contrib/forms/cardiology_set/Forms2_Cardiology/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Forms2_Cardiology");
   5 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  12 <script type="text/javascript" src="../../../library/dialog.js"></script>
  13 <script type="text/javascript" src="../../../library/textformat.js"></script>
  14 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  15 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  16 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  17 <script language='JavaScript'> var mypcc = '1'; </script>
  18
  19 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  20 <form method=post action="<?php echo $rootdir;?>/forms/Forms2_Cardiology/save.php?mode=new" name="Forms2_Cardiology" onSubmit="return top.restoreSession()">
  21 <hr>
  22 <h1> <?php xl("Forms2_Cardiology",'e') ?> </h1>
  23 <hr>
  24 <input type="submit" name="submit form" value="submit form" />
  25
  26  <table width="100%">
  27
  28             <tr>
  29
  30                 <td class="text">
  31                     <strong> <?php xl("Recommended Subacute Bacterial Endocarditis Prophylaxis",'e') ?> </strong></td>
  32             </tr>
  33
  34             <tr>
  35
  36                 <td class='text'>
  37
  38 <table>
  39
  40 <tr><td> recommended subacute bacterial endocarditis prophylaxis</td> <td><label><input type="checkbox" name="_recommended_subacute_bacterial_endocarditis_prophylaxis[]" value="None" /> <?php xl("None",'e') ?> </label> <label><input type="checkbox" name="_recommended_subacute_bacterial_endocarditis_prophylaxis[]" value="Standard" /> <?php xl("Standard",'e') ?> </label></td></tr>
  41
  42 </table>
  43
  44 <table>
  45
  46
  47 </table>
  48
  49                     <br />
  50
  51 <table>
  52
  53 <tr><td> other</td> <td><input type="text" name="_other"  /></td></tr>
  54
  55 </table>
  56                 </td>
  57             </tr>
  58
  59             <tr>
  60
  61                 <td class='text'>
  62
  63                     <strong> <?php xl("Check the letter below describing the level of exercise tolerance in which the
  64                         applicant is able to participate.",'e') ?> </strong></td>
  65             </tr>
  66
  67             <tr>
  68
  69                 <td class='text'>
  70
  71 <table>
  72
  73 <tr><td> full active participation with no restrictions</td> <td><label><input type="checkbox" name="_full_active_participation_with_no_restrictions" value="yes" /></label></td></tr>
  74
  75 </table>
  76                 </td>
  77             </tr>
  78
  79             <tr>
  80
  81                 <td class='text'>
  82
  83 <table>
  84
  85 <tr><td> full active participation with moderate exercise</td> <td><label><input type="checkbox" name="_full_active_participation_with_moderate_exercise" value="yes" /></label></td></tr>
  86
  87 </table>
  88                 </td>
  89             </tr>
  90
  91             <tr>
  92
  93                 <td class='text'>
  94
  95 <table>
  96
  97 <tr><td> partial active participation with light exercise</td> <td><label><input type="checkbox" name="_partial_active_participation_with_light_exercise" value="yes" /></label></td></tr>
  98
  99 </table>
 100                 </td>
 101             </tr>
 102
 103             <tr>
 104
 105                 <td class='text'>
 106
 107 <table>
 108
 109 <tr><td> limited active participation with no exercise</td> <td><label><input type="checkbox" name="_limited_active_participation_with_no_exercise" value="yes" /></label></td></tr>
 110
 111 </table>
 112                 </td>
 113             </tr>
 114
 115         </table>
 116
 117         <table width="100%">
 118
 119             <tr>
 120
 121                 <td class='text' colspan="3">
 122                     <b> <?php xl("Allergies:",'e') ?> </b></td>
 123             </tr>
 124
 125             <tr>
 126
 127                 <td class='text'>
 128
 129                     Medication/Trigger
 130                 </td>
 131
 132                 <td class='text'>
 133
 134                     Date of the last Reaction
 135                 </td>
 136
 137                 <td class='text'>
 138
