contrib/forms/hearingtest/new.php

   1 <!-- Form generated from formsWiz  -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: hearingtest");
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <form method=post action="<?echo $rootdir;?>/forms/hearingtest/save.php?mode=new" name="my_form">
  12 <span class="title">Hearing Test</span><br><br>
  13 <input type=checkbox name='with_hearing_aid'  ><span class=text>With hearing Aid?</span><br>
  14 <table>
  15 <tr>
  16 <td>
  17 <span class=text>Right Ear 250: </span><input type=entry name="right_ear_250" value="" ><br>
  18 <span class=text>Right Ear 500: </span><input type=entry name="right_ear_500" value="" ><br>
  19 <span class=text>Right Ear 1000: </span><input type=entry name="right_ear_1000" value="" ><br>
  20 <span class=text>Right Ear 2000: </span><input type=entry name="right_ear_2000" value="" ><br>
  21 <span class=text>Right Ear 3000: </span><input type=entry name="right_ear_3000" value="" ><br>
  22 <span class=text>Right Ear 4000: </span><input type=entry name="right_ear_4000" value="" ><br>
  23 <span class=text>Right Ear 5000: </span><input type=entry name="right_ear_5000" value="" ><br>
  24 <span class=text>Right Ear 6000: </span><input type=entry name="right_ear_6000" value="" ><br>
  25 </td>
  26 <td>
  27 <span class=text>Left Ear 250: </span><input type=entry name="left_ear_250" value="" ><br>
  28 <span class=text>Left Ear 500: </span><input type=entry name="left_ear_500" value="" ><br>
  29 <span class=text>Left Ear 1000: </span><input type=entry name="left_ear_1000" value="" ><br>
  30 <span class=text>Left Ear 2000: </span><input type=entry name="left_ear_2000" value="" ><br>
  31 <span class=text>Left Ear 3000: </span><input type=entry name="left_ear_3000" value="" ><br>
  32 <span class=text>Left Ear 4000: </span><input type=entry name="left_ear_4000" value="" ><br>
  33 <span class=text>Left Ear 5000: </span><input type=entry name="left_ear_5000" value="" ><br>
  34 <span class=text>Left Ear 6000: </span><input type=entry name="left_ear_6000" value="" ><br>
  35 </td>
  36 </tr>
  37 </table>
  38 <br>
  39 <table>
  40 <tr>
  41 <td valign=top>
  42 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 name="additional_notes" ></textarea>
  43 </td>
  44 </tr>
  45 </table>
  46 <br>
  47 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  48 <br>
  49 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[Don't Save]</a>
  50 </form>
  51 <?php
  52 formFooter();
  53 ?>