contrib/forms/pain/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: pain");
   6 ?>
   7 <html><head>
   8 <?php html_header_show();?>
   9 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  10 </head>
  11 <body class="body_top">
  12 <form method=post action="<?php echo $rootdir;?>/forms/pain/save.php?mode=new" name="my_form">
  13 <span class="title">Pain Evaluation</span><br><br>
  14
  15
  16 <input type=checkbox name='dull'  ><span class=text>Dull</span>
  17 <input type=checkbox name='colicky'  ><span class=text>Colicky</span>
  18 <input type=checkbox name='sharp'  ><span class=text>Sharp</span>
  19 <span class=text>Duration of Pain: </span><input type=entry name="duration_of_pain" value="" ><br>
  20
  21
  22 <span class=text>History of Pain: </span><br><textarea cols=40 rows=4 wrap=virtual name="history_of_pain" ></textarea><br>
  23
  24
  25 <table><tr><td>
  26 <table><tr>
  27 <td><span class=text>Accompanying Symptoms Vomitting: </span></td><td><input type=entry name="accompanying_symptoms_vomitting" value="" ></td>
  28 </tr><tr>
  29 <td><span class=text>Accompanying Symptoms Nausea: </span></td><td><input type=entry name="accompanying_symptoms_nausea" value="" ></td>
  30 </tr><tr>
  31 <td><span class=text>Accompanying Symptoms Headache: </span></td><td><input type=entry name="accompanying_symptoms_headache" value="" ></td>
  32 </tr></table>
  33 </td><td>
  34 <span class=text>Accompanying Symptoms Other: </span><br><textarea cols=40 rows=8 wrap=virtual name="accompanying_symptoms_other" ></textarea><br>
  35 </td></tr></table>
  36
  37 <table>
  38 <tr><td>
  39 <span class=text>Pain Referred to Other Sites?: </span><br><textarea cols=40 rows=4 wrap=virtual name="pain_referred_to_other_sites" ></textarea>
  40 </td><td>
  41 <span class=text>What Relieves Pain?: </span><br><textarea cols=40 rows=4 wrap=virtual name="what_relieves_pain" ></textarea>
  42 </td></tr><tr><td>
  43 <span class=text>What Makes Pain Worse (Movement/Positions/Activities)?: </span><br><textarea cols=40 rows=4 wrap=virtual name="what_makes_pain_worse" ></textarea>
  44 </td><td>
  45 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=4 wrap=virtual name="additional_notes" ></textarea>
  46 </td></tr></table>
  47
  48 <br>
  49 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  50 <br>
  51 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[Don't Save]</a>
  52 </form>
  53 <?php
  54 formFooter();
  55 ?>