1 <!-- Form generated from formsWiz
-->
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';
9 <?php
html_header_show();?
>
10 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
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
>
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
>
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
>
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
>
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
>
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
>
154 <span
class=text
><?php
xl('Additional Notes: ','e'); ?
></span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="additional_notes" ></textarea
><br
>
156 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php
xl('Save','e');?
>]</a
>
158 <a href
="<?php echo "$rootdir/patient_file
/encounter
/$returnurl";?>" class="link"
159 onclick
="top.restoreSession()">[<?php
xl('Don\'t Save','e');?
>]</a
>