contrib/forms/immunization_record/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 ?>
   7
   8 <html>
   9 <head>
  10 <title>Form: ACOG Immunization record</title>
  11 <? include("../../acog_printable_h.css"); ?>
  12 </head>
  13
  14 <?
  15    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  16    if ($fres){
  17      $patient = sqlFetchArray($fres);
  18    }
  19    $fres=sqlStatement("select * from form_immunization_record where id='".$id."'");
  20    if ($fres){
  21      $ir = sqlFetchArray($fres);
  22    }
  23 ?>
  24 <body>
  25
  26 <div class="srvChapter">Immunization record<sup>*</sup></div>
  27 <div style="border: solid 2pt black; background-color:#FFFFFF;">
  28   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  29     <tr align="left" valign="bottom">
  30       <td colspan="4" class="fibody2" id="bordR">Patient name: <? echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'}; ?></td>
  31       <td colspan="2" class="fibody2" id="bordR">Birth date: <? echo $patient{'DOB'}; ?></td>
  32       <td colspan="2" class="fibody2">ID No: <?  echo $patient{'id'};  ?></td>
  33       </tr>
  34     <tr align="center" valign="middle">
  35       <td width="9%" class="ficaption2" id="bordR">age</td>
  36       <td width="13%" class="ficaption2" id="bordR">Tetanus-Diphteria booster </td>
  37       <td width="13%" class="ficaption2" id="bordR">Influenza vaccine </td>
  38       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
  39       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine</td>
  40       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
  41       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
  42       <td width="13%" class="ficaption2">Varicella vaccine </td>
  43     </tr>
  44     <tr align="center" valign="middle">
  45       <td class="fibody2" id="bordR">13-18</td>
  46       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
  47       <td class="fibody2" id="bordR">Based on risk </td>
  48       <td class="fibody2" id="bordR">Based on risk</td>
  49       <td class="fibody2" id="bordR">Based on risk</td>
  50       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
  51       <td class="fibody2" id="bordR">Based on risk</td>
  52       <td class="fibody2">Based on risk</td>
  53     </tr>
  54     <tr align="center" valign="middle">
  55       <td class="fibody2" id="bordR">19-39</td>
  56       <td class="fibody2" id="bordR">Every 10 years </td>
  57       <td class="fibody2" id="bordR">Based on risk</td>
  58       <td class="fibody2" id="bordR">Based on risk</td>
  59       <td class="fibody2" id="bordR">Based on risk</td>
  60       <td class="fibody2" id="bordR">Based on risk</td>
  61       <td class="fibody2" id="bordR">Based on risk</td>
  62       <td class="fibody2">Based on risk</td>
  63     </tr>
  64     <tr align="center" valign="middle">
  65       <td class="fibody2" id="bordR">40-64</td>
  66       <td class="fibody2" id="bordR">Every 10 years</td>
  67       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
  68       <td class="fibody2" id="bordR">Based on risk</td>
  69       <td class="fibody2" id="bordR">Based on risk</td>
  70       <td class="fibody2" id="bordR">Based on risk</td>
  71       <td class="fibody2" id="bordR">Based on risk</td>
  72       <td class="fibody2">Based on risk</td>
  73     </tr>
  74     <tr align="center" valign="middle">
  75       <td class="fibody2" id="bordR">65 and older </td>
  76       <td class="fibody2" id="bordR">Every 10 years</td>
  77       <td class="fibody2" id="bordR">Annually</td>
  78       <td class="fibody2" id="bordR">Once</td>
  79       <td class="fibody2" id="bordR">&nbsp;</td>
  80       <td class="fibody2" id="bordR">Based on risk</td>
  81       <td class="fibody2" id="bordR">Based on risk</td>
  82       <td class="fibody2">Based on risk</td>
  83     </tr>
  84   </table>
  85 </div>
  86 <p>&nbsp;</p>
  87 <div style="border: solid 2pt black; background-color:#FFFFFF;">
  88   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  89 <?
  90 $vacci=0;
  91   $vacc_tetanus = explode("|~", $ir["vacc_tetanus"]);
  92   $vacc_influenza = explode("|~", $ir["vacc_influenza"]);
  93   $vacc_pneumococcal = explode("|~", $ir["vacc_pneumococcal"]);
  94   $vacc_mmr = explode("|~", $ir["vacc_mmr"]);
  95   $vacc_hep_a = explode("|~", $ir["vacc_hep_a"]);
  96   $vacc_hep_b = explode("|~", $ir["vacc_hep_b"]);
  97   $vacc_varicella= explode("|~", $ir["vacc_varicella"]);
  98 while ($vacci<20){
  99 print <<<EOL
 100     <tr align="left" valign="bottom">
 101       <td width="9%" class="fibody5" id="bordR">Date</td>
 102       <td width="13%" class="fibody5" id="bordR">${vacc_tetanus[$vacci]}&nbsp;</td>
 103       <td width="13%" class="fibody5" id="bordR">${vacc_influenza[$vacci]}&nbsp;</td>
 104       <td width="13%" class="fibody5" id="bordR">${vacc_pneumococcal[$vacci]}&nbsp;</td>
 105       <td width="13%" class="fibody5" id="bordR">${vacc_mmr[$vacci]}&nbsp;</td>
 106       <td width="13%" class="fibody5" id="bordR">${vacc_hep_b[$vacci]}&nbsp;</td>
 107       <td width="13%" class="fibody5" id="bordR">${vacc_hep_a[$vacci]}&nbsp;</td>
 108       <td width="13%" class="fibody5">${vacc_varicella[$vacci]}&nbsp;</td>
 109     </tr>
 110 EOL;
 111 $vacci++;
 112 }
 113 ?>
 114   </table>
 115 </div>
 116 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 117 </body>
 118 </html>