contrib/forms/neurologicalreview/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: neurologicalreview");
   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/neurologicalreview/save.php?mode=new" name="my_form">
  12 <span class="title">Neurological Review</span><br><br>
  13 <table>
  14 <tr>
  15 <td valign=top>
  16 <table>
  17 <tr><td><span class=text>Burning: </span></td><td><input type=entry name="burning" value="" ></td></tr>
  18 <tr><td><span class=text>Confusion: </span></td><td><input type=entry name="confusion" value="" ></td></tr>
  19 <tr><td><span class=text>Dizziness: </span></td><td><input type=entry name="dizziness" value="" ></td></tr>
  20 <tr><td><span class=text>Dysphasia: </span></td><td><input type=entry name="dysphasia" value="" ></td></tr>
  21 <tr><td><span class=text>Facial tic: </span></td><td><input type=entry name="facial_tic" value="" ></td></tr>
  22 <tr><td><span class=text>Focal weakness: </span></td><td><input type=entry name="focal_weakness" value="" ></td></tr>
  23 <tr><td><span class=text>Forgetfulness: </span></td><td><input type=entry name="forgetfulness" value="" ></td></tr>
  24 </table>
  25 </td><td valign=top>
  26 <table>
  27 <tr><td><span class=text>Headache: </span></td><td><input type=entry name="headache" value="" ></td></tr>
  28 <tr><td><span class=text>Hyperesthesia: </span></td><td><input type=entry name="hyperesthesia" value="" ></td></tr>
  29 <tr><td><span class=text>Lightheadedness: </span></td><td><input type=entry name="lightheadedness" value="" ></td></tr>
  30 <tr><td><span class=text>Numbness: </span></td><td><input type=entry name="numbness" value="" ></td></tr>
  31 <tr><td><span class=text>Paralysis: </span></td><td><input type=entry name="paralysis" value="" ></td></tr>
  32 <tr><td><span class=text>Paresthesia: </span></td><td><input type=entry name="paresthesia" value="" ></td></tr>
  33 </table>
  34 </td>
  35 </tr>
  36 </table>
  37
  38 <table>
  39 <tr><td>
  40 <span class=text>Symptoms of Problems: </span><br><textarea cols=40 rows=8 wrap=virtual name="symptoms_of_problems" ></textarea>
  41 </td><td>
  42 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8  wrap=virtual name="additional_notes" ></textarea>
  43 </td>
  44 </tr>
  45 </table>
  46
  47 <br>
  48 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  49 <br>
  50 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[Don't Save]</a>
  51 </form>
  52 <?php
  53 formFooter();
  54 ?>