contrib/forms/chiropractor_set/Chiro_personal_injury_form/print.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Chiro_personal_injury_form");
   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 <form method=post action="<?php echo $rootdir;?>/forms/Chiro_personal_injury_form/save.php?mode=new" name="my_form" onSubmit="return top.restoreSession()">
  12 <h1> Chiro personal injury form </h1>
  13 <hr>
  14 <input type="submit" name="submit form" value="submit form" /> <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  15
  16 <Table width="100%" cellpadding="0" cellspacing="0">
  17
  18     <tr>
  19
  20    <td class="text"    style="border:solid 1px #000000"   >
  21
  22 <table>
  23
  24 <tr><td class="text" > Patient Name/(Nombre):</td><td class="text"   ><input type="text" name="_patient_name"  /></td></tr>
  25
  26 </table>
  27     </td>
  28
  29    <td class="text"    style="border:solid 1px #000000"   >
  30
  31 <table>
  32
  33 <tr><td class="text" > Middle Name</td><td class="text"   ><input type="text" name="_middle_name"  /></td></tr>
  34
  35 </table>
  36     </td>
  37
  38    <td class="text"    style="border:solid 1px #000000"   >
  39
  40 <table>
  41
  42 <tr><td class="text" > Last Name</td><td class="text"   ><input type="text" name="_last_name"  /></td></tr>
  43
  44 </table>
  45     </td>
  46     </tr>
  47
  48     <tr>
  49
  50    <td class="text"    style="border:solid 1px #000000"    colspan="3">
  51
  52 <table>
  53
  54 <tr><td class="text" > Address/ (Direction)</td><td class="text"   ><input type="text" name="_address_direction"  /></td></tr>
  55
  56 </table>
  57     </td>
  58     </tr>
  59
  60     <tr>
  61
  62    <td class="text"    style="border:solid 1px #000000"    width="33%">
  63
  64 <table>
  65
  66 <tr><td class="text" > City:</td><td class="text"   ><input type="text" name="_city"  /></td></tr>
  67
  68 </table>
  69     </td>
  70
  71    <td class="text"    style="border:solid 1px #000000"    width="33%">
  72
  73 <table>
  74
  75 <tr><td class="text" > State:</td><td class="text"   ><input type="text" name="_state"  /></td></tr>
  76
  77 </table>
  78     </td>
  79
  80    <td class="text"    style="border:solid 1px #000000"    width="33%">
  81
  82 <table>
  83
  84 <tr><td class="text" > Zip:</td><td class="text"   ><input type="text" name="_zip"  /></td></tr>
  85
  86 </table>
  87     </td>
  88     </tr>
  89
  90     <tr>
  91
  92    <td class="text"    style="border:solid 1px #000000"   >
  93
  94 <table>
  95
  96 <tr><td class="text" > Phone #(Telefono) Home</td><td class="text"   ><input type="text" name="_phone_number_home"  /></td></tr>
  97
  98 </table>
  99     </td>
 100
 101     <td class="text"    style="border:solid 1px #000000"   >
 102
 103 <table>
 104
 105 <tr><td class="text" >Work</td><td class="text"   ><input type="text" name="_phone_number_work"  /></td></tr>
 106
 107 </table>
 108     </td>
 109
 110    <td class="text"    style="border:solid 1px #000000"   >&nbsp;
 111
 112
 113     </td>
 114     </tr>
 115
 116     <tr>
 117
 118    <td class="text"    style="border:solid 1px #000000"   >
 119
 120 <table>
 121
 122 <tr><td class="text" > Sex:(Sexo):</td><td class="text"   ><label><input type="checkbox" name="_sex[]" value="male" /> <?php Xl("male",'e') ?> </label> <label><input type="checkbox" name="_sex[]" value="female" /> <?php Xl("female",'e') ?> </label></td></tr>
 123
 124 </table>
 125     </td>
 126
 127    <td class="text"    style="border:solid 1px #000000"   >
 128
 129 <table>
 130
 131 <tr><td class="text" > Date of Birth:(Feeha de Nacimiento)</td><td class="text"   ><input type="text" name="_date_of_birth"  /></td></tr>
 132
 133 </table>
 134     </td>
 135
 136    <td class="text"    style="border:solid 1px #000000"   >
 137
 138 <table>
 139
 140 <tr><td class="text" > Social Security.#:(Seguro Social)</td><td class="text"   ><input type="text" name="_social_security"  /></td></tr>
 141
 142 </table>
 143     </td>
 144     </tr>
 145
 146     <tr>
 147
 148    <td class="text"    style="border:solid 1px #000000"     colspan="3">
 149
 150 <table>
 151
 152 <tr><td class="text" > Nature of Accident(Accidence):</td><td class="text"   ><label><input type="checkbox" name="_nature_of_accident[]" value="automobile" /> <?php Xl("Automobile(Auto)",'e') ?> </label> <label><input type="checkbox" name="_nature_of_accident[]" value="slip and fall" /> <?php Xl("Slip And Fall(Caida)",'e') ?> </label> <label><input type="checkbox" name="_nature_of_accident[]" value="work related" /> <?php Xl("Work Related(Trabajo)",'e') ?> </label></td></tr>
 153
 154 </table>
 155
 156 <table>
 157
 158 <tr><td class="text" > Other(Otros)</td><td class="text"   ><input type="text" name="_other"  /></td></tr>