 139                     Type of Reaction
 140                 </td>
 141             </tr>
 142
 143             <tr>
 144
 145                 <td class='text'>
 146
 147                     Medication Trigger1:textfield
 148                 </td>
 149
 150                 <td class='text'>
 151
 152 <table>
 153
 154 <tr><td> date of the last reaction1</td> <td><input type="text" name="_date_of_the_last_reaction1"  /></td></tr>
 155
 156 </table>
 157                 </td>
 158
 159                 <td class='text'>
 160
 161 <table>
 162
 163 <tr><td> type of reaction1</td> <td><input type="text" name="_type_of_reaction1"  /></td></tr>
 164
 165 </table>
 166                 </td>
 167             </tr>
 168
 169             <tr>
 170
 171                 <td class='text'>
 172
 173 <table>
 174
 175 <tr><td> medication trigger2</td> <td><input type="text" name="_medication_trigger2"  /></td></tr>
 176
 177 </table>
 178                 </td>
 179
 180                 <td class='text'>
 181
 182 <table>
 183
 184 <tr><td> date of the last reaction2</td> <td><input type="text" name="_date_of_the_last_reaction2"  /></td></tr>
 185
 186 </table>
 187                 </td>
 188
 189                 <td class='text'>
 190
 191 <table>
 192
 193 <tr><td> type of reaction2</td> <td><input type="text" name="_type_of_reaction2"  /></td></tr>
 194
 195 </table>
 196                 </td>
 197             </tr>
 198
 199             <tr>
 200
 201                 <td class='text'>
 202
 203 <table>
 204
 205 <tr><td> medication trigger3</td> <td><input type="text" name="_medication_trigger3"  /></td></tr>
 206
 207 </table>
 208                 </td>
 209
 210                 <td class='text'>
 211
 212 <table>
 213
 214 <tr><td> date of the last reaction3</td> <td><input type="text" name="_date_of_the_last_reaction3"  /></td></tr>
 215
 216 </table>
 217                 </td>
 218
 219                 <td class='text'>
 220
 221 <table>
 222
 223 <tr><td> type of reaction3</td> <td><input type="text" name="_type_of_reaction3"  /></td></tr>
 224
 225 </table>
 226                 </td>
 227             </tr>
 228
 229         </table>
 230
 231         <table width="100%">
 232
 233             <tr>
 234
 235                 <td class='text' colspan="2">
 236                     <strong> <?php xl("Medications:",'e') ?> </strong></td>
 237             </tr>
 238
 239             <tr>
 240
 241                 <td class='text'>
 242
 243                     Medication / Strength / SIG:
 244                 </td>
 245
 246                 <td class='text'>
 247
 248                     Special Instructions:
 249                 </td>
 250             </tr>
 251
 252             <tr>
 253
 254                 <td class='text'>
 255
 256 <table>
 257
 258 <tr><td> medication strength  sig1</td> <td><input type="text" name="_medication_strength__sig1"  /></td></tr>
 259
 260 </table>
 261                 </td>
 262
 263                 <td class='text'>
 264
 265 <table>
 266
 267 <tr><td> special instructions1</td> <td><input type="text" name="_special_instructions1"  /></td></tr>
 268
 269 </table>
 270                 </td>
 271             </tr>
 272
 273             <tr>
 274
 275                 <td class='text'>
 276
 277 <table>
 278
 279 <tr><td> medication strength  sig2</td> <td><input type="text" name="_medication_strength__sig2"  /></td></tr>
 280
 281 </table>
 282                 </td>
 283
 284                 <td class='text'>
 285
 286 <table>
 287
 288 <tr><td> special instructions2</td> <td><input type="text" name="_special_instructions2"  /></td></tr>
 289
 290 </table>
 291                 </td>
 292             </tr>
 293
 294             <tr>
 295
 296                 <td class='text'>
 297
 298 <table>
 299
 300 <tr><td> medication strength  sig3</td> <td><input type="text" name="_medication_strength__sig3"  /></td></tr>
 301
 302 </table>
 303                 </td>
 304
 305                 <td class='text'>
 306
 307 <table>
 308
 309 <tr><td> special instructions3</td> <td><input type="text" name="_special_instructions3"  /></td></tr>
 310
 311 </table>
 312                 </td>
 313             </tr>
 314
 315             <tr>
 316
