contrib/forms/immunization_record/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 ?>
  12
  13
  14
  15 <html>
  16
  17 <head>
  18 <?php html_header_show();?>
  19
  20 <title>Form: ACOG Immunization record</title>
  21
  22 <?php include("../../acog_printable_h.css"); ?>
  23
  24 </head>
  25
  26
  27
  28 <?php
  29
  30    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  31
  32    if ($fres){
  33
  34      $patient = sqlFetchArray($fres);
  35
  36    }
  37
  38    $fres=sqlStatement("select * from form_immunization_record where id='".$id."'");
  39
  40    if ($fres){
  41
  42      $ir = sqlFetchArray($fres);
  43
  44    }
  45
  46 ?>
  47
  48 <body>
  49
  50
  51
  52 <div class="srvChapter">Immunization record<sup>*</sup></div>
  53
  54 <div style="border: solid 2pt black; background-color:#FFFFFF;">
  55
  56   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  57
  58     <tr align="left" valign="bottom">
  59
  60       <td colspan="4" class="fibody2" id="bordR">Patient name: <?php echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'}; ?></td>
  61
  62       <td colspan="2" class="fibody2" id="bordR">Birth date: <?php echo $patient{'DOB'}; ?></td>
  63
  64       <td colspan="2" class="fibody2">ID No: <?php  echo $patient{'id'};  ?></td>
  65
  66       </tr>
  67
  68     <tr align="center" valign="middle">
  69
  70       <td width="9%" class="ficaption2" id="bordR">age</td>
  71
  72       <td width="13%" class="ficaption2" id="bordR">Tetanus-Diphteria booster </td>
  73
  74       <td width="13%" class="ficaption2" id="bordR">Influenza vaccine </td>
  75
  76       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
  77
  78       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine</td>
  79
  80       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
  81
  82       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
  83
  84       <td width="13%" class="ficaption2">Varicella vaccine </td>
  85
  86     </tr>
  87
  88     <tr align="center" valign="middle">
  89
  90       <td class="fibody2" id="bordR">13-18</td>
  91
  92       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
  93
  94       <td class="fibody2" id="bordR">Based on risk </td>
  95
  96       <td class="fibody2" id="bordR">Based on risk</td>
  97
  98       <td class="fibody2" id="bordR">Based on risk</td>
  99
 100       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
 101
 102       <td class="fibody2" id="bordR">Based on risk</td>
 103
 104       <td class="fibody2">Based on risk</td>
 105
 106     </tr>
 107
 108     <tr align="center" valign="middle">
 109
 110       <td class="fibody2" id="bordR">19-39</td>
 111
 112       <td class="fibody2" id="bordR">Every 10 years </td>
 113
 114       <td class="fibody2" id="bordR">Based on risk</td>
 115
 116       <td class="fibody2" id="bordR">Based on risk</td>
 117
 118       <td class="fibody2" id="bordR">Based on risk</td>
 119
 120       <td class="fibody2" id="bordR">Based on risk</td>
 121
 122       <td class="fibody2" id="bordR">Based on risk</td>
 123
 124       <td class="fibody2">Based on risk</td>
 125
 126     </tr>
 127
 128     <tr align="center" valign="middle">
 129
 130       <td class="fibody2" id="bordR">40-64</td>
 131
 132       <td class="fibody2" id="bordR">Every 10 years</td>
 133
 134       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
 135
 136       <td class="fibody2" id="bordR">Based on risk</td>
 137
 138       <td class="fibody2" id="bordR">Based on risk</td>
 139
 140       <td class="fibody2" id="bordR">Based on risk</td>
 141
 142       <td class="fibody2" id="bordR">Based on risk</td>
 143
 144       <td class="fibody2">Based on risk</td>
 145
 146     </tr>
 147
 148     <tr align="center" valign="middle">
 149
 150       <td class="fibody2" id="bordR">65 and older </td>
 151
 152       <td class="fibody2" id="bordR">Every 10 years</td>
 153
 154       <td class="fibody2" id="bordR">Annually</td>
 155
 156       <td class="fibody2" id="bordR">Once</td>
 157
 158       <td class="fibody2" id="bordR">&nbsp;</td>
 159
 160       <td class="fibody2" id="bordR">Based on risk</td>
 161
 162       <td class="fibody2" id="bordR">Based on risk</td>
 163
 164       <td class="fibody2">Based on risk</td>
 165
 166     </tr>
 167
 168   </table>
 169
 170 </div>
 171
 172 <p>&nbsp;</p>
 173
 174 <div style="border: solid 2pt black; background-color:#FFFFFF;">
 175
 176   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 177
 178 <?php
 179
 180
 181 $vacci=0;
 182
 183   $vacc_tetanus = explode("|~", $ir["vacc_tetanus"]);
 184
 185   $vacc_influenza = explode("|~", $ir["vacc_influenza"]);
 186
 187   $vacc_pneumococcal = explode("|~", $ir["vacc_pneumococcal"]);
 188
 189   $vacc_mmr = explode("|~", $ir["vacc_mmr"]);
 190
 191   $vacc_hep_a = explode("|~", $ir["vacc_hep_a"]);
 192
 193   $vacc_hep_b = explode("|~", $ir["vacc_hep_b"]);
 194
 195   $vacc_varicella= explode("|~", $ir["vacc_varicella"]);
 196
 197 while ($vacci<20){
 198
 199 print <<<EOL
 200
 201     <tr align="left" valign="bottom">
 202
 203       <td width="9%" class="fibody5" id="bordR">Date</td>
 204
 205       <td width="13%" class="fibody5" id="bordR">${vacc_tetanus[$vacci]}&nbsp;</td>
 206
 207       <td width="13%" class="fibody5" id="bordR">${vacc_influenza[$vacci]}&nbsp;</td>
 208
 209       <td width="13%" class="fibody5" id="bordR">${vacc_pneumococcal[$vacci]}&nbsp;</td>
 210
 211       <td width="13%" class="fibody5" id="bordR">${vacc_mmr[$vacci]}&nbsp;</td>
 212
 213       <td width="13%" class="fibody5" id="bordR">${vacc_hep_b[$vacci]}&nbsp;</td>
 214
 215       <td width="13%" class="fibody5" id="bordR">${vacc_hep_a[$vacci]}&nbsp;</td>
 216
 217       <td width="13%" class="fibody5">${vacc_varicella[$vacci]}&nbsp;</td>
 218
 219     </tr>
 220
 221 EOL;
 222
 223 $vacci++;
 224
 225 }
 226
 227 ?>
 228
 229   </table>
 230
 231 </div>
 232
 233 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 234
 235 </body>
 236
 237 </html>