Minor improvement to fee sheet to show code set Labels rather than ids and changed...
[openemr.git] / interface / forms / reviewofs / new.php
blobbfb2caca2e22661e1f56ae578c457facdd834155
1 <!-- Form generated from formsWiz -->
2 <?php
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: reviewofs");
6 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
7 ?>
8 <html><head>
9 <?php html_header_show();?>
10 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
11 </head>
12 <body class="body_top">
13 <form method=post action="<?php echo $rootdir;?>/forms/reviewofs/save.php?mode=new"
14 name="my_form" onsubmit="return top.restoreSession()">
15 <span class="title"><?php xl('Review of Systems Checks','e'); ?></span><br><br>
17 <table><tr><td valign=top>
19 <span class=bold><?php xl('General','e'); ?></span><br>
20 <input type=checkbox name='fever' ><span class=text><?php xl('Fever','e'); ?></span><br>
21 <input type=checkbox name='chills' ><span class=text><?php xl('Chills','e'); ?></span><br>
22 <input type=checkbox name='night_sweats' ><span class=text><?php xl('Night Sweats','e'); ?></span><br>
23 <input type=checkbox name='weight_loss' ><span class=text><?php xl('Weight Loss','e'); ?></span><br>
24 <input type=checkbox name='poor_appetite' ><span class=text><?php xl('Poor Appetite','e'); ?></span><br>
25 <input type=checkbox name='insomnia' ><span class=text><?php xl('Insomnia','e'); ?></span><br>
26 <input type=checkbox name='fatigued' ><span class=text><?php xl('Fatigued','e'); ?></span><br>
27 <input type=checkbox name='depressed' ><span class=text><?php xl('Depressed','e'); ?></span><br>
28 <input type=checkbox name='hyperactive' ><span class=text><?php xl('Hyperactive','e'); ?></span><br>
29 <input type=checkbox name='exposure_to_foreign_countries' ><span class=text><?php xl('Exposure to Foreign Countries','e'); ?></span><br>
30 <span class=bold><?php xl('Skin','e'); ?></span><br>
31 <input type=checkbox name='rashes' ><span class=text><?php xl('Rashes','e'); ?></span><br>
32 <input type=checkbox name='infections' ><span class=text><?php xl('Infections','e'); ?></span><br>
33 <input type=checkbox name='ulcerations' ><span class=text><?php xl('Ulcerations','e'); ?></span><br>
34 <input type=checkbox name='pemphigus' ><span class=text><?php xl('Pemphigus','e'); ?></span><br>
35 <input type=checkbox name='herpes' ><span class=text><?php xl('Herpes','e'); ?></span><br>
37 </td><td valign=top>
39 <span class=bold><?php xl('HEENT','e'); ?></span><br>
40 <input type=checkbox name='cataracts' ><span class=text><?php xl('Cataracts','e'); ?></span><br>
41 <input type=checkbox name='cataract_surgery' ><span class=text><?php xl('Cataract Surgery','e'); ?></span><br>
42 <input type=checkbox name='glaucoma' ><span class=text><?php xl('Glaucoma','e'); ?></span><br>
43 <input type=checkbox name='double_vision' ><span class=text><?php xl('Double Vision','e'); ?></span><br>
44 <input type=checkbox name='blurred_vision' ><span class=text><?php xl('Blurred Vision','e'); ?></span><br>
45 <input type=checkbox name='poor_hearing' ><span class=text><?php xl('Poor Hearing','e'); ?></span><br>
46 <input type=checkbox name='headaches' ><span class=text><?php xl('Headaches','e'); ?></span><br>
47 <input type=checkbox name='ringing_in_ears' ><span class=text><?php xl('Ringing in Ears','e'); ?></span><br>
48 <input type=checkbox name='bloody_nose' ><span class=text><?php xl('Bloody Nose','e'); ?></span><br>