 317                 <td class='text'>
 318
 319 <table>
 320
 321 <tr><td> medication strength  sig4</td> <td><input type="text" name="_medication_strength__sig4"  /></td></tr>
 322
 323 </table>
 324                 </td>
 325
 326                 <td class='text'>
 327
 328 <table>
 329
 330 <tr><td> special instructions4</td> <td><input type="text" name="_special_instructions4"  /></td></tr>
 331
 332 </table>
 333                 </td>
 334             </tr>
 335
 336             <tr>
 337
 338                 <td class='text'>
 339
 340 <table>
 341
 342 <tr><td> medication strength  sig5</td> <td><input type="text" name="_medication_strength__sig5"  /></td></tr>
 343
 344 </table>
 345                 </td>
 346
 347                 <td class='text'>
 348
 349 <table>
 350
 351 <tr><td> special instructions5</td> <td><input type="text" name="_special_instructions5"  /></td></tr>
 352
 353 </table>
 354                 </td>
 355             </tr>
 356
 357         </table>
 358
 359         <table>
 360
 361             <tr>
 362
 363                 <td class='text' align="center">
 364
 365                     <strong> <?php xl("Non-prescription medications we stock in the camp infirmary are listed below:
 366                         Please check those which we SHOULD NOT administer",'e') ?> </strong></td>
 367             </tr>
 368
 369             <tr>
 370
 371                 <td class='text'>
 372
 373 <table>
 374
 375 <tr><td> non prescription medications</td> <td><label><input type="checkbox" name="_non_prescription_medications[]" value="Acetaminophen" /> <?php xl("Acetaminophen",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Advil" /> <?php xl("Advil",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Benadryl" /> <?php xl("Benadryl",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Caladryl" /> <?php xl("Caladryl",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Chloraseptic Spray" /> <?php xl("Chloraseptic Spray",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Cough Medicine" /> <?php xl("Cough Medicine",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Dramamine" /> <?php xl("Dramamine",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Kaopectate" /> <?php xl("Kaopectate",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Meclazine" /> <?php xl("Meclazine",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Milk of Magnesia" /> <?php xl("Milk of Magnesia",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Pepto Bismol" /> <?php xl("Pepto Bismol",'e') ?> </label> <label><input type="checkbox" name="_non_prescription_medications[]" value="Sudafed" /> <?php xl("Sudafed",'e') ?> </label></td></tr>
 376
 377 </table>
 378                 </td>
 379             </tr>
 380
 381         </table>
 382
 383         <table width="100%">
 384
 385             <tr>
 386
 387                 <td class='text'>
 388
 389 <table>
 390
 391 <tr><td> describe any recent operations or serious illness</td> <td><textarea name="_describe_any_recent_operations_or_serious_illness"  rows="4" cols="40"></textarea></td></tr>
 392
 393 </table>
 394                 </td>
 395             </tr>
 396
 397             <tr>
 398
 399                 <td class='text'>
 400
 401 <table>
 402
 403 <tr><td> describe any physical disability effecting camp activity</td> <td><textarea name="_describe_any_physical_disability_effecting_camp_activity"  rows="4" cols="40"></textarea></td></tr>
 404
 405 </table>
 406                 </td>
 407             </tr>
 408
 409             <tr>
 410
 411                 <td class='text'>
 412
 413 <table>
 414
 415 <tr><td> describe any pertinent findings on examination</td> <td><textarea name="_describe_any_pertinent_findings_on_examination"  rows="4" cols="40"></textarea></td></tr>
 416
 417 </table>
 418                 </td>
 419             </tr>
 420
 421         </table>
 422
 423         <table width="100%">
 424
 425             <tr>
 426
 427                 <td class='text' colspan="4">
 428                     <strong> <?php xl("Cardiac Rhythm/Device History",'e') ?> </strong></td>
 429             </tr>
 430
 431             <tr>
 432
 433                 <td class='text' style="width: 498px">
 434
 435 <table>
