1 <!DOCTYPE HTML
PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
3 "http://www.w3.org/TR/html4/loose.dtd">
7 include_once("../../globals.php");
9 include_once("$srcdir/api.inc");
11 include_once("$srcdir/forms.inc");
13 include_once("$srcdir/calendar.inc");
22 <?php
html_header_show();?
>
24 <title
>Form
: High risk screening record
</title
>
26 <?php
include("../../acog_printable_h.css"); ?
>
34 $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
38 $patient = sqlFetchArray($fres);
42 $fres=sqlStatement("select * from form_high_risk_screening_record where id=$id");
46 $fdata = sqlFetchArray($fres);
52 <body
<?php
echo $top_bg_line;?
>>
56 <div
class="srvChapter">High risk screening record
* </div
>
58 <div style
="border: solid 2px black; background-color:#FFFFFF;">
60 <table border
="0" cellpadding
="2" cellspacing
="0">
62 <tr align
="left" valign
="bottom">
64 <td colspan
="6" class="fibody2" id
="bordR">Patient name
: <?php
echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'}; ?
></td
>
66 <td colspan
="5" class="fibody2" id
="bordR">Birth date
: <?php
echo $patient{'DOB'}; ?
></td
>
68 <td colspan
="4" class="fibody2">ID No
: <?php
echo $patient{'id'}; ?
></td
>
72 <tr align
="center" valign
="middle">
74 <td
class="ficaption2" id
="bordR"> 
;</td
>
76 <td width
="6%" class="ficaption2" id
="bordR">HEMO
-<br
>
82 <td width
="6%" class="ficaption2" id
="bordR">BONE DENSITY
<br
>
86 <td width
="6%" class="ficaption2" id
="bordR">BACTERI
-<br
>
90 <td width
="6%" class="ficaption2" id
="bordR">STD
<br
>
94 <td width
="6%" class="ficaption2" id
="bordR">HIV test
* </td
>
96 <td width
="6%" class="ficaption2" id
="bordR">Genetic testing
</td
>
98 <td width
="6%" class="ficaption2" id
="bordR">Rubella titer
</td
>
100 <td width
="6%" class="ficaption2" id
="bordR">TB skin test
</td
>
102 <td width
="6%" class="ficaption2" id
="bordR">Lipid profile assessment
</td
>
104 <td width
="6%" class="ficaption2" id
="bordR">Mammo
-<br
>
108 <td width
="6%" class="ficaption2" id
="bordR">Fasting
<br
>
112 <td width
="6%" class="ficaption2" id
="bordR">TSH
<br
>
116 <td width
="6%" class="ficaption2" id
="bordR">COLORECTAL
<br
>
122 <td width
="6%" class="ficaption2">HEPATITIS C
<br
>
136 $hemoglobin, $bone_density, $bacteriuria, $std, $hiv, $genetic, $rubella, $tb_skin,
138 $lipid, $mammography, $fasting_glucose, $tsh, $cancer, $hepatitis_c
140 ) = explode("|~",$fdata["record_".$rsi]);
142 list( $hemoglobin_date, $hemoglobin_res) = explode(';', $hemoglobin);
144 list( $bone_density_date, $bone_density_res) = explode(';', $bone_density);
146 list( $bacteriuria_date, $bacteriuria_res) = explode(';', $bacteriuria);
148 list( $std_date, $std_res) = explode(';', $std);
150 list( $hiv_date, $hiv_res) = explode(';', $hiv);
152 list( $genetic_date, $genetic_res) = explode(';', $genetic);
154 list( $rubella_date, $rubella_res) = explode(';', $rubella);
156 list( $tb_skin_date, $tdb_skin_res) = explode(';', $tdb_skin);
158 list( $lipid_date, $lipid_res) = explode(';', $lipid);
160 list( $mammography_date, $mammography_res) = explode(';', $mammography);
162 list( $fasting_glucose_date, $fasting_glucose_res) = explode(';', $fasting_glucose);
164 list( $tsh_date, $tsh_res) = explode(';', $tsh);
166 list( $cancer_date, $cancer_res) = explode(';', $cancer);
168 list( $hepatitis_c_date, $hepatitis_c_res) = explode(';', $hepatitis_c);
174 <tr align="left" valign="bottom">
176 <td class="fibody3" id="bordR">Date:</td>
178 <td class="fibody3" id="bordR">${hemoglobin_date} </td>
180 <td class="fibody3" id="bordR">${bone_density_date} </td>
182 <td class="fibody3" id="bordR">${bacteriuria_date} </td>
184 <td class="fibody3" id="bordR">${std_date} </td>
186 <td class="fibody3" id="bordR">${hiv_date} </td>
188 <td class="fibody3" id="bordR">${genetic_date} </td>
190 <td class="fibody3" id="bordR">${rubella_date} </td>
192 <td class="fibody3" id="bordR">${tb_skin_date} </td>
194 <td class="fibody3" id="bordR">${lipid_date} </td>
196 <td class="fibody3" id="bordR">${mammography_date} </td>
198 <td class="fibody3" id="bordR">${fasting_glucose_date} </td>
200 <td class="fibody3" id="bordR">${tsh_date} </td>
202 <td class="fibody3" id="bordR">${cancer_date} </td>
204 <td class="fibody3">${hepatitis_c_date} </td>
208 <tr align="left" valign="bottom">
210 <td class="fibody2" id="bordR">Result:</td>
212 <td class="fibody2" id="bordR">${hemoglobin_res} </td>
214 <td class="fibody2" id="bordR">${bone_density_res} </td>
216 <td class="fibody2" id="bordR">${bacteriuria_res} </td>
218 <td class="fibody2" id="bordR">${std_res} </td>
220 <td class="fibody2" id="bordR">${hiv_res} </td>
222 <td class="fibody2" id="bordR">${genetic_res} </td>
224 <td class="fibody2" id="bordR">${rubella_res} </td>
226 <td class="fibody2" id="bordR">${tb_skin_res} </td>
228 <td class="fibody2" id="bordR">${lipid_res} </td>
230 <td class="fibody2" id="bordR">${mammography_res} </td>
232 <td class="fibody2" id="bordR">${fasting_glucose_res} </td>
234 <td class="fibody2" id="bordR">${tsh_res} </td>
236 <td class="fibody2" id="bordR">${cancer_res} </td>
238 <td class="fibody2">${hepatitis_c_res} </td>
254 <p
><sup
>*</sup
>See Table of High
-Risk Factors
.</p
>
256 <p
><sup
>**</sup
>Check state requirements before recording results
.</p
>