contrib/forms/cardiology_set/Forms3_Cardiology/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Forms3_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 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  12 <form method=post action="<?php echo $rootdir;?>/forms/Forms3_Cardiology/save.php?mode=new" name="Forms3_Cardiology" onSubmit="return top.restoreSession()">
  13 <hr>
  14 <h1> <?php xl("Forms3_Cardiology",'e') ?> </h1>
  15 <hr>
  16 <input type="submit" name="submit form" value="submit form" />
  17
  18 <table width="100%" cellpadding="0" cellspacing="0">
  19
  20     <tr>
  21
  22         <td class='text'   valign="top">
  23
  24             <table width="100%" cellpadding="0" cellspacing="0">
  25
  26                 <tr>
  27
  28                     <td class='text'   style="border: 1px #000000 solid;">
  29
  30 <table>
  31
  32 <tr><td class='text'  > date</td> <td class='text'  ><input type="text" name="_date"  /></td></tr>
  33
  34 </table>
  35                     </td>
  36
  37                     <td class='text'    style="border: 1px #000000 solid;">
  38
  39 <table>
  40
  41 <tr><td class='text'  > name</td> <td class='text'  ><input type="text" name="_name"  /></td></tr>
  42
  43 </table>
  44                     </td>
  45
  46
  47                 </tr>
  48
  49                 <tr>
  50
  51                         <td class='text'   colspan='2' style="border: 1px #000000 solid;">
  52
  53 <table>
  54
  55 <tr><td class='text'  > chief complaint</td> <td class='text'  ><input type="text" name="_chief_complaint"  /></td></tr>
  56
  57 </table>
  58             </td></tr>
  59
  60             </table>
  61         </td>
  62     </tr>
  63
  64     <tr>
  65
  66         <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
  67
  68             <table width="100%" cellpadding="0" cellspacing="0">
  69
  70                 <tr>
  71
  72
  73
  74                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
  75
  76 <table>
  77
  78 <tr><td class='text'  > wt</td> <td class='text'  ><input type="text" name="_wt"  /></td></tr>
  79
  80 </table>
  81                     </td>
  82
  83                     <td class='text'   style="border: 1px #000000 solid;">
  84
  85 <table>
  86
  87 <tr><td class='text'  > bp</td> <td class='text'  ><input type="text" name="_bp"  /></td></tr>
  88
  89 </table>
  90                     </td>
  91
  92                      <td class='text'   style="border: 1px #000000 solid;">
  93
  94 <table>
  95
  96 <tr><td class='text'  > p</td> <td class='text'  ><input type="text" name="_p"  /></td></tr>
  97
  98 </table>
  99                     </td>
 100
 101                     <td class='text'   style="border: 1px #000000 solid;">
 102
 103 <table>
 104
 105 <tr><td class='text'  > t</td> <td class='text'  ><input type="text" name="_t"  /></td></tr>
 106
 107 </table>
 108                     </td>
 109
 110                 <td class='text'   style="border: 1px #000000 solid;">
 111
 112 <table>
 113
 114 <tr><td class='text'  > r</td> <td class='text'  ><input type="text" name="_r"  /></td></tr>
 115
 116 </table>
 117                   </td>
 118
 119                 <td class='text'   style="border: 1px #000000 solid;">
 120
 121 <table>
 122
 123 <tr><td class='text'  > ht</td> <td class='text'  ><input type="text" name="_ht"  /></td></tr>
 124
 125 </table>
 126                   </td>
 127                 </tr>
 128
 129
 130
 131             </table>
 132         </td>
 133     </tr>
 134
 135
 136
 137
 138
 139
 140
 141
 142
 143     <tr>
 144
 145          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 146
 147             <table width="100%" cellpadding="0" cellspacing="0">
 148
 149                 <tr>
 150
 151                     <td class='text'   colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;">
 152
 153                         <h3>
 154
 155                             HPI
 156
 157                         </h3>
 158                     </td>
 159                 </tr>
 160
 161                 <tr>
 162
 163
 164
 165                     <td class='text'    style="border: 1px #000000 solid;">
 166
 167 <table>
 168
 169 <tr><td class='text'  > location</td> <td class='text'  ><input type="text" name="_location"  /></td></tr>
 170
 171 </table>
 172                     </td>
 173
 174                     <td class='text'   style="border: 1px #000000 solid;">
 175
 176 <table>
 177
 178 <tr><td class='text'  > quality</td> <td class='text'  ><input type="text" name="_quality"  /></td></tr>
 179
 180 </table>
 181                     </td>
 182
 183                      <td class='text'   style="border: 1px #000000 solid;">
 184
 185 <table>
 186
 187 <tr><td class='text'  > severity</td> <td class='text'  ><input type="text" name="_severity"  /></td></tr>
 188
 189 </table>
 190                     </td>
 191
 192                     <td class='text'   style="border: 1px #000000 solid;">
 193
 194 <table>
 195
 196 <tr><td class='text'  > duration</td> <td class='text'  ><input type="text" name="_duration"  /></td></tr>
 197
 198 </table>
 199                     </td>
 200
