contrib/forms/cardiology_set/Forms3_Cardiology/print.php

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