49 <input type=checkbox name='sinusitis' ><span class=text><?php xl('Sinusitis','e'); ?></span><br>
50 <input type=checkbox name='sinus_surgery' ><span class=text><?php xl('Sinus Surgery','e'); ?></span><br>
51 <input type=checkbox name='dry_mouth' ><span class=text><?php xl('Dry Mouth','e'); ?></span><br>
52 <input type=checkbox name='strep_throat' ><span class=text><?php xl('Strep Throat','e'); ?></span><br>
53 <input type=checkbox name='tonsillectomy' ><span class=text><?php xl('Tonsillectomy','e'); ?></span><br>
54 <input type=checkbox name='swollen_lymph_nodes' ><span class=text><?php xl('Swollen Lymph Nodes','e'); ?></span><br>
55 <input type=checkbox name='throat_cancer' ><span class=text><?php xl('Throat Cancer','e'); ?></span><br>
56 <input type=checkbox name='throat_cancer_surgery' ><span class=text><?php xl('Throat Cancer Surgery','e'); ?></span><br>
58 </td><td valign=top>
60 <span class=bold><?php xl('Cardiovascular','e'); ?></span><br>
61 <input type=checkbox name='heart_attack' ><span class=text><?php xl('Heart Attack','e'); ?></span><br>
62 <input type=checkbox name='irregular_heart_beat' ><span class=text><?php xl('Irregular Heart Beat','e'); ?></span><br>
63 <input type=checkbox name='chest_pains' ><span class=text><?php xl('Chest Pains','e'); ?></span><br>
64 <input type=checkbox name='shortness_of_breath' ><span class=text><?php xl('Shortness of Breath','e'); ?></span><br>
65 <input type=checkbox name='high_blood_pressure' ><span class=text><?php xl('High Blood Pressure','e'); ?></span><br>
66 <input type=checkbox name='heart_failure' ><span class=text><?php xl('Heart Failure','e'); ?></span><br>
67 <input type=checkbox name='poor_circulation' ><span class=text><?php xl('Poor Circulation','e'); ?></span><br>
68 <input type=checkbox name='vascular_surgery' ><span class=text><?php xl('Vascular Surgery','e'); ?></span><br>
69 <input type=checkbox name='cardiac_catheterization' ><span class=text><?php xl('Cardiac Catheterization','e'); ?></span><br>
70 <input type=checkbox name='coronary_artery_bypass' ><span class=text><?php xl('Coronary Artery Bypass','e'); ?></span><br>
71 <input type=checkbox name='heart_transplant' ><span class=text><?php xl('Heart Transplant','e'); ?></span><br>
72 <input type=checkbox name='stress_test' ><span class=text><?php xl('Stress Test','e'); ?></span><br>
73 <span class=bold><?php xl('Endocrine','e'); ?></span><br>
74 <input type=checkbox name='insulin_dependent_diabetes' ><span class=text><?php xl('Insulin Dependent Diabetes','e'); ?></span><br>
75 <input type=checkbox name='noninsulin_dependent_diabetes' ><span class=text><?php xl('Non-Insulin Dependent Diabetes','e'); ?></span><br>
76 <input type=checkbox name='hypothyroidism' ><span class=text><?php xl('Hypothyroidism','e'); ?></span><br>
77 <input type=checkbox name='hyperthyroidism' ><span class=text><?php xl('Hyperthyroidism','e'); ?></span><br>
78 <input type=checkbox name='cushing_syndrom' ><span class=text><?php xl('Cushing Syndrome','e'); ?></span><br>
79 <input type=checkbox name='addison_syndrom' ><span class=text><?php xl('Addison Syndrome','e'); ?></span><br>
81 </td><td valign=top>
83 <span class=bold><?php xl('Pulmonary','e'); ?></span><br>
84 <input type=checkbox name='emphysema' ><span class=text><?php xl('Emphysema','e'); ?></span><br>
85 <input type=checkbox name='chronic_bronchitis' ><span class=text><?php xl('Chronic Bronchitis','e'); ?></span><br>
