contrib/forms/ped_pain/form.php

   1 <?php
   2
   3 /*
   4 pediatric pain form
   5 This form works as new and editing,
   6 */
   7 ?>
   8 <TABLE span class=text>
   9 <th><H2><U>Pediatric Pain Form</U></H2></th>
  10 <TR>
  11         <TD >Location:</TD>
  12         <TD>
  13                 <SELECT NAME="location">
  14                 <option <?php if ($obj["location"]=='ear') print 'selected' ;?> >ear
  15                 <option <?php if ($obj["location"]=='troat') print 'selected'; ?>>troat
  16                 <option <?php if ($obj["location"]=='stomach') print 'selected'; ?>>stomach
  17                 <option <?php if ($obj["location"]=='head') print 'selected'; ?>>head
  18                 </SELECT>
  19         </TD>
  20         <TD >Duration:</TD>
  21         <TD>
  22                 <SELECT NAME="duration">
  23                 <option <?php if ($obj["duration"]=='one hour') print 'selected'; ?>>one hour
  24                 <option <?php if ($obj["duration"]=='twelve hours') print 'selected'; ?>>twelve hours
  25                 <option <?php if ($obj["duration"]=='one day') print 'selected'; ?>>one day
  26                 <option <?php if ($obj["duration"]=='two days') print 'selected'; ?>>two days
  27                 <option <?php if ($obj["duration"]=='three days') print 'selected'; ?>>three days
  28                 <option <?php if ($obj["duration"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  29                 </SELECT>
  30         </TD>
  31         <TD >Severity:</TD>
  32         <TD>
  33                 <SELECT NAME="severity">
  34                 <option <?php if ($obj["severity"]=='consolable') print 'selected'; ?>>consolable
  35                 <option <?php if ($obj["severity"]=='consolable with difficulty') print 'selected'; ?>>consolable with difficulty
  36                 <option <?php if ($obj["severity"]=='inconsolable') print 'selected'; ?>>inconsolable
  37                 </SELECT>
  38         </TD>
  39 </TR>
  40 <TR>
  41         <TD >Fever:</TD>
  42         <TD>
  43                 <SELECT NAME="fever">
  44                 <option <?php if ($obj["fever"]=='no') print 'selected'; ?>>no
  45                 <option <?php if ($obj["fever"]=='yes') print 'selected'; ?>>yes
  46                 <option <?php if ($obj["fever"]=='98') print 'selected'; ?>>98
  47                 <option <?php if ($obj["fever"]=='98,5') print 'selected'; ?>>98,5
  48                 <option <?php if ($obj["fever"]=='99') print 'selected'; ?>>99
  49                 <option <?php if ($obj["fever"]=='99,5') print 'selected'; ?>>99,5
  50                 <option <?php if ($obj["fever"]=='100') print 'selected'; ?>>100
  51                 <option <?php if ($obj["fever"]=='100,5') print 'selected'; ?>>100,5
  52                 <option <?php if ($obj["fever"]=='101') print 'selected'; ?>>101
  53                 <option <?php if ($obj["fever"]=='101,5') print 'selected'; ?>>101,5
  54                 <option <?php if ($obj["fever"]=='102') print 'selected'; ?>>102
  55                 <option <?php if ($obj["fever"]=='102,5') print 'selected'; ?>>102,5
  56                 <option <?php if ($obj["fever"]=='103') print 'selected'; ?>>103
  57                 <option <?php if ($obj["fever"]=='103,5') print 'selected'; ?>>103,5
  58                 <option <?php if ($obj["fever"]=='104') print 'selected'; ?>>104
  59                 <option <?php if ($obj["fever"]=='104,5') print 'selected'; ?>>104,5
  60                 <option <?php if ($obj["fever"]=='105 ') print 'selected'; ?>>105
  61                 </SELECT>
  62         </TD>
  63         <TD >Lethargy:</TD>
  64         <TD>
  65                 <SELECT NAME="lethargy">
  66                 <option <?php if ($obj["lethargy"]=='no') print 'selected'; ?>>no
  67                 <option <?php if ($obj["lethargy"]=='yes') print 'selected'; ?>>yes
  68                 </SELECT>
