contrib/forms/high_risk_screening_record/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_high_risk_screening_record';
   7 $ftitle = 'High risk screening record';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  17   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  18   $id = $newid;
  19   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  20   exit;
  21   }
  22   }
  23 ?>
  24 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  25 "http://www.w3.org/TR/html4/loose.dtd">
  26
  27 <html>
  28 <head>
  29 <?php html_header_show();?>
  30 <title>Form: High risk screening record</title>
  31 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  32 <link rel=stylesheet href="../../acog.css" type="text/css">
  33 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  34 <script language="JavaScript" type="text/JavaScript">
  35 window.onload = initialize;
  36 </script>
  37 </head>
  38
  39 <?php
  40    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  41    if ($fres){
  42      $patient = sqlFetchArray($fres);
  43    }
  44 ?>
  45 <body <?echo $top_bg_line;?>>
  46
  47 <form action="<?echo $rootdir;?>/forms/high_risk_screening_record/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  48 <?php include("../../acog_menu.inc"); ?>
  49 <div class="srvChapter">High risk screening  record <a href="#" onMouseOver="toolTip('See Table of High-Risk Factors.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  50 <div style="border: solid 2px black; background-color:#FFFFFF;">
  51   <table  border="0" cellpadding="2" cellspacing="0">
  52     <tr align="left" valign="bottom">
  53       <td colspan="6" class="fibody2" id="bordR">patient name:
  54         <input name="pname" type="text" class="fullin" id="pname" style="width: 70%" value="<?php
  55
  56           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  57           ?>"></td>
  58       <td colspan="5" class="fibody2" id="bordR">Birth date:
  59         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?php
  60
  61           echo $patient{'DOB'};
  62           ?>"></td>
  63       <td colspan="4" class="fibody2">ID No:
  64         <input name="hr_pid" type="text" class="fullin" id="hr_pid" style="width:80%" value="<?php
  65
  66           echo $patient{'id'};
  67           ?>"></td>
  68       </tr>
  69     <tr align="center" valign="middle">
  70       <td class="ficaption2" id="bordR">&nbsp;</td>
  71       <td width="6%" class="ficaption2" id="bordR">HEMO-<br>
  72         GLOBIN<br>
  73         TEST</td>
  74       <td width="6%" class="ficaption2" id="bordR">BONE DENSITY<br>
  75         SCREENING</td>
  76       <td width="6%" class="ficaption2" id="bordR">BACTERI-<br>
  77         URIA&nbsp;TEST</td>
  78       <td width="6%" class="ficaption2" id="bordR">STD<br>
  79         TESTING</td>
  80       <td width="6%" class="ficaption2" id="bordR">HIV test <a href="#" onMouseOver="toolTip('Check state requirements before recording results.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  81       <td width="6%" class="ficaption2" id="bordR">Genetic testing </td>
  82       <td width="6%" class="ficaption2" id="bordR">Rubella titer </td>
  83       <td width="6%" class="ficaption2" id="bordR">TB skin test </td>
  84       <td width="6%" class="ficaption2" id="bordR">Lipid profile assessment </td>
  85       <td width="6%" class="ficaption2" id="bordR">mammo-<br>
  86         graphy</td>
  87       <td width="6%" class="ficaption2" id="bordR">FASTING<br>
  88         GLUCOSE TEST</td>
  89       <td width="6%" class="ficaption2" id="bordR">TSH<br>
  90         TEST</td>
  91       <td width="6%" class="ficaption2" id="bordR">COLORECTAL<br>
  92         CANCER<br>
  93         SCREENING</td>
  94       <td width="6%" class="ficaption2">HEPATITIS C<br>
  95         VIRUS TEST</td>
  96     </tr>
  97 <?