86 <input type=checkbox name='interstitial_lung_disease' ><span class=text><?php xl('Interstitial Lung Disease','e'); ?></span><br>
87 <input type=checkbox name='shortness_of_breath_2' ><span class=text><?php xl('Shortness of Breath','e'); ?></span><br>
88 <input type=checkbox name='lung_cancer' ><span class=text><?php xl('Lung Cancer','e'); ?></span><br>
89 <input type=checkbox name='lung_cancer_surgery' ><span class=text><?php xl('Lung Cancer Surgery','e'); ?></span><br>
90 <input type=checkbox name='pheumothorax' ><span class=text><?php xl('Pheumothorax','e'); ?></span><br>
91 <span class=bold><?php xl('Genitourinary','e'); ?></span><br>
92 <input type=checkbox name='kidney_failure' ><span class=text><?php xl('Kidney Failure','e'); ?></span><br>
93 <input type=checkbox name='kidney_stones' ><span class=text><?php xl('Kidney Stones','e'); ?></span><br>
94 <input type=checkbox name='kidney_cancer' ><span class=text><?php xl('Kidney Cancer','e'); ?></span><br>
95 <input type=checkbox name='kidney_infections' ><span class=text><?php xl('Kidney Infections','e'); ?></span><br>
96 <input type=checkbox name='bladder_infections' ><span class=text><?php xl('Bladder Infections','e'); ?></span><br>
97 <input type=checkbox name='bladder_cancer' ><span class=text><?php xl('Bladder Cancer','e'); ?></span><br>
98 <input type=checkbox name='prostate_problems' ><span class=text><?php xl('Prostate Problems','e'); ?></span><br>
99 <input type=checkbox name='prostate_cancer' ><span class=text><?php xl('Prostate Cancer','e'); ?></span><br>
100 <input type=checkbox name='kidney_transplant' ><span class=text><?php xl('Kidney Transplant','e'); ?></span><br>
101 <input type=checkbox name='sexually_transmitted_disease' ><span class=text><?php xl('Sexually Transmitted Disease','e'); ?></span><br>
102 <input type=checkbox name='burning_with_urination' ><span class=text><?php xl('Burning with Urination','e'); ?></span><br>
103 <input type=checkbox name='discharge_from_urethra' ><span class=text><?php xl('Discharge From Urethra','e'); ?></span><br>
105 </td><td valign=top>
107 <span class=bold><?php xl('Gastrointestinal','e'); ?></span><br>
108 <input type=checkbox name='stomach_pains' ><span class=text><?php xl('Stomach Pains','e'); ?></span><br>
109 <input type=checkbox name='peptic_ulcer_disease' ><span class=text><?php xl('Peptic Ulcer Disease','e'); ?></span><br>
110 <input type=checkbox name='gastritis' ><span class=text><?php xl('Gastritis','e'); ?></span><br>
111 <input type=checkbox name='endoscopy' ><span class=text><?php xl('Endoscopy','e'); ?></span><br>
112 <input type=checkbox name='polyps' ><span class=text><?php xl('Polyps','e'); ?></span><br>
113 <input type=checkbox name='colonoscopy' ><span class=text><?php xl('Colonoscopy','e'); ?></span><br>
114 <input type=checkbox name='colon_cancer' ><span class=text><?php xl('Colon Cancer','e'); ?></span><br>
115 <input type=checkbox name='colon_cancer_surgery' ><span class=text><?php xl('Colon Cancer Surgery','e'); ?></span><br>
116 <input type=checkbox name='ulcerative_colitis' ><span class=text><?php xl('Ulcerative Colitis','e'); ?></span><br>
117 <input type=checkbox name='crohns_disease' ><span class=text><?php xl('Crohn\'s Disease','e'); ?></span><br>
118 <input type=checkbox name='appendectomy' ><span class=text><?php xl('Appendectomy','e'); ?></span><br>
119 <input type=checkbox name='divirticulitis' ><span class=text><?php xl('Diverticulitis','e'); ?></span><br>