 201                     <td class='text'   style="border: 1px #000000 solid;">&nbsp;
 202
 203
 204                   </td>
 205                 </tr>
 206
 207 <tr>
 208
 209 <td class='text'   style="border: 1px #000000 solid;">
 210
 211 <table>
 212
 213 <tr><td class='text'  > timing</td> <td class='text'  ><input type="text" name="_timing"  /></td></tr>
 214
 215 </table>
 216             </td>
 217
 218                 <td class='text'   style="border: 1px #000000 solid;">
 219
 220 <table>
 221
 222 <tr><td class='text'  > context</td> <td class='text'  ><input type="text" name="_context"  /></td></tr>
 223
 224 </table>
 225             </td>
 226
 227                 <td class='text'   style="border: 1px #000000 solid;">
 228
 229 <table>
 230
 231 <tr><td class='text'  > modifying factors</td> <td class='text'  ><input type="text" name="_modifying_factors"  /></td></tr>
 232
 233 </table>
 234             </td>
 235
 236                 <td class='text'   style="border: 1px #000000 solid;">
 237
 238 <table>
 239
 240 <tr><td class='text'  > signs symptoms</td> <td class='text'  ><input type="text" name="_signs_symptoms"  /></td></tr>
 241
 242 </table>
 243             </td>
 244
 245                 <td class='text'   style="border: 1px #000000 solid;">
 246
 247 <table>
 248
 249 <tr><td class='text'  > status of chronic illness</td> <td class='text'  ><input type="text" name="_status_of_chronic_illness"  /></td></tr>
 250
 251 </table>
 252             </td></tr>
 253
 254
 255
 256
 257
 258             </table>
 259         </td>
 260     </tr>
 261
 262
 263
 264      <tr>
 265
 266          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 267
 268             <table width="100%" cellpadding="0" cellspacing="0">
 269
 270                 <tr>
 271
 272                     <td class='text'   align="center" style="border: 1px #000000 solid; height: 15px;">
 273
 274                             ROS
 275
 276
 277                     </td>
 278
 279         <td class='text'   align="center" style="border: 1px #000000 solid; height: 15px;">
 280
 281
 282
 283                             +
 284
 285
 286                   </td>
 287
 288         <td class='text'   align="center" style="border: 1px #000000 solid; height: 15px;">
 289
 290
 291
 292                             -
 293
 294
 295                   </td>
 296                 </tr>
 297
 298                 <tr>
 299
 300                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 301
 302                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 303                         Systemic</td>
 304
 305                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 306
 307                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 308
 309 <table>
 310
 311 <tr><td class='text'  > systemic positive</td> <td class='text'  ><input type="text" name="_systemic_positive"  /></td></tr>
 312
 313 </table>
 314                     </td>
 315
 316                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 317
 318                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 319
 320 <table>
 321
 322 <tr><td class='text'  > systemic negative</td> <td class='text'  ><input type="text" name="_systemic_negative"  /></td></tr>
 323
 324 </table>
 325                     </td>
 326                 </tr>
 327
 328                 <tr>
 329
 330                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 331
 332                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 333                         ENT</td>
 334
 335                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 336
 337                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 338
 339 <table>
 340
 341 <tr><td class='text'  > ent positive</td> <td class='text'  ><input type="text" name="_ent_positive"  /></td></tr>
 342
 343 </table>
 344                     </td>
 345
 346                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 347
 348                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 349
 350 <table>
 351
 352 <tr><td class='text'  > ent negative</td> <td class='text'  ><input type="text" name="_ent_negative"  /></td></tr>
 353
 354 </table>
 355                     </td>
 356                 </tr>
 357
 358                 <tr>
 359
 360                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 361
 362                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 363                         Eyes</td>
 364
 365                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 366
 367                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 368
 369 <table>
 370
 371 <tr><td class='text'  > eyes positive</td> <td class='text'  ><input type="text" name="_eyes_positive"  /></td></tr>
 372
 373 </table>
 374                     </td>
 375
 376                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 377
 378                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 379
 380 <table>
 381
 382 <tr><td class='text'  > eyes negative</td> <td class='text'  ><input type="text" name="_eyes_negative"  /></td></tr>
 383
 384 </table>
 385                     </td>
