contrib/forms/ped_fever/form.php

   1 <?
   2 /*
   3 Pediatric Fever form
   4 This form works as new and editing,
   5 */
   6 ?>
   7 <TABLE span class=text>
   8 <th><H2><U>Pediatric Fever Form</U></H2></th>
   9 <TR>
  10         <TD>Fever: </TD>
  11         <TD>
  12         <INPUT TYPE="text" NAME="fever_temp" value="<? if ($obj["fever_temp"]!='') print $obj["fever_temp"]; ?>">
  13         </TD>
  14         <TD>Measured:</TD>
  15         <TD>
  16                 <SELECT NAME="measured">
  17                 <option <? if ($obj["measured"]=='axillary') print 'selected' ;?> >axillary
  18                 <option <? if ($obj["measured"]=='oral') print 'selected' ;?> >oral
  19                 <option <? if ($obj["measured"]=='rectal') print 'selected' ;?> >rectal
  20                 <option <? if ($obj["measured"]=='not measured') print 'selected' ;?> >not measured
  21                 </SELECT>
  22         </TD>
  23         <TD>Duration:</TD>
  24         <TD>
  25                 <SELECT NAME="duration">
  26                 <option <? if ($obj["duration"]=='one hour') print 'selected'; ?>>one hour
  27                 <option <? if ($obj["duration"]=='twelve hours') print 'selected'; ?>>twelve hours
  28                 <option <? if ($obj["duration"]=='one day') print 'selected'; ?>>one day
  29                 <option <? if ($obj["duration"]=='two days') print 'selected'; ?>>two days
  30                 <option <? if ($obj["duration"]=='three days') print 'selected'; ?>>three days
  31                 <option <? if ($obj["duration"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  32                 </SELECT>
  33         </TD>
  34 </TR>
  35 <TR>
  36         <TD>Takink Medication:</TD>
  37         <TD>
  38                 <SELECT NAME="taking_medication">
  39                 <option <? if ($obj["taking_medication"]=='no') print 'selected'; ?>>no
  40                 <option <? if ($obj["taking_medication"]=='yes') print 'selected'; ?>>yes
  41         </TD>
  42         <TD>Responds to Tylenol:</TD>
  43         <TD>
  44                 <SELECT NAME="responds_to_tylenol">
  45                 <option <? if ($obj["responds_to_tylenol"]=='n/a') print 'selected'; ?>>n/a
  46                 <option <? if ($obj["responds_to_tylenol"]=='no') print 'selected'; ?>>no
  47                 <option <? if ($obj["responds_to_tylenol"]=='yes') print 'selected'; ?>>yes
  48         </TD>
  49         <TD>Responds to Molrtin</TD>
  50         <TD>
  51                 <SELECT NAME="responds_to_moltrin">
  52                 <option <? if ($obj["responds_to_moltrin"]=='n/a') print 'selected'; ?>>n/a
  53                 <option <? if ($obj["responds_to_moltrin"]=='no') print 'selected'; ?>>no
  54                 <option <? if ($obj["responds_to_moltrin"]=='yes') print 'selected'; ?>>yes
  55
  56         </TD>
  57 </TR>
  58 </TR>
  59         <TD >Pain:</TD>
  60         <TD>
  61                 <SELECT NAME="pain">
  62                 <option <? if ($obj["pain"]=='no pain') print 'selected' ;?> >no pain
  63                 <option <? if ($obj["pain"]=='moderate') print 'selected'; ?>>moderate
  64                 <option <? if ($obj["pain"]=='intense') print 'selected'; ?>>intense
  65                 <option <? if ($obj["pain"]=='severe') print 'selected'; ?>>severe
  66                 </SELECT>
  67         </TD>
  68         <TD >Lethargy:</TD>
  69         <TD>
  70                 <SELECT NAME="lethargy">
  71                 <option <? if ($obj["lethargy"]=='no') print 'selected'; ?>>no
  72                 <option <? if ($obj["lethargy"]=='yes') print 'selected'; ?>>yes
  73                 </SELECT>
  74         </TD>
  75         <TD >Vomiting:</TD>
  76         <TD>
  77                 <SELECT NAME="vomiting">
