view.php

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