contrib/forms/individual_treatment_plan/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: individual_treatment_plan");
   5 ?>
   6 <html><head>
   7 <?php html_header_show();?>
   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/individual_treatment_plan/save.php?mode=new" name="my_form">
  12 <br>
  13 <span class="title"><center>Individual Treatment Plan</center></span><br><br>
  14 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  15 <img src="../../../images/space.gif" width="5" height="1">
  16 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit" onclick="top.restoreSession()">[Don't Save]</a></center>
  17 <br>
  18
  19 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  20 $result = SqlFetchArray($res); ?>
  21
  22 <b>Date of Referral:</b>&nbsp;<input type="text" name="date_of_referal">
  23 <img src="../../../images/space.gif" width="260" height="1">
  24 <b>Date of Plan:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  25
  26 <img src="../../../images/space.gif" width="28" height="1">
  27 <b>Client Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  28 <img src="../../../images/space.gif" width="292" height="1">
  29 <b>DCN:</b>
  30 <img src="../../../images/space.gif" width="1" height="1">
  31 <input type="text" name="dcn"> <br><br>
  32
  33 <b>ICD/9/CM Code:</b>&nbsp;<input type="text" name="icd9">
  34 <img src="../../../images/space.gif" width="200" height="1">
  35 <b>Prognosis:</b>&nbsp;<input type="text" name="prognosis"><br><br>
  36
  37 <b>Diagnosis Description:</b><br>
  38 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ></textarea><br><br>
  39
  40 <b>Presenting Problem Description and Psychosocial Information:</b><br>
  41 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ></textarea><br><br>
  42
  43 <b>Frequency:</b>&nbsp;<input type="text" name="frequency" size="12" maxlength="10">
  44 <img src="../../../images/space.gif" width="40" height="1">
  45 <b>Duration:</b>&nbsp;<input type="text" name="duration" size="12" maxlength="10">
  46 <img src="../../../images/space.gif" width="40" height="1">
  47 <b>Scope:</b>&nbsp;<input type="text" name="scope" size="12" maxlength="10"><br><br>
  48
  49 <b>Short Term Goals:</b>
  50 <img src="../../../images/space.gif" width="162" height="1">
  51 <b>Time Frame:</b><br>
  52 <input type="text" name="short_term_goals_1" size="42" maxlength="40">
  53 <img src="../../../images/space.gif" width="6" height="1">
  54 <input type="text" name="time_frame_1" size="16" maxlength="15"><br>
  55
  56 <input type="text" name="short_term_goals_2" size="42" maxlength="40">
  57 <img src="../../../images/space.gif" width="6" height="1">
  58 <input type="text" name="time_frame_2" size="16" maxlength="15"><br>
  59
  60 <input type="text" name="short_term_goals_3" size="42" maxlength="40">
  61 <img src="../../../images/space.gif" width="6" height="1">
  62 <input type="text" name="time_frame_3" size="16" maxlength="15"><br><br>
  63
  64 <b>Long Term Goals:</b><br>
  65 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ></textarea><br><br>
  66
  67 <b>Discharge Criteria:</b><br>
  68 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ></textarea><br><br>
  69
  70 <b>Recommendations:</b><br>
  71 <input type="checkbox" name="individual_family_therapy">&nbsp;<b>Individual and / or Family Therapy</b></input>
  72 <img src="../../../images/space.gif" width="6" height="1">
  73 <input type="checkbox" name="substance_abuse">&nbsp;<b>Substance Abuse</b></input><br>
  74
  75 <input type="checkbox" name="group_therapy">&nbsp;<b>Group Therapy - psychoeducational group</b></input>
  76 <img src="../../../images/space.gif" width="6" height="1">
  77 <input type="checkbox" name="parenting">&nbsp;<b>Parenting</b></input><br><br>
  78
  79 <b>Action Steps by supports - family:</b><br>
  80 <textarea cols=85 rows=3 wrap=virtual name="action_steps_by_supports" ></textarea><br><br>
  81
  82 <b>Other supports - agencies</b>
  83 <b>Name:</b>
  84 <img src="../../../images/space.gif" width="38" height="1">
  85 <b>Contact Information</b><br>
  86 <input type="text" name="other_supports_name_1" size="37" maxlength="35">
  87 <img src="../../../images/space.gif" width="6" height="1">
  88 <input type="text" name="other_supports_contact_1" size="37" maxlength="35"><br>
  89
  90 <input type="text" name="other_supports_name_2" size="37" maxlength="35">
  91 <img src="../../../images/space.gif" width="6" height="1">
  92 <input type="text" name="other_supports_contact_2" size="37" maxlength="35"><br><br>
  93
  94 <b>Medications</b>
  95 <img src="../../../images/space.gif" width="204" height="1">
  96 <b>Referrals</b><br>
  97
  98 <input type="text" name="medications_1" size="42" maxlength="40">
  99 <img src="../../../images/space.gif" width="6" height="1">
 100 <input type="text" name="referrals_1" size="42" maxlength="40"><br>
 101
 102 <input type="text" name="medications_2" size="42" maxlength="40">
 103 <img src="../../../images/space.gif" width="6" height="1">
 104 <input type="text" name="referrals_2" size="42" maxlength="40"><br><br>
 105
 106
 107 <br><br>
 108 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 109 <img src="../../../images/space.gif" width="5" height="1">
 110 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit" onclick="top.restoreSession()">[Don't Save]</a></center>
 111 <br>
 112 </form>
 113 <?php
 114 formFooter();
 115 ?>