 159
 160 </table>
 161     </td>
 162     </tr>
 163
 164     <tr>
 165
 166    <td class="text"    colspan="3" >
 167
 168     <table width="100%" cellpadding="0" cellspacing="0">
 169
 170     <tr>
 171
 172    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 173
 174 <table>
 175
 176 <tr><td class="text" > Date of Accident: (Feeha da Accidente)</td><td class="text"   ><input type="text" name="_date_of_accident"  /></td></tr>
 177
 178 </table>
 179     </td>
 180     </tr>
 181
 182     <tr>
 183
 184    <td class="text"    style="border:solid 1px #000000"    width="50%">
 185
 186 <table>
 187
 188 <tr><td class="text" > Insurance Name:</td><td class="text"   ><input type="text" name="_insurance_name"  /></td></tr>
 189
 190 </table>
 191     </td>
 192
 193    <td class="text"    style="border:solid 1px #000000"    width="50%">
 194
 195 <table>
 196
 197 <tr>
 198  <td class="text"   > Phone #:</td>
 199  <td class="text"   ><input type="text" name="_phone_no"  /></td></tr>
 200
 201 </table>
 202     </td>
 203     </tr>
 204
 205     <tr>
 206
 207    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 208
 209 <table>
 210
 211 <tr><td class="text" > Address (Direction):</td><td class="text"   ><input type="text" name="_address_of_insurance_company"  /></td></tr>
 212
 213 </table>
 214     </td>
 215     </tr>
 216
 217     <tr>
 218
 219    <td class="text"    style="border:solid 1px #000000"   >
 220
 221 <table>
 222
 223 <tr><td class="text" > Claim # (Numerom de Recalmo):</td><td class="text"   ><input type="text" name="_claim_number"  /></td></tr>
 224
 225 </table>
 226     </td>
 227
 228    <td class="text"    style="border:solid 1px #000000"   >
 229
 230 <table>
 231
 232 <tr><td class="text" > Policy (Numero de Poliza):</td><td class="text"   ><input type="text" name="_policy_number"  /></td></tr>
 233
 234 </table>
 235     </td>
 236     </tr>
 237
 238     <tr>
 239
 240    <td class="text"    style="border:solid 1px #000000"   >
 241
 242 <table>
 243
 244 <tr><td class="text" > Attorney Name(Nombre de Abogado):</td><td class="text"   ><input type="text" name="_attorney_name"  /></td></tr>
 245
 246 </table>
 247     </td>
 248
 249    <td class="text"    style="border:solid 1px #000000"   >
 250
 251 <table>
 252
 253 <tr>
 254  <td class="text"   > Attorney Phone#(Telefone de Abogado)</td>
 255  <td class="text"   ><input type="text" name="_attorney_phone_number"  /></td></tr>
 256
 257 </table>
 258     </td>
 259     </tr>
 260
 261     <tr>
 262
 263    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 264
 265 <table>
 266
 267 <tr><td class="text" > Attorney address / (Direccion):</td><td class="text"   ><input type="text" name="_attorney_address"  /></td></tr>
 268
 269 </table>
 270     </td>
 271     </tr>
 272
 273     </table>
 274     </td>
 275     </tr>
 276
 277     <tr>
 278
 279    <td class="text"       colspan="3" >
 280
 281     <table width="100%" cellpadding="0" cellspacing="0">
 282
 283     <tr>
 284
 285
 286
 287    <td class="text"    style="border:solid 1px #000000"    width="50%">
 288
 289 <table>
 290
 291 <tr><td class="text" > Health Insurance(Plan Medico):</td><td class="text"   ><input type="text" name="_health_insurance"  /></td></tr>
 292
 293 </table>
 294     </td>
 295
 296    <td class="text"    style="border:solid 1px #000000"    width="50%">
 297
 298 <table>
 299
 300 <tr><td class="text" >Phone#</td><td class="text"   ><input type="text" name="_health_insurance_phone_number"  /></td></tr>
 301
 302 </table>
 303         </td>
 304     </tr>
 305
 306     <tr>
 307
 308    <td class="text"    style="border:solid 1px #000000"    colspan="3">
 309
 310 <table>
 311
 312 <tr><td class="text" > Address: </td><td class="text"   ><input type="text" name="_address_of_health_insurance"  /></td></tr>
 313
 314 </table>
 315     </td>
 316
 317
 318     </tr>
 319
 320     <tr>
 321
 322    <td class="text"    style="border:solid 1px #000000"   >
 323
 324 <table>
 325
 326 <tr><td class="text" > Subscriber ID #</td><td class="text"   ><input type="text" name="_subscriber_id_number"  /></td></tr>
 327
 328 </table>
 329     </td>
 330
 331    <td class="text"    style="border:solid 1px #000000"   >
 332
 333 <table>
 334
 335 <tr><td class="text" > Group #</td><td class="text"   ><input type="text" name="_group_number"  /></td></tr>
 336
 337 </table>
 338     </td>
 339     </tr>
 340
 341
 342
 343     </table>
 344     </td>
 345     </tr>
 346
 347
 348
 349     </table>
 350 <table></table><input type="submit" name="submit form" value="submit form" />  <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 351
 352 </form>
 353 <?php
 354 formFooter();
 355 ?>