1 <!-- Ankle Injury View Form created by Nikolai Vitsyn by
2004/02/19 -->
3 include_once("../../globals.php");
6 <?php
html_header_show();?
>
7 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
9 <body
class="body_top">
11 include_once("$srcdir/api.inc");
12 $obj = formFetch("form_ankleinjury", $_GET["id"]);
14 <form method
=post action
="<?php echo $rootdir?>/forms/ankleinjury/save.php?mode=update&id=<?php echo $_GET["id
"];?>" name
="my_form">
15 <span
class="title"><?php
xl('Ankle Evaluation Form','e');?
></span
><br
></br
>
17 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php
xl('Save','e');?
>]</a
>
19 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
20 onclick
="top.restoreSession()">[<?php
xl('Don\'t Save Changes','e');?
>]</a
>
23 <span
class=text
>Date of Injury
: </span
><input type
=entry name
="ankle_date_of_injuary" value
="<?php echo stripslashes($obj{"ankle_date_of_injuary
"});?>" >
24 <td align
="right"><?php
xl('Work related?','e');?
>:</td
>
25 <td
><input type
=checkbox name
="ankle_work_related" <?php
if ($obj{"ankle_work_related"} == "on")
26 echo "checked";;?
>><span
class=text
></span
><br
></td
>
30 <td align
="right"><?php
xl('Foot:','e');?
></td
>
31 <td
><input type
=radio name
="ankle_foot" value
="Left" <?php
if ($obj{"ankle_foot"} == "Left")
32 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
33 <td align
="right"><?php
xl('Left:','e');?
></td
>
34 <td
><input type
=radio name
="ankle_foot" value
="Right" <?php
if ($obj{"ankle_foot"} == "Right")
35 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
36 <td align
="right"><?php
xl('Right:','e');?
></td
>
42 <td align
="right"><?php
xl('Severity of Pain:','e');?
></td
>
43 <td align
="right">1:</td
>
44 <td
><input type
=radio name
="ankle_severity_of_pain" value
="1" <?php
if ($obj{"ankle_severity_of_pain"} == "1")
45 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
47 <td align
="right">2:</td
>
48 <td
><input type
=radio name
="ankle_severity_of_pain" value
="2" <?php
if ($obj{"ankle_severity_of_pain"} == "2")
49 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
51 <td align
="right">3:</td
>
52 <td
><input type
=radio name
="ankle_severity_of_pain" value
="3" <?php
if ($obj{"ankle_severity_of_pain"} == "3")
53 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
58 <td align
="right"><?php
xl('Significant Swelling:','e');?
></td
>
59 <td
><input type
=checkbox name
="ankle_significant_swelling" <?php
if ($obj{"ankle_significant_swelling"} == "on")
60 {echo "checked";};?
>><span
class=text
></span
><br
>
67 <td align
="right"><?php
xl('Onset of Swelling:','e');?
></td
>
68 <td
><input type
=radio name
="ankle_onset_of_swelling" value
="within minutes" <?php
if ($obj{"ankle_onset_of_swelling"} == "within minutes")
69 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
70 <td align
="right"><?php
xl('within minutes:','e');?
></td
>
71 <td
><input type
=radio name
="ankle_onset_of_swelling" value
="within hours" <?php
if ($obj{"ankle_onset_of_swelling"} == "within hours")
72 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
73 <td align
="right"><?php
xl('within hours:','e');?
></td
>
77 <span
class="text"><?php
xl('How did Injury Occur?:','e');?
></span
></br
>
78 <textarea name
="ankle_how_did_injury_occur" cols
="67" rows
="4" wrap
="virtual name">
79 <?php
echo stripslashes($obj{"ankle_how_did_injury_occur"});?
></textarea
>
82 <table
><th colspan
="5"><?php
xl('Ottawa Ankle Rules','e');?
></th
>
84 <td align
="right"><?php
xl('Bone Tenderness:','e');?
></td
>
85 <td align
="right"><?php
xl('Medial malleolus:','e');?
></td
>
86 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Medial malleolus" <?php
if ($obj{"ankle_ottawa_bone_tenderness"} == "Medial malleolus")
87 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
88 <td align
="right"><?php
xl('Lateral malleolus:','e');?
></td
>
89 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Lateral malleolus" <?php
if ($obj{"ankle_ottawa_bone_tenderness"} == "Lateral malleolus")
90 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
91 <td align
="right"><?php
xl('Base of fifth (5th) Metarsal:','e');?
></td
>
92 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Base of fifth (5th) Metarsal" <?php
if ($obj{"ankle_ottawa_bone_tenderness"} == "Base of fifth (5th) Metarsal")
93 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
94 <td align
="right"><?php
xl('At the Navicular:','e');?
></td
>
95 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="At the Navicular" <?php
if ($obj{"ankle_ottawa_bone_tenderness"} == "At the Navicular")
96 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
102 <td align
="right"><?php
xl('Able to Bear Weight four (4) steps:','e');?
></td
>
103 <td align
="right"><?php
xl('Yes:','e');?
></td
>
104 <td
><input type
=radio name
="ankle_able_to_bear_weight_steps" value
="Yes" <?php
if ($obj{"ankle_able_to_bear_weight_steps"} == "Yes")
105 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
106 <td align
="right"><?php
xl('No:','e');?
></td
>
107 <td
><input type
=radio name
="ankle_able_to_bear_weight_steps" value
="No" <?php
if ($obj{"ankle_able_to_bear_weight_steps"} == "No")
108 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
113 <tr
><th
><?php
xl('X-Ray Interpretation:','e');?
></th
> <th
><?php
xl('Additional X-RAY Notes:','e');?
></th
></tr
>
116 <input type
=entry name
="ankle_x_ray_interpretation" value
="<?php echo
117 stripslashes($obj{"ankle_x_ray_interpretation
"});?>" size
="50">
120 <textarea name
="ankle_additional_x_ray_notes" cols
="30" rows
="1" wrap
="virtual name">
121 <?php
echo stripslashes($obj{"ankle_additional_x_ray_notes"});?
></textarea
>
127 <tr
><th
><?php
xl('Diagnosis:','e');?
></th
><th
><?php
xl('Additional Diagnosis:','e');?
></th
></tr
>
129 <td
><input type
=entry name
="ankle_diagnosis1" value
="<?php echo
130 stripslashes($obj{"ankle_diagnosis1
"});?>" size
="50">
133 <textarea name
="ankle_additional_diagnisis" rows
="2" cols
="30" wrap
="virtual name">
134 <?php
echo stripslashes($obj{"ankle_additional_diagnisis"});?
></textarea
>
138 <td
><input type
=entry name
="ankle_diagnosis2" value
="<?php echo
139 stripslashes($obj{"ankle_diagnosis2
"});?>" size
="50"></td
>
141 <td
><input type
=entry name
="ankle_diagnosis3" value
="<?php echo
142 stripslashes($obj{"ankle_diagnosis3
"});?>" size
="50"></td
>
144 <td
><input type
=entry name
="ankle_diagnosis4" value
="<?php echo
145 stripslashes($obj{"ankle_diagnosis4
"});?>" size
="50"></td
>
149 <table
><tr
><th
><?php
xl('Plan:','e');?
></th
><tr
>
151 <textarea name
="ankle_plan" rows
="4" cols
="67" wrap
="virtual name">
152 <?php
echo stripslashes($obj{"ankle_plan"});?
></textarea
>
155 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php
xl('Save','e');?
>]</a
>
157 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
158 onclick
="top.restoreSession()">[<?php
xl('Don\'t Save Changes','e');?
>]</a
>