contrib/forms/routine_screening_record/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_routine_screening_record';
   7 $ftitle = 'Routine screening record';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  17   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  18   $id = $newid;
  19   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  20   exit;
  21   }
  22   }
  23 ?>
  24 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  25 "http://www.w3.org/TR/html4/loose.dtd">
  26
  27 <html>
  28 <head>
  29 <title>Form: Routine screening record</title>
  30 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  31 <link rel=stylesheet href="../../acog.css" type="text/css">
  32 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  33 <script language="JavaScript" type="text/JavaScript">
  34 window.onload = initialize;
  35 </script>
  36 </head>
  37
  38 <?
  39    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  40    if ($fres){
  41      $patient = sqlFetchArray($fres);
  42    }
  43 ?>
  44 <body <?echo $top_bg_line;?>>
  45
  46 <form action="<?echo $rootdir;?>/forms/routine_screening_record/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  47 <? include("../../acog_menu.inc"); ?>
  48 <div class="srvChapter">Routine screening record <a href="#" onMouseOver="toolTip('The <strong>Routine Screening Record</strong> includes those screening tests recommended by ACOG for routine use and provides reminders for recommended frequency of services.', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  49 <div style="border: solid 2px black; background-color:#FFFFFF;">
  50   <table  border="0" cellpadding="2" cellspacing="0">
  51     <tr align="left" valign="bottom">
  52       <td colspan="4" class="fibody2" id="bordR">patient name:
  53         <input name="pname" type="text" class="fullin" id="pname" style="width: 74%" value="<?
  54           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  55           ?>"></td>
  56       <td colspan="4" class="fibody2" id="bordR">Birth date:
  57         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  58           echo $patient{'DOB'};
  59           ?>"></td>
  60       <td colspan="3" class="fibody2">ID No:
  61         <input name="rs_pid" type="text" class="fullin" id="rs_pid" style="width:80%" value="<?
  62           echo $patient{'id'};
  63           ?>"></td>
  64       </tr>
  65     <tr align="center" valign="middle">
  66       <td class="ficaption2" id="bordR">age</td>
  67       <td width="9%" class="ficaption2" id="bordR">Cervical cytology </td>
  68       <td width="9%" class="ficaption2" id="bordR">Lipid profile assessment<a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  69       <td width="9%" class="ficaption2" id="bordR">Mammo-<br>
  70         graphy<a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  71       <td width="9%" class="ficaption2" id="bordR">Colorectal cancer screening <a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  72       <td width="9%" class="ficaption2" id="bordR">Bone density screening <a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"> <img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  73       <td width="9%" class="ficaption2" id="bordR">Chlamydia screening <a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a> </td>
  74       <td width="9%" class="ficaption2" id="bordR">Gonor-<br>
  75         rhea screening <a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a> </td>
  76       <td width="9%" class="ficaption2" id="bordR">Urinalysis</td>
  77       <td width="9%" class="ficaption2" id="bordR">Fasting glucose test <a href="#" onMouseOver="toolTip('This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  78       <td width="9%" class="ficaption2">Thyroid stimulating hormone screening </td>
  79     </tr>
  80     <tr align="center" valign="middle">
  81       <td class="fibody2" id="bordR">13-18</td>
  82       <td class="fibody2" id="bordR">ANNUALLY BEGINNING
  83         APPROXIMATELY 3 YEARS
  84         AFTER INITIATION OF
  85         SEXUAL INTERCOURSE</td>
  86       <td class="fibody2" id="bordR">&nbsp; </td>