 436
 437 <tr><td> does applicant have a history of dysrhythmias</td> <td><label><input type="radio" name="_does_applicant_have_a_history_of_dysrhythmias" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="radio" name="_does_applicant_have_a_history_of_dysrhythmias" value="NO" /> <?php xl("NO",'e') ?> </label></td></tr>
 438
 439 </table>
 440                 </td>
 441
 442                 <td class='text'>
 443
 444 <table>
 445
 446
 447 </table>
 448             </tr>
 449
 450             <tr>
 451
 452                 <td class='text' colspan="24">
 453
 454 <table>
 455
 456
 457 </table>
 458             </tr>
 459
 460             <tr>
 461
 462                 <td class='text' colspan="4">
 463
 464 <table>
 465
 466
 467 </table>
 468             </tr>
 469
 470             <tr>
 471
 472                 <td class='text' style="width: 498px">
 473
 474 <table>
 475
 476 <tr><td> does applicant have a pacemaker or icd</td> <td><label><input type="radio" name="_does_applicant_have_a_pacemaker_or_icd" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="radio" name="_does_applicant_have_a_pacemaker_or_icd" value="NO" /> <?php xl("NO",'e') ?> </label></td></tr>
 477
 478 </table>
 479                 </td>
 480
 481                 <td class='text'>
 482
 483 <table>
 484
 485
 486 </table>
 487             </tr>
 488
 489             <tr>
 490
 491                 <td class='text' colspan="2">
 492
 493 <table>
 494
 495
 496 </table>
 497             </tr>
 498
 499         </table>
 500
 501         <table width="100%">
 502
 503             <tr>
 504
 505                 <td class='text' colspan="4">
 506                     <strong> <?php xl("Pacemaker",'e') ?> </strong></td>
 507             </tr>
 508
 509             <tr>
 510
 511                 <td class='text' style="width: 25%">
 512
 513 <table>
 514
 515 <tr><td> pacemaker brand</td> <td><input type="text" name="_pacemaker_brand"  /></td></tr>
 516
 517 </table>
 518                 </td>
 519
 520                 <td class='text' style="width: 25%">
 521
 522 <table>
 523
 524 <tr><td> pacemaker model</td> <td><input type="text" name="_pacemaker_model"  /></td></tr>
 525
 526 </table>
 527                 </td>
 528
 529                 <td class='text' colspan="2" style="width: 50%">
 530
 531 <table>
 532
 533
 534 </table>
 535                 </td>
 536             </tr>
 537
 538             <tr>
 539
 540                 <td class='text'>
 541
 542 <table>
 543
 544 <tr><td> pacemaker programmed to</td> <td><input type="text" name="_pacemaker_programmed_to"  /></td></tr>
 545
 546 </table>
 547                 </td>
 548
 549                 <td class='text'>
 550
 551 <table>
 552
 553 <tr><td> pacemaker mode</td> <td><input type="text" name="_pacemaker_mode"  /></td></tr>
 554
 555 </table>
 556                 </td>
 557
 558                 <td class='text'>
 559
 560 <table>
 561
 562 <tr><td> pacemaker lower rate</td> <td><input type="text" name="_pacemaker_lower_rate"  /></td></tr>
 563
 564 </table>
 565                 </td>
 566
 567                 <td class='text'>
 568
 569 <table>
 570
 571 <tr><td> pacemaker upper rate</td> <td><input type="text" name="_pacemaker_upper_rate"  /></td></tr>
 572
 573 </table>
 574                 </td>
 575             </tr>
 576
 577         </table>
 578
 579         <table width="100%">
 580
 581             <tr>
 582
 583                 <td class='text' colspan="6">
 584                     <strong> <?php xl("ICD",'e') ?> </strong></td>
 585             </tr>
 586
 587             <tr>
 588
 589                 <td class='text'>
 590
 591 <table>
 592
 593 <tr><td> icd brand</td> <td><input type="text" name="_icd_brand"  /></td></tr>
 594
 595 </table>
 596                     </td>
 597
 598                 <td class='text'>
 599
 600 <table>
 601
 602 <tr><td> icd model</td> <td><input type="text" name="_icd_model"  /></td></tr>
 603
 604 </table>
 605                     </td>
 606
 607                 <td class='text'>
 608
 609 <table>
 610
 611 <tr><td>
 612 <span class='text'><?php xl(' icd date of last interrogation (yyyy-mm-dd): ','e') ?></span>
 613 </td><td>