 386                 </tr>
 387
 388                 <tr>
 389
 390                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 391
 392                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 393                         Lymph</td>
 394
 395                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 396
 397                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 398
 399 <table>
 400
 401 <tr><td class='text'  > lymph positive</td> <td class='text'  ><input type="text" name="_lymph_positive"  /></td></tr>
 402
 403 </table>
 404                     </td>
 405
 406                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 407
 408                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 409
 410 <table>
 411
 412 <tr><td class='text'  > lymph negative</td> <td class='text'  ><input type="text" name="_lymph_negative"  /></td></tr>
 413
 414 </table>
 415                     </td>
 416                 </tr>
 417
 418                 <tr>
 419
 420                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 421
 422                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 423                         Resp</td>
 424
 425                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 426
 427                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 428
 429 <table>
 430
 431 <tr><td class='text'  > resp positive</td> <td class='text'  ><input type="text" name="_resp_positive"  /></td></tr>
 432
 433 </table>
 434                     </td>
 435
 436                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 437
 438                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 439
 440 <table>
 441
 442 <tr><td class='text'  > resp negative</td> <td class='text'  ><input type="text" name="_resp_negative"  /></td></tr>
 443
 444 </table>
 445                     </td>
 446                 </tr>
 447
 448                 <tr>
 449
 450                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 451
 452                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 453                         CV</td>
 454
 455                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 456
 457                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 458
 459 <table>
 460
 461 <tr><td class='text'  > cv positive</td> <td class='text'  ><input type="text" name="_cv_positive"  /></td></tr>
 462
 463 </table>
 464                     </td>
 465
 466                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 467
 468                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 469
 470 <table>
 471
 472 <tr><td class='text'  > cv negative</td> <td class='text'  ><input type="text" name="_cv_negative"  /></td></tr>
 473
 474 </table>
 475                     </td>
 476                 </tr>
 477
 478                 <tr>
 479
 480                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 481
 482                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 483                         GI</td>
 484
 485                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 486
 487                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 488
 489 <table>
 490
 491 <tr><td class='text'  > gi positive</td> <td class='text'  ><input type="text" name="_gi_positive"  /></td></tr>
 492
 493 </table>
 494                     </td>
 495
 496                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 497
 498                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 499
 500 <table>
 501
 502 <tr><td class='text'  > gi negative</td> <td class='text'  ><input type="text" name="_gi_negative"  /></td></tr>
 503
 504 </table>
 505                     </td>
 506                 </tr>
 507
 508                 <tr>
 509
 510                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 511
 512                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 513                         GU</td>
 514
 515                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 516
 517                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 518
 519 <table>
 520
 521 <tr><td class='text'  > gu positive</td> <td class='text'  ><input type="text" name="_gu_positive"  /></td></tr>
 522
 523 </table>
 524                     </td>
 525
 526                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 527
 528                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 529
 530 <table>
 531
 532 <tr><td class='text'  > gu negative</td> <td class='text'  ><input type="text" name="_gu_negative"  /></td></tr>
 533
 534 </table>
 535                     </td>
 536                 </tr>
 537
 538                 <tr>
 539
 540                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 541
 542                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 543                         Skin</td>
 544
 545                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 546
 547                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 548
 549 <table>
 550