  98 $rsi = 1;
  99 while ($rsi <  13){
 100 print <<<EOL
 101     <tr align="left" valign="bottom">
 102       <td class="fibody3" id="bordR">Date:</td>
 103       <td class="fibody3" id="bordR"><input name="hemoglobin_date_${rsi}" type="text" class="fullin2"></td>
 104       <td class="fibody3" id="bordR"><input name="bone_density_date_${rsi}" type="text" class="fullin2"></td>
 105       <td class="fibody3" id="bordR"><input name="bacteriuria_date_${rsi}" type="text" class="fullin2"></td>
 106       <td class="fibody3" id="bordR"><input name="std_date_${rsi}" type="text" class="fullin2"></td>
 107       <td class="fibody3" id="bordR"><input name="hiv_date_${rsi}" type="text" class="fullin2"></td>
 108       <td class="fibody3" id="bordR"><input name="genetic_date_${rsi}" type="text" class="fullin2"></td>
 109       <td class="fibody3" id="bordR"><input name="rubella_date_${rsi}" type="text" class="fullin2"></td>
 110       <td class="fibody3" id="bordR"><input name="tb_skin_date_${rsi}" type="text" class="fullin2"></td>
 111       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" class="fullin2"></td>
 112       <td class="fibody3" id="bordR"><input name="mammography_date_${rsi}" type="text" class="fullin2"></td>
 113       <td class="fibody3" id="bordR"><input name="fasting_glucose_date_${rsi}" type="text" class="fullin2"></td>
 114       <td class="fibody3" id="bordR"><input name="tsh_date_${rsi}" type="text" class="fullin2"></td>
 115       <td class="fibody3" id="bordR"><input name="cancer_date_${rsi}" type="text" class="fullin2"></td>
 116       <td class="fibody3"><input name="hepatitis_c_date_${rsi}" type="text" class="fullin2"></td>
 117     </tr>
 118     <tr align="left" valign="bottom">
 119       <td class="fibody2" id="bordR">Result:</td>
 120       <td class="fibody2" id="bordR"><input name="hemoglobin_res_${rsi}" type="text" class="fullin2"></td>
 121       <td class="fibody2" id="bordR"><input name="bone_density_res_${rsi}" type="text" class="fullin2"></td>
 122       <td class="fibody2" id="bordR"><input name="bacteriuria_res_${rsi}" type="text" class="fullin2"></td>
 123       <td class="fibody2" id="bordR"><input name="std_res_${rsi}" type="text" class="fullin2"></td>
 124       <td class="fibody2" id="bordR"><input name="hiv_res_${rsi}" type="text" class="fullin2"></td>
 125       <td class="fibody2" id="bordR"><input name="genetic_res_${rsi}" type="text" class="fullin2"></td>
 126       <td class="fibody2" id="bordR"><input name="rubella_res_${rsi}" type="text" class="fullin2"></td>
 127       <td class="fibody2" id="bordR"><input name="tb_skin_res_${rsi}" type="text" class="fullin2"></td>
 128       <td class="fibody2" id="bordR"><input name="lipid_res_${rsi}" type="text" class="fullin2"></td>
 129       <td class="fibody2" id="bordR"><input name="mammography_res_${rsi}" type="text" class="fullin2"></td>
 130       <td class="fibody2" id="bordR"><input name="fasting_glucose_res_${rsi}" type="text" class="fullin2"></td>
 131       <td class="fibody2" id="bordR"><input name="tsh_res_${rsi}" type="text" class="fullin2"></td>
 132       <td class="fibody2" id="bordR"><input name="cancer_res_${rsi}" type="text" class="fullin2"></td>
 133       <td class="fibody2"><input name="hepatitis_c_res_${rsi}" type="text" class="fullin2"></td>
 134     </tr>
 135 EOL;
 136 $rsi++;
 137 }
 138 ?>
 139   </table>
 140 </div>
 141 <p>&nbsp;</p>
 142 <table width="100%" border="0">
 143   <tr>
 144     <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 145     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 146      onclick="top.restoreSession()">[Don't Save]</a> </td>
 147   </tr>
 148 </table>
 149 </form>
 150 <?php
 151 formFooter();
 152 ?>
 153 </body>
 154 </html>