 614 <input type='text' size='10' name='_icd_date_of_last_interrogation' id='_icd_date_of_last_interrogation' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 615 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 616 id='img__icd_date_of_last_interrogation' border='0' alt='[?]' style='cursor:pointer'
 617 title='Click here to choose a date'>
 618 <script>
 619 Calendar.setup({inputField:'_icd_date_of_last_interrogation', ifFormat:'%Y-%m-%d', button:'img__icd_date_of_last_interrogation'});
 620 </script>
 621 </td></tr>
 622
 623 </table>
 624                     </td>
 625             </tr>
 626
 627             <tr>
 628
 629                 <td class='text' colspan="3">
 630
 631 <table>
 632
 633 <tr><td> has icd discharged recently and how often</td> <td><input type="text" name="_has_icd_discharged_recently_and_how_often"  /></td></tr>
 634
 635 </table>
 636                 </td>
 637             </tr>
 638
 639         </table>
 640
 641         <table width="100%">
 642
 643             <tr>
 644
 645                 <td class='text' colspan="2">
 646                     <strong> <?php xl("Cardiac Transplant Only",'e') ?> </strong></td>
 647             </tr>
 648
 649             <tr>
 650
 651                 <td class='text'>
 652
 653 <table>
 654
 655 <tr><td> date of transplant</td> <td><input type="text" name="_date_of_transplant"  /></td></tr>
 656
 657 </table>
 658                 </td>
 659
 660                 <td class='text'>
 661
 662 <table>
 663
 664 <tr><td> surgeon</td> <td><input type="text" name="_surgeon"  /></td></tr>
 665
 666 </table>
 667                 </td>
 668             </tr>
 669
 670             <tr>
 671
 672                 <td class='text'>
 673
 674 <table>
 675
 676 <tr><td> name of center</td> <td><input type="text" name="_name_of_center"  /></td></tr>
 677
 678 </table>
 679                 </td>
 680
 681                 <td class='text'>
 682
 683 <table>
 684
 685 <tr><td> phone</td> <td><input type="text" name="_phone"  /></td></tr>
 686
 687 </table>
 688                 </td>
 689             </tr>
 690
 691             <tr>
 692
 693                 <td class='text'>
 694
 695 <table>
 696
 697 <tr><td> evidence of rejection</td> <td><label><input type="radio" name="_evidence_of_rejection" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="radio" name="_evidence_of_rejection" value="NO" /> <?php xl("NO",'e') ?> </label></td></tr>
 698
 699 </table>
 700                 </td>
 701
 702                 <td class='text'>
 703
 704 <table>
 705
 706 <tr><td>
 707 <span class='text'><?php xl(' last cardiac biopsy date (yyyy-mm-dd): ','e') ?></span>
 708 </td><td>
 709 <input type='text' size='10' name='_last_cardiac_biopsy_date' id='_last_cardiac_biopsy_date' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 710 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 711 id='img__last_cardiac_biopsy_date' border='0' alt='[?]' style='cursor:pointer'
 712 title='Click here to choose a date'>
 713 <script>
 714 Calendar.setup({inputField:'_last_cardiac_biopsy_date', ifFormat:'%Y-%m-%d', button:'img__last_cardiac_biopsy_date'});
 715 </script>
 716 </td></tr>
 717
 718 </table>
 719                 </td>
 720             </tr>
 721
 722             <tr>
 723
 724                 <td class='text' colspan="2">
 725
 726 <table>
 727
 728 <tr><td> if evidence of rejection then type and grade</td> <td><textarea name="_if_evidence_of_rejection_then_type_and_grade"  rows="4" cols="40"></textarea></td></tr>
 729
 730 </table>
 731                 </td>
 732             </tr>
 733
 734         </table>
 735
 736         <table width="100%">
 737
 738             <tr>
 739
 740                 <td class='text' colspan="5">
 741                     <strong> <?php xl("Physical Exam:",'e') ?> </strong></td>
 742             </tr>
 743
 744             <tr>
 745
 746                 <td class='text'>
 747
 748 <table>
 749
 750 <tr><td> height</td> <td><input type="text" name="_height"  /></td></tr>
 751
 752 </table>
 753                 </td>
 754
 755                 <td class='text'>
 756
 757 <table>
 758
 759 <tr><td> weight</td> <td><input type="text" name="_weight"  /></td></tr>
 760
 761 </table>
 762                 </td>
 763
 764                 <td class='text'>
