contrib/forms/immunization_record/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <?php html_header_show();?>
  23
  24 <title>Form: ACOG Immunization record</title>
  25
  26 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  27
  28 <link rel=stylesheet href="../../acog.css" type="text/css">
  29
  30 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  31
  32 <script language="JavaScript" type="text/JavaScript">
  33
  34 <!--
  35
  36 window.onload = initialize;
  37
  38 //-->
  39
  40 </script>
  41
  42 </head>
  43
  44
  45
  46 <?php
  47
  48    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  49
  50    if ($fres){
  51
  52      $patient = sqlFetchArray($fres);
  53
  54    }
  55
  56    $fres=sqlStatement("select * from form_immunization_record where id='".$id."'");
  57
  58    if ($fres){
  59
  60      $ir = sqlFetchArray($fres);
  61
  62    }
  63
  64 ?>
  65
  66 <body <?php echo $top_bg_line;?>>
  67
  68
  69
  70
  71
  72 <form action="<?php echo $rootdir;?>/forms/immunization_record/save.php?mode=update&id=<?php echo $id;?>" method="post" enctype="multipart/form-data" name="my_form">
  73
  74 <?php include("../../acog_menu.inc"); ?>
  75
  76 <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>
  77
  78 <div style="border: solid 2px black; background-color:#FFFFFF;">
  79
  80   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  81
  82     <tr align="left" valign="bottom">
  83
  84       <td colspan="4" class="fibody2" id="bordR">patient name:
  85
  86         <input name="pname" type="text" class="fullin" id="pname" style="width: 74%" value="<?php
  87
  88
  89           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  90
  91           ?>"></td>
  92
  93       <td colspan="2" class="fibody2" id="bordR">Birth date:
  94
  95         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?php
  96
  97
  98           echo $patient{'DOB'};
  99
 100           ?>"></td>
 101
 102       <td colspan="2" class="fibody2">ID No:
 103
 104         <input name="pl_pid" type="text" class="fullin" id="pl_pid" style="width:80%" value="<?php
 105
 106
 107           echo $patient{'id'};
 108
 109           ?>"></td>
 110
 111       </tr>
 112
 113     <tr align="center" valign="middle">
 114
 115       <td width="9%" class="ficaption2" id="bordR">age</td>
 116
 117       <td width="13%" class="ficaption2" id="bordR">Tetanus-<br>
 118
 119         Diphteria<br>
 120
 121         booster </td>
 122
 123       <td width="13%" class="ficaption2" id="bordR">Influenza<br>
 124
 125         vaccine </td>
 126
 127       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
 128
 129       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine </td>
 130
 131       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
 132
 133       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
 134
 135       <td width="13%" class="ficaption2">Varicella vaccine </td>
 136
 137     </tr>
 138
 139     <tr align="center" valign="middle">
 140
 141       <td class="fibody2" id="bordR">13-18</td>
 142
 143       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
 144
 145       <td class="fibody2" id="bordR">Based on risk </td>
 146
 147       <td class="fibody2" id="bordR">Based on risk</td>
 148
 149       <td class="fibody2" id="bordR">Based on risk</td>
 150
 151       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
 152
 153       <td class="fibody2" id="bordR">Based on risk</td>
 154
 155       <td class="fibody2">Based on risk</td>
 156
 157     </tr>
 158
 159     <tr align="center" valign="middle">
 160
 161       <td class="fibody2" id="bordR">19-39</td>
 162
 163       <td class="fibody2" id="bordR">Every 10 years </td>
 164
 165       <td class="fibody2" id="bordR">Based on risk</td>
 166
 167       <td class="fibody2" id="bordR">Based on risk</td>
 168