  87       <td class="fibody2" id="bordR">&nbsp; </td>
  88       <td class="fibody2" id="bordR">&nbsp; </td>
  89       <td class="fibody2" id="bordR">&nbsp; </td>
  90       <td class="fibody2" id="bordR">        SEXUALLY ACTIVE WOMEN
  91         UNDER AGE 25</td>
  92       <td class="fibody2" id="bordR">SEXUALLY ACTIVE
  93         ADOLES-<br>
  94         CENTS</td>
  95       <td class="fibody2" id="bordR">&nbsp;</td>
  96       <td class="fibody2" id="bordR">&nbsp;</td>
  97       <td class="fibody2">&nbsp;</td>
  98     </tr>
  99     <tr align="center" valign="middle">
 100       <td class="fibody2" id="bordR">19-39</td>
 101       <td class="fibody2" id="bordR">ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS</td>
 102       <td class="fibody2" id="bordR">&nbsp; </td>
 103       <td class="fibody2" id="bordR">&nbsp; </td>
 104       <td class="fibody2" id="bordR">&nbsp; </td>
 105       <td class="fibody2" id="bordR">&nbsp; </td>
 106       <td class="fibody2" id="bordR"> SEXUALLY ACTIVE WOMEN<br>
 107 UNDER AGE 25</td>
 108       <td class="fibody2" id="bordR">&nbsp; </td>
 109       <td class="fibody2" id="bordR">&nbsp;</td>
 110       <td class="fibody2" id="bordR">&nbsp;</td>
 111       <td class="fibody2">&nbsp;</td>
 112     </tr>
 113     <tr align="center" valign="middle">
 114       <td class="fibody2" id="bordR">40-64</td>
 115       <td class="fibody2" id="bordR">EVERY 2–3 YEARS AFTER 3
 116         CONSECuTIVE NEGATIVE TEST
 117         RESULTS IF NO HISTORY OF
 118         CIN 2 OR 3,
 119         IMMUNOSUP-<br>
 120         PRESSION,
 121         HIV INFECTION, OR DES
 122         EXPOSURE IN UTERO</td>
 123       <td class="fibody2" id="bordR">EVERY 5 YEARS
 124         BEGINNING
 125         AT AGE 45</td>
 126       <td class="fibody2" id="bordR">EVERY 1–2 YEARS UNTIL
 127         AGE 50; YEARLY
 128         BEGINNING AT AGE 50</td>
 129       <td class="fibody2" id="bordR">        BEGINNING AT AGE 50
 130         YEARLY FOBT OR FLEXIBLE
 131         SIGMOIDOSCOPY EVERY
 132         5 YEARS OR YEARLY FOBT
 133         PLUS FLEXIBLE
 134         SIGMOIDOSCOPY EVERY 5
 135         YEARS OR DCBE EVERY 5
 136         YEARS OR COLONOSCOPY
 137         EVERY 10 YEARS</td>
 138       <td class="fibody2" id="bordR">&nbsp; </td>
 139       <td class="fibody2" id="bordR">&nbsp; </td>
 140       <td class="fibody2" id="bordR">&nbsp; </td>
 141       <td class="fibody2" id="bordR">&nbsp;</td>
 142       <td class="fibody2" id="bordR">EVERY 3 YEARS
 143         AFTER AGE 45</td>
 144       <td class="fibody2">EVERY 5 YEARS
 145         BEGINNING AT AGE 50</td>
 146     </tr>
 147     <tr align="center" valign="middle">
 148       <td class="fibody2" id="bordR">65 and older </td>
 149       <td class="fibody2" id="bordR">EVERY 2–3 YEARS AFTER 3<br>
 150         CONSECUTIVE NEGATIVE TEST
 151         RESULTS IF NO HISTORY OF
 152         CIN 2 OR 3,
 153         IMMUNOSUP-<br>
 154         PRESSION,
 155         HIV INFECTION, OR DES
 156         EXPOSURE IN UTERO</td>
 157       <td class="fibody2" id="bordR">EVERY 5 YEARS</td>
 158       <td class="fibody2" id="bordR">YEARLY OR AS
 159         APPROPRIATE</td>
 160       <td class="fibody2" id="bordR">        YEARLY FOBT OR FLEXIBLE
 161         SIGMOIDOSCOPY EVERY
 162         5 YEARS OR YEARLY FOBT
 163         PLUS FLEXIBLE
 164         SIGMOIDOSCOPY EVERY
 165         YEARS OR DCBE EVERY
 166         YEARS OR COLONOSCOPY
 167         EVERY 10 YEARS</td>
 168       <td class="fibody2" id="bordR">        IN THE ABSENCE OF
 169         NEW RISK FACTORS,
 170         SUBSEQUENT SCREENING
 171         NOT MORE FREQUENTLY
 172         THAN EVERY 2 YEARS</td>
 173       <td class="fibody2" id="bordR">&nbsp; </td>
 174       <td class="fibody2" id="bordR">&nbsp; </td>
 175       <td class="fibody2" id="bordR">YEARLY OR AS
 176         APPROPRIATE</td>
 177       <td class="fibody2" id="bordR">EVERY 3 YEARS</td>
 178       <td class="fibody2">EVERY 5 YEARS</td>
 179     </tr>
 180     <tr align="left" valign="bottom">
 181       <td colspan="11" class="fibody2" style="border-bottom: 2px solid black;">&nbsp;</td>
 182       </tr>
 183 <?