  69         </TD>
  70         <TD >Vomiting:</TD>
  71         <TD>
  72                 <SELECT NAME="vomiting">
  73                 <option <?php if ($obj["vomiting"]=='no') print 'selected'; ?>>no
  74                 <option <?php if ($obj["vomiting"]=='yes') print 'selected'; ?>>yes
  75                 </SELECT>
  76         </TD>
  77 </TR>
  78 <TR>
  79         <TD colspan=2 >Able to take oral hydration:</TD>
  80         <TD>
  81                 <SELECT NAME="oral_hydration_capable">
  82                 <option <?php if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?>>yes
  83                 <option <?php if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?>>no
  84                 </SELECT>
  85         </TD>
  86         <TD colspan=2 >Urine output at least every 6 hrs.</TD>
  87         <TD>
  88                 <SELECT NAME="urine_output_last_6_hours">
  89                 <option <?php if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?>>yes
  90                 <option <?php if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?>>no
  91                 </SELECT>
  92                 With Pain?:
  93                 <SELECT NAME="pain_with_urination">
  94                 <option <?php if ($obj["pain_with_urination"]=='no') print 'selected'; ?>>no
  95                 <option <?php if ($obj["pain_with_urination"]=='yes') print 'selected'; ?>>yes
  96                 </SELECT>
  97
  98         </TD>
  99 </TR>
 100 <TR>
 101         <TD colspan=2 >Cough or difficulty breathing:</TD>
 102         <TD>
 103                 <SELECT NAME="cough_or_breathing_difficulty">
 104                 <option <?php if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?>>no
 105                 <option <?php if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?>>yes
 106                 </SELECT>
 107         </TD>
 108         <TD colspan=2 >Able to sleep confortably</TD>
 109         <TD>
 110                 <SELECT NAME="able_to_sleep">
 111                 <option <?php if ($obj["able_to_sleep"]=='yes') print 'selected'; ?>>yes
 112                 <option <?php if ($obj["able_to_sleep"]=='no') print 'selected'; ?>>no
 113                 </SELECT>
 114         </TD>
 115 </TR>
 116 <TR>
 117         <TD>Nasal Discharge:</TD>
 118         <TD>
 119                 <SELECT NAME="nasal_discharge">
 120                 <option <?php if ($obj["nasal_discharge"]=='no') print 'selected'; ?>>no
 121                 <option <?php if ($obj["nasal_discharge"]=='yes') print 'selected'; ?>>yes
 122                 </SELECT>
 123         </TD>
 124         <TD>Prior Hospitalization</TD>
 125         <TD>
 126                 <SELECT NAME="previous_hospitalization">
 127                 <option <?php if ($obj["previous_hospitalization"]=='no') print 'selected'; ?>>no
 128                 <option <?php if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?>>yes
 129                 </SELECT>
 130         </TD>
 131         <TD>Siblings affected?:</TD>
 132         <TD>
 133                 <SELECT NAME="siblings_affected">
 134                 <option <?php if ($obj["siblings_affected"]=='no') print 'selected'; ?>>no
 135                 <option <?php if ($obj["siblings_affected"]=='yes') print 'selected'; ?>>yes
 136                 </SELECT>
 137         </TD>
 138 </TR>
 139 <TR>
 140         <TD colspan=2>Immunization up to date:
 141                 <SELECT NAME="immunization_up_to_date">
 142                 <option <?php if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?>>yes
 143                 <option <?php if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?>>no
 144                 </SELECT>
 145         </TD>
 146         <TD colspan=4 align=left valign=top>Notes:
 147         <TEXTAREA NAME="notes" ROWS="3" COLS="40">
 148         <?php if ($obj["notes"]!='') print $obj["notes"]; ?>
 149         </TEXTAREA></TD>
 150 </TR>
 151 </TABLE>