 169       <td class="fibody2" id="bordR">Based on risk</td>
 170
 171       <td class="fibody2" id="bordR">Based on risk</td>
 172
 173       <td class="fibody2" id="bordR">Based on risk</td>
 174
 175       <td class="fibody2">Based on risk</td>
 176
 177     </tr>
 178
 179     <tr align="center" valign="middle">
 180
 181       <td class="fibody2" id="bordR">40-64</td>
 182
 183       <td class="fibody2" id="bordR">Every 10 years</td>
 184
 185       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
 186
 187       <td class="fibody2" id="bordR">Based on risk</td>
 188
 189       <td class="fibody2" id="bordR">Based on risk</td>
 190
 191       <td class="fibody2" id="bordR">Based on risk</td>
 192
 193       <td class="fibody2" id="bordR">Based on risk</td>
 194
 195       <td class="fibody2">Based on risk</td>
 196
 197     </tr>
 198
 199     <tr align="center" valign="middle">
 200
 201       <td class="fibody2" id="bordR">65 and older </td>
 202
 203       <td class="fibody2" id="bordR">Every 10 years</td>
 204
 205       <td class="fibody2" id="bordR">Annually</td>
 206
 207       <td class="fibody2" id="bordR">Once</td>
 208
 209       <td class="fibody2" id="bordR">&nbsp;</td>
 210
 211       <td class="fibody2" id="bordR">Based on risk</td>
 212
 213       <td class="fibody2" id="bordR">Based on risk</td>
 214
 215       <td class="fibody2">Based on risk</td>
 216
 217     </tr>
 218
 219   </table>
 220
 221 </div>
 222
 223 <p>&nbsp;</p>
 224
 225 <div style="border: solid 2px black; background-color:#FFFFFF;">
 226
 227   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 228
 229 <?php
 230
 231
 232 $vacci=0;
 233
 234   $vacc_tetanus = explode("|~", $ir["vacc_tetanus"]);
 235
 236   $vacc_influenza = explode("|~", $ir["vacc_influenza"]);
 237
 238   $vacc_pneumococcal = explode("|~", $ir["vacc_pneumococcal"]);
 239
 240   $vacc_mmr = explode("|~", $ir["vacc_mmr"]);
 241
 242   $vacc_hep_a = explode("|~", $ir["vacc_hep_a"]);
 243
 244   $vacc_hep_b = explode("|~", $ir["vacc_hep_b"]);
 245
 246   $vacc_varicella= explode("|~", $ir["vacc_varicella"]);
 247
 248 while ($vacci<20){
 249
 250 print <<<EOL
 251
 252     <tr align="left" valign="bottom">
 253
 254       <td width="9%" class="fibody2" id="bordR">Date</td>
 255
 256       <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2" value="${vacc_tetanus[$vacci]}"></td>
 257
 258       <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2" value="${vacc_influenza[$vacci]}"></td>
 259
 260       <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2" value="${vacc_pneumococcal[$vacci]}"></td>
 261
 262       <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2" value="${vacc_mmr[$vacci]}"></td>
 263
 264       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2" value="${vacc_hep_b[$vacci]}"></td>
 265
 266       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2" value="${vacc_hep_a[$vacci]}"></td>
 267
 268       <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2" value="${vacc_varicella[$vacci]}"></td>
 269
 270     </tr>
 271
 272 EOL;
 273
 274 $vacci++;
 275
 276 }
 277
 278 ?>
 279
 280   </table>
 281
 282 </div>
 283
 284 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 285
 286 <p>&nbsp;</p>
 287
 288 <table width="100%" border="0">
 289
 290   <tr>
 291
 292     <td align="left" width="100"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 293
 294     <td align="left" nowrap> <a href="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>" target="_blank" class="link_submit"
 295
 296      onclick="top.restoreSession()">[Printable form]</a> </td>
 297
 298     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 299
 300      onclick="top.restoreSession()">[Don't Save]</a> </td>
 301
 302   </tr>
 303
 304 </table>
 305
 306 </form>
 307
 308 <?php
 309
 310 formFooter();
 311
 312 ?>
 313
 314 </body>
 315
 316 </html>