 184 $rsi = 1;
 185 while ($rsi <  9){
 186 print <<<EOL
 187     <tr align="left" valign="bottom">
 188       <td class="fibody2" id="bordR">Date</td>
 189       <td class="fibody3" id="bordR"><input name="cervical_date_${rsi}" type="text" class="fullin2"></td>
 190       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" class="fullin2"></td>
 191       <td class="fibody3" id="bordR"><input name="mammo_date_${rsi}" type="text" class="fullin2"></td>
 192       <td class="fibody3" id="bordR"><input name="colorectal_date_${rsi}" type="text" class="fullin2"></td>
 193       <td class="fibody3" id="bordR"><input name="bone_date_${rsi}" type="text" class="fullin2"></td>
 194       <td class="fibody3" id="bordR"><input name="chlamyd_date_${rsi}" type="text" class="fullin2"></td>
 195       <td class="fibody3" id="bordR"><input name="gonor_date_${rsi}" type="text" class="fullin2"></td>
 196       <td class="fibody3" id="bordR"><input name="urinal_date_${rsi}" type="text" class="fullin2"></td>
 197       <td class="fibody3" id="bordR"><input name="glucose_date_${rsi}" type="text" class="fullin2"></td>
 198       <td class="fibody3"><input name="thyroid_date_${rsi}" type="text" class="fullin2"></td>
 199     </tr>
 200     <tr align="left" valign="bottom">
 201       <td class="fibody2" id="bordR">result</td>
 202       <td class="fibody5" id="bordR"><input name="cervical_res_${rsi}" type="text" class="fullin2"></td>
 203       <td class="fibody5" id="bordR"><input name="lipid_res_${rsi}" type="text" class="fullin2"></td>
 204       <td class="fibody5" id="bordR"><input name="mammo_res_${rsi}" type="text" class="fullin2"></td>
 205       <td class="fibody5" id="bordR"><input name="colorectal_res_${rsi}" type="text" class="fullin2"></td>
 206       <td class="fibody5" id="bordR"><input name="bone_res_${rsi}" type="text" class="fullin2"></td>
 207       <td class="fibody5" id="bordR"><input name="chlamyd_res_${rsi}" type="text" class="fullin2"></td>
 208       <td class="fibody5" id="bordR"><input name="gonor_res_${rsi}" type="text" class="fullin2"></td>
 209       <td class="fibody5" id="bordR"><input name="urinal_res_${rsi}" type="text" class="fullin2"></td>
 210       <td class="fibody5" id="bordR"><input name="glucose_res_${rsi}" type="text" class="fullin2"></td>
 211       <td class="fibody5"><input name="thyroid_res_${rsi}" type="text" class="fullin2"></td>
 212     </tr>
 213 EOL;
 214 $rsi++;
 215 }
 216 ?>
 217   </table>
 218 </div>
 219 <p>&nbsp;</p>
 220 <table width="100%" border="0">
 221   <tr>
 222     <td align="left"> <a href="javascript:document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 223     <td align="right"> <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link_submit">[Don't Save]</a> </td>
 224   </tr>
 225 </table>
 226 </form>
 227 <?php
 228 formFooter();
 229 ?>
 230 </body>
 231 </html>