contrib/forms/immunization_record/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_immunization_record';
   7 $ftitle = 'Immunization record';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  17   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  18   $id = $newid;
  19   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  20   exit;
  21   }
  22   }
  23 ?>
  24 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  25 "http://www.w3.org/TR/html4/loose.dtd">
  26
  27 <html>
  28 <head>
  29 <?php html_header_show();?>
  30 <title>Form: ACOG Immunization record</title>
  31 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  32 <link rel=stylesheet href="../../acog.css" type="text/css">
  33 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  34 <script language="JavaScript" type="text/JavaScript">
  35 <!--
  36 window.onload = initialize;
  37 //-->
  38 </script>
  39 </head>
  40
  41 <?php
  42    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  43    if ($fres){
  44      $patient = sqlFetchArray($fres);
  45    }
  46 ?>
  47 <body <?php echo $top_bg_line;?>>
  48
  49
  50 <form action="<?php echo $rootdir;?>/forms/immunization_record/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  51 <?php include("../../acog_menu.inc"); ?>
  52 <div class="srvChapter">Immunization record<sup><a href="#" onClick="toolTip('The Immunization Record lists immunization services recommended by ACOG for either routine use or in high-risk patients, as defined in the enclosed table of high-risk factors. space for listing problems and immunization services allows the same form to be used for years.<br><br>For immunizations based on risk refer to the Table of High-Risk Factors')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0"></a></sup></div>
  53 <div style="border: solid 2px black; background-color:#FFFFFF;">
  54   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  55     <tr align="left" valign="bottom">
  56       <td colspan="4" class="fibody2" id="bordR">patient name:
  57         <input name="pname" type="text" class="fullin" id="pname" style="width: 74%" value="<?php
  58
  59           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  60           ?>"></td>
  61       <td colspan="2" class="fibody2" id="bordR">Birth date:
  62         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?php
  63
  64           echo $patient{'DOB'};
  65           ?>"></td>
  66       <td colspan="2" class="fibody2">ID No:
  67         <input name="pl_pid" type="text" class="fullin" id="pl_pid" style="width:80%" value="<?php
  68
  69           echo $patient{'id'};
  70           ?>"></td>
  71       </tr>
  72     <tr align="center" valign="middle">
  73       <td width="9%" class="ficaption2" id="bordR">age</td>
  74       <td width="13%" class="ficaption2" id="bordR">Tetanus-<br>
  75         Diphteria<br>
  76         booster </td>
  77       <td width="13%" class="ficaption2" id="bordR">Influenza<br>
  78         vaccine </td>
  79       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
  80       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine </td>
  81       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
  82       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
  83       <td width="13%" class="ficaption2">Varicella vaccine </td>
  84     </tr>
  85     <tr align="center" valign="middle">
  86       <td class="fibody2" id="bordR">13-18</td>
  87       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
  88       <td class="fibody2" id="bordR">Based on risk </td>
  89       <td class="fibody2" id="bordR">Based on risk</td>
  90       <td class="fibody2" id="bordR">Based on risk</td>
  91       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
  92       <td class="fibody2" id="bordR">Based on risk</td>
  93       <td class="fibody2">Based on risk</td>
  94     </tr>
  95     <tr align="center" valign="middle">
  96       <td class="fibody2" id="bordR">19-39</td>
  97       <td class="fibody2" id="bordR">Every 10 years </td>
  98       <td class="fibody2" id="bordR">Based on risk</td>
  99       <td class="fibody2" id="bordR">Based on risk</td>
 100       <td class="fibody2" id="bordR">Based on risk</td>
 101       <td class="fibody2" id="bordR">Based on risk</td>
 102       <td class="fibody2" id="bordR">Based on risk</td>
 103       <td class="fibody2">Based on risk</td>
 104     </tr>
 105     <tr align="center" valign="middle">
 106       <td class="fibody2" id="bordR">40-64</td>
 107       <td class="fibody2" id="bordR">Every 10 years</td>
 108       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
 109       <td class="fibody2" id="bordR">Based on risk</td>
 110       <td class="fibody2" id="bordR">Based on risk</td>
 111       <td class="fibody2" id="bordR">Based on risk</td>
 112       <td class="fibody2" id="bordR">Based on risk</td>
 113       <td class="fibody2">Based on risk</td>
 114     </tr>
 115     <tr align="center" valign="middle">
 116       <td class="fibody2" id="bordR">65 and older </td>
 117       <td class="fibody2" id="bordR">Every 10 years</td>
 118       <td class="fibody2" id="bordR">Annually</td>
 119       <td class="fibody2" id="bordR">Once</td>
 120       <td class="fibody2" id="bordR">&nbsp;</td>
 121       <td class="fibody2" id="bordR">Based on risk</td>
 122       <td class="fibody2" id="bordR">Based on risk</td>
 123       <td class="fibody2">Based on risk</td>
 124     </tr>
 125   </table>
 126 </div>
 127 <p>&nbsp;</p>
 128 <div style="border: solid 2px black; background-color:#FFFFFF;">
 129   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 130 <?php
 131
 132 $vacci=0;
 133 while ($vacci<20){
 134 print <<<EOL
 135     <tr align="left" valign="bottom">
 136       <td width="9%" class="fibody2" id="bordR">Date</td>
 137       <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2"></td>
 138       <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2"></td>
 139       <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2"></td>
 140       <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2"></td>
 141       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2"></td>
 142       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2"></td>
 143       <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2"></td>
 144     </tr>
 145 EOL;
 146 $vacci++;
 147 }
 148 ?>
 149   </table>
 150 </div>
 151 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 152 <p>&nbsp;</p>
 153 <table width="100%" border="0">
 154   <tr>
 155     <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 156     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 157      onclick="top.restoreSession()">[Don't Save]</a> </td>
 158   </tr>
 159 </table>
 160 </form>
 161 <?php
 162 formFooter();
 163 ?>
 164 </body>
 165 </html>