120 <input type=checkbox name='divirticulitis_surgery' ><span class=text><?php xl('Diverticulitis Surgery','e'); ?></span><br>
121 <input type=checkbox name='gall_stones' ><span class=text><?php xl('Gall Stones','e'); ?></span><br>
122 <input type=checkbox name='cholecystectomy' ><span class=text><?php xl('Cholecystectomy','e'); ?></span><br>
123 <input type=checkbox name='hepatitis' ><span class=text><?php xl('Hepatitis','e'); ?></span><br>
124 <input type=checkbox name='cirrhosis_of_the_liver' ><span class=text><?php xl('Cirrhosis of the Liver','e'); ?></span><br>
125 <input type=checkbox name='splenectomy' ><span class=text><?php xl('Splenectomy','e'); ?></span><br>
127 </td><td valign=top>
129 <span class=bold><?php xl('Musculoskeletal','e'); ?></span><br>
130 <input type=checkbox name='osetoarthritis' ><span class=text><?php xl('Osetoarthritis','e'); ?></span><br>
131 <input type=checkbox name='rheumotoid_arthritis' ><span class=text><?php xl('Rheumotoid Arthritis','e'); ?></span><br>
132 <input type=checkbox name='lupus' ><span class=text><?php xl('Lupus','e'); ?></span><br>
133 <input type=checkbox name='ankylosing_sondlilitis' ><span class=text><?php xl('Ankylosing Spondlilitis','e'); ?></span><br>
134 <input type=checkbox name='swollen_joints' ><span class=text><?php xl('Swollen Joints','e'); ?></span><br>
135 <input type=checkbox name='stiff_joints' ><span class=text><?php xl('Stiff Joints','e'); ?></span><br>
136 <input type=checkbox name='broken_bones' ><span class=text><?php xl('Broken Bones','e'); ?></span><br>
137 <input type=checkbox name='neck_problems' ><span class=text><?php xl('Neck Problems','e'); ?></span><br>
138 <input type=checkbox name='back_problems' ><span class=text><?php xl('Back Problems','e'); ?></span><br>
139 <input type=checkbox name='back_surgery' ><span class=text><?php xl('Back Surgery','e'); ?></span><br>
140 <input type=checkbox name='scoliosis' ><span class=text><?php xl('Scoliosis','e'); ?></span><br>
141 <input type=checkbox name='herniated_disc' ><span class=text><?php xl('Herniated Disc','e'); ?></span><br>
142 <input type=checkbox name='shoulder_problems' ><span class=text><?php xl('Shoulder Problems','e'); ?></span><br>
143 <input type=checkbox name='elbow_problems' ><span class=text><?php xl('Elbow Problems','e'); ?></span><br>
144 <input type=checkbox name='wrist_problems' ><span class=text><?php xl('Wrist Problems','e'); ?></span><br>
145 <input type=checkbox name='hand_problems' ><span class=text><?php xl('Hand Problems','e'); ?></span><br>
146 <input type=checkbox name='hip_problems' ><span class=text><?php xl('Hip Problems','e'); ?></span><br>
147 <input type=checkbox name='knee_problems' ><span class=text><?php xl('Knee Problems','e'); ?></span><br>
148 <input type=checkbox name='ankle_problems' ><span class=text><?php xl('Ankle Problems','e'); ?></span><br>
149 <input type=checkbox name='foot_problems' ><span class=text><?php xl('Foot Problems','e'); ?></span><br>
150 </td>
151 </tr>
152 </table>
154 <span class=text><?php xl('Additional Notes: ','e'); ?></span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea><br>
155 <br>
156 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e');?>]</a>
157 <br>
158 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link"
159 onclick="top.restoreSession()">[<?php xl('Don\'t Save','e');?>]</a>
160 </form>
161 <?php
162 formFooter();