  78                 <option <? if ($obj["vomiting"]=='no') print 'selected'; ?>>no
  79                 <option <? if ($obj["vomiting"]=='yes') print 'selected'; ?>>yes
  80                 </SELECT>
  81         </TD>
  82 </TR>
  83
  84 <TR>
  85         <TD colspan=2 >Able to take oral hydration:</TD>
  86         <TD>
  87                 <SELECT NAME="oral_hydration_capable">
  88                 <option <? if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?>>yes
  89                 <option <? if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?>>no
  90                 </SELECT>
  91         </TD>
  92         <TD colspan=2 >Urine output at least every 6 hrs.</TD>
  93         <TD>
  94                 <SELECT NAME="urine_output_last_6_hours">
  95                 <option <? if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?>>yes
  96                 <option <? if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?>>no
  97                 </SELECT>
  98                 With Pain?:
  99                 <SELECT NAME="pain_with_urination">
 100                 <option <? if ($obj["pain_with_urination"]=='no') print 'selected'; ?>>no
 101                 <option <? if ($obj["pain_with_urination"]=='yes') print 'selected'; ?>>yes
 102                 </SELECT>
 103
 104         </TD>
 105 </TR>
 106 <TR>
 107         <TD colspan=2 >Cough or difficulty breathing:</TD>
 108         <TD>
 109                 <SELECT NAME="cough_or_breathing_difficulty">
 110                 <option <? if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?>>no
 111                 <option <? if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?>>yes
 112                 </SELECT>
 113         </TD>
 114         <TD colspan=2 >Able to sleep confortably</TD>
 115         <TD>
 116                 <SELECT NAME="able_to_sleep">
 117                 <option <? if ($obj["able_to_sleep"]=='yes') print 'selected'; ?>>yes
 118                 <option <? if ($obj["able_to_sleep"]=='no') print 'selected'; ?>>no
 119                 </SELECT>
 120         </TD>
 121 </TR>
 122 <TR>
 123         <TD>Nasal Discharge:</TD>
 124         <TD>
 125                 <SELECT NAME="nasal_discharge">
 126                 <option <? if ($obj["nasal_discharge"]=='no') print 'selected'; ?>>no
 127                 <option <? if ($obj["nasal_discharge"]=='yes') print 'selected'; ?>>yes
 128                 </SELECT>
 129         </TD>
 130         <TD>Prior Hospitalization</TD>
 131         <TD>
 132                 <SELECT NAME="previous_hospitalization">
 133                 <option <? if ($obj["previous_hospitalization"]=='no') print 'selected'; ?>>no
 134                 <option <? if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?>>yes
 135                 </SELECT>
 136         </TD>
 137         <TD>Siblings affected?:</TD>
 138         <TD>
 139                 <SELECT NAME="siblings_affected">
 140                 <option <? if ($obj["siblings_affected"]=='no') print 'selected'; ?>>no
 141                 <option <? if ($obj["siblings_affected"]=='yes') print 'selected'; ?>>yes
 142                 </SELECT>
 143         </TD>
 144 </TR>
 145 <TR>
 146         <TD colspan=2 valign="top">Immunization up to date:
 147                 <SELECT NAME="immunization_up_to_date">
 148                 <option <? if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?>>yes
 149                 <option <? if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?>>no
 150                 </SELECT>
 151         </TD>
 152         <TD colspan=4 align=left valign=top>Notes:
 153         <TEXTAREA NAME="notes" ROWS="3" COLS="40">
 154         <? if ($obj["notes"]!='') print $obj["notes"]; ?>
 155         </TEXTAREA></TD>
 156 </TR>
 157 </TABLE>
 158
 159