 765
 766 <table>
 767
 768 <tr><td> heart rate</td> <td><input type="text" name="_heart_rate"  /></td></tr>
 769
 770 </table>
 771                 </td>
 772
 773                 <td class='text' >
 774
 775 <table>
 776
 777 <tr><td> o2 saturation</td> <td><input type="text" name="_o2_saturation"  /></td></tr>
 778
 779 </table>
 780                 </td>
 781             </tr>
 782
 783             <tr>
 784
 785                 <td class='text' colspan="4">
 786                     Blood Pressures:</td>
 787             </tr>
 788
 789             <tr>
 790
 791                 <td class='text'>
 792
 793 <table>
 794
 795 <tr><td> bp ra</td> <td><input type="text" name="_bp_ra"  /></td></tr>
 796
 797 </table>
 798                 </td>
 799
 800                 <td class='text'>
 801
 802 <table>
 803
 804 <tr><td> bp la</td> <td><input type="text" name="_bp_la"  /></td></tr>
 805
 806 </table>
 807                 </td>
 808
 809                 <td class='text'>
 810
 811 <table>
 812
 813 <tr><td> bp rl</td> <td><input type="text" name="_bp_rl"  /></td></tr>
 814
 815 </table>
 816                 </td>
 817
 818                 <td class='text'>
 819
 820 <table>
 821
 822 <tr><td> bp ll</td> <td><input type="text" name="_bp_ll"  /></td></tr>
 823
 824 </table>
 825                 </td>
 826
 827
 828             </tr>
 829
 830             <tr>
 831
 832                 <td class='text' colspan="4">
 833                     Pulses:</td>
 834             </tr>
 835
 836             <tr>
 837
 838                 <td class='text'>
 839
 840 <table>
 841
 842 <tr><td> pulses rue</td> <td><input type="text" name="_pulses_rue"  /></td></tr>
 843
 844 </table>
 845                 </td>
 846
 847                 <td class='text'>
 848
 849 <table>
 850
 851 <tr><td> pulses lue</td> <td><input type="text" name="_pulses_lue"  /></td></tr>
 852
 853 </table>
 854                 </td>
 855
 856                 <td class='text'>
 857
 858 <table>
 859
 860 <tr><td> pulses rle</td> <td><input type="text" name="_pulses_rle"  /></td></tr>
 861
 862 </table>
 863                 </td>
 864
 865                 <td class='text'>
 866
 867 <table>
 868
 869 <tr><td> pulses lle</td> <td><input type="text" name="_pulses_lle"  /></td></tr>
 870
 871 </table>
 872                 </td>
 873
 874
 875             </tr>
 876
 877             <tr>
 878
 879                 <td class='text' >
 880
 881 <table>
 882
 883 <tr><td> cardiovascular</td> <td><input type="text" name="_cardiovascular"  /></td></tr>
 884
 885 </table>
 886                 </td>
 887
 888                 <td class='text' colspan="2">
 889
 890 <table>
 891
 892 <tr><td> precordial activity</td> <td><input type="text" name="_precordial_activity"  /></td></tr>
 893
 894 </table>
 895                 </td>
 896
 897                 <td class='text'>
 898
 899 <table>
 900
 901 <tr><td> murmurs</td> <td><input type="text" name="_murmurs"  /></td></tr>
 902
 903 </table>
 904                 </td>
 905             </tr>
 906
 907             <tr>
 908
 909                 <td class='text' colspan="2">
 910
 911 <table>
 912
 913 <tr><td> neurological</td> <td><input type="text" name="_neurological"  /></td></tr>
 914
 915 </table>
 916                 </td>
 917
 918                 <td class='text' colspan="2">
 919
 920 <table>
 921
 922 <tr><td> lungs</td> <td><input type="text" name="_lungs"  /></td></tr>
 923
 924 </table>
 925                 </td>
 926             </tr>
 927
 928             <tr>
 929
 930                 <td class='text' colspan="2" style="height: 21px">
 931
 932 <table>
 933
 934 <tr><td> abdomen</td> <td><input type="text" name="_abdomen"  /></td></tr>
 935
 936 </table>
 937                 </td>
 938
 939                 <td class='text' colspan="2" style="height: 21px">
 940
 941 <table>
 942
 943 <tr><td> gi gu</td> <td><input type="text" name="_gi_gu"  /></td></tr>
 944
 945 </table>
 946                 </td>
 947             </tr>
 948
 949         </table>
 950 <table></table><input type="submit" name="submit form" value="submit form" />
 951 </form>
 952 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 953 <?php
 954 formFooter();
 955 ?>