 551 <tr><td class='text'  > skin positive</td> <td class='text'  ><input type="text" name="_skin_positive"  /></td></tr>
 552
 553 </table>
 554                     </td>
 555
 556                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 557
 558                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 559
 560 <table>
 561
 562 <tr><td class='text'  > skin negative</td> <td class='text'  ><input type="text" name="_skin_negative"  /></td></tr>
 563
 564 </table>
 565                     </td>
 566                 </tr>
 567
 568                 <tr>
 569
 570                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 571
 572                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 573                         MS</td>
 574
 575                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 576
 577                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 578
 579
 580                       <table>
 581
 582 <tr><td class='text'  > ms positive</td> <td class='text'  ><input type="text" name="_ms_positive"  /></td></tr>
 583 </table>
 584                   </td>
 585
 586                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 587
 588                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 589
 590 <table>
 591
 592 <tr><td class='text'  > ms negative</td> <td class='text'  ><input type="text" name="_ms_negative"  /></td></tr>
 593
 594 </table>
 595                     </td>
 596                 </tr>
 597
 598                 <tr>
 599
 600                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 601
 602                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 603                         Psych</td>
 604
 605                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 606
 607                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 608
 609 <table>
 610
 611 <tr><td class='text'  > psych positive</td> <td class='text'  ><input type="text" name="_psych_positive"  /></td></tr>
 612
 613 </table>
 614                     </td>
 615
 616                     <td class='text'   align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 617
 618                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 619
 620 <table>
 621
 622 <tr><td class='text'  > psych negative</td> <td class='text'  ><input type="text" name="_psych_negative"  /></td></tr>
 623
 624 </table>
 625                     </td>
 626                 </tr>
 627
 628                 <tr>
 629
 630                     <td class='text'    align="left" colspan="3" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 631
 632                         border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 633
 634 <table>
 635
 636 <tr><td class='text'  > all other ros negative </td> <td class='text'  ><textarea name="_all_other_ros_negative_"  rows="4" cols="40"></textarea></td></tr>
 637
 638 </table>
 639                     </td>
 640                 </tr>
 641
 642
 643
 644
 645
 646
 647
 648             </table>
 649         </td>
 650     </tr>
 651
 652
 653
 654
 655
 656       <tr>
 657
 658          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 659
 660             <table width="100%" cellpadding="0" cellspacing="0">
 661
 662                 <tr>
 663
 664                     <td class='text'   colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
 665
 666 <table>
 667
 668 <tr><td class='text'  > past famiy social history</td> <td class='text'  ><textarea name="_past_famiy_social_history"  rows="4" cols="40"></textarea></td></tr>
 669
 670 </table>
 671                     </td>
 672                 </tr>
 673
 674
 675
 676                  <tr>
 677
 678
 679
 680                     <td class='text'   style="border: 1px #000000 solid; height: 27px;">
 681
 682 <table>
 683
 684 <tr><td class='text'  > ph no change since</td> <td class='text'  ><input type="text" name="_ph_no_change_since"  /></td></tr>
 685
 686 </table>
 687                     </td>
 688
 689                     <td class='text'   style="border: 1px #000000 solid; height: 27px;">
 690
 691 <table>
 692
 693 <tr><td class='text'  > fh no change since</td> <td class='text'  ><input type="text" name="_fh_no_change_since"  /></td></tr>
 694
 695 </table>
 696                     </td>
 697
 698                      <td class='text'   style="border: 1px #000000 solid; height: 27px;">
 699
 700 <table>
 701
 702 <tr><td class='text'  > sh no change since</td> <td class='text'  ><input type="text" name="_sh_no_change_since"  /></td></tr>
 703
 704 </table>
 705                     </td>
 706                 </tr>
 707
 708 <tr><td class='text'   colspan='3'>
 709
 710 <table>
 711
 712 <tr><td class='text'  ><?php xl("Examination",'e') ?></td>
 713 <td class='text'  ><textarea name="examination"  rows="4" cols="40"></textarea></td></tr>
 714
 715 </table>
 716 </td></tr>
 717
 718
 719
 720             </table>
 721         </td>
 722     </tr>
 723
 724 </table>
 725 <table></table><input type="submit" name="submit form" value="submit form" />
 726 </form>
 727 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 728 <?php
 729 formFooter();
 730 ?>