
  60 <br />
  61 <table>
  62 <tr>
  63 <td valign=top>
  64 <span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 name="additional_notes" ></textarea>
  65 </td>
  66 </tr>
  67 </table>
  68 <br />
  69 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  70 <br />
  71 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save]</a>
  72 </form>
  73 <?php
  74 formFooter();
  75 ?>