contrib/forms/ped_GI/form.php

   1 <?
   2 /*
   3 Pediatric GI assesment
   4 This form works as new and editing,
   5 */
   6 ?>
   7 <TABLE span class=text>
   8 <th><H2><U>Pediatric GI Form</U></H2></th>
   9
  10 <TR>
  11         <TD>Has Diarrhea:</TD>
  12         <TD>
  13                 <SELECT NAME="diarrhea">
  14                 <option <? if ($obj["diarrhea"]=='no') print 'selected'; ?>>no
  15                 <option <? if ($obj["diarrhea"]=='yes') print 'selected'; ?>>yes
  16                 </SELECT>
  17         </TD>
  18         <TD>Every bowel movement:</TD>
  19         <TD>
  20                 <SELECT NAME="with_every_bowel_movement">
  21                 <option <? if ($obj["with_every_bowel_movement"]=='n/a') print 'selected'; ?>>n/a
  22                 <option <? if ($obj["with_every_bowel_movement"]=='no') print 'selected'; ?>>no
  23                 <option <? if ($obj["with_every_bowel_movement"]=='yes') print 'selected'; ?>>yes
  24                 </SELECT>
  25         </TD>
  26         <TD>After Every meal:</TD>
  27         <TD>
  28                 <SELECT NAME="after_every_meal">
  29                 <option <? if ($obj["after_every_meal"]=='n/a') print 'selected'; ?>>n/a
  30                 <option <? if ($obj["after_every_meal"]=='no') print 'selected'; ?>>no
  31                 <option <? if ($obj["after_every_meal"]=='yes') print 'selected'; ?>>yes
  32                 </SELECT>
  33         </TD>
  34 </TD>
  35 <TR>
  36         <TD>Blood or mocus in stool:</TD>
  37         <TD>
  38                 <SELECT NAME="blood_or_mucus_in_stool">
  39                 <option <? if ($obj["blood_or_mucus_in_stool"]=='no') print 'selected'; ?>>no
  40                 <option <? if ($obj["blood_or_mucus_in_stool"]=='blood') print 'selected'; ?>>blood
  41                 <option <? if ($obj["blood_or_mucus_in_stool"]=='mucus') print 'selected'; ?>>mucus
  42                 <option <? if ($obj["blood_or_mucus_in_stool"]=='both') print 'selected'; ?>>both
  43                 </SELECT>
  44         </TD>
  45         <TD>Onset:</TD>
  46         <TD>
  47                 <SELECT NAME="diarrhea_onset">
  48                 <option <? if ($obj["diarrhea_onset"]=='one hour') print 'selected'; ?>>one hour
  49                 <option <? if ($obj["diarrhea_onset"]=='twelve hours') print 'selected'; ?>>twelve hours
  50                 <option <? if ($obj["diarrhea_onset"]=='one day') print 'selected'; ?>>one day
  51                 <option <? if ($obj["diarrhea_onset"]=='two days') print 'selected'; ?>>two days
  52                 <option <? if ($obj["diarrhea_onset"]=='three days') print 'selected'; ?>>three days
  53                 <option <? if ($obj["diarrhea_onset"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  54                 </SELECT>
  55         </TD>
  56         <TD>Worms:</TD>
  57         <TD>
  58                 <SELECT NAME="worms">
  59                 <option <? if ($obj["worms"]=='no') print 'selected'; ?>>no
  60                 <option <? if ($obj["worms"]=='yes') print 'selected'; ?>>yes
  61                 </SELECT>
  62         </TD>
  63 </TR>
  64
  65 <TR>
  66         <TD>Vomiting:</TD>
  67         <TD>
  68                 <SELECT NAME="vomits">
  69                 <option <? if ($obj["vomits"]=='no') print 'selected'; ?>>no
  70                 <option <? if ($obj["vomits"]=='yes') print 'selected'; ?>>yes
  71                 </SELECT>
  72         </TD>
  73         <TD>Duration:</TD>
  74         <TD>
  75                 <SELECT NAME="duration">
  76                 <option <? if ($obj["duration"]=='one hour') print 'selected'; ?>>one hour
  77                 <option <? if ($obj["duration"]=='twelve hours') print 'selected'; ?>>twelve hours
  78                 <option <? if ($obj["duration"]=='one day') print 'selected'; ?>>one day
  79                 <option <? if ($obj["duration"]=='two days') print 'selected'; ?>>two days
  80                 <option <? if ($obj["duration"]=='three days') print 'selected'; ?>>three days
  81                 <option <? if ($obj["duration"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  82                 </SELECT>
  83         </TD>
  84         <TD >Proyectile:</TD>
  85         <TD>
  86                 <SELECT NAME="projectile">
  87                 <option <? if ($obj["projectile"]=='n/a') print 'selected'; ?>>n/a
  88                 <option <? if ($obj["projectile"]=='no') print 'selected'; ?>>no
  89                 <option <? if ($obj["projectile"]=='yes') print 'selected'; ?>>yes
  90                 </SELECT>
  91         </TD>
  92 </TR>
  93 <TR>
  94         <TD >+ often than 2 hours:</TD>
  95         <TD>
  96                 <SELECT NAME="more_often_than_2_hours">
  97                 <option <? if ($obj["more_often_than_2_hours"]=='n/a') print 'selected' ;?> >n/a
  98                 <option <? if ($obj["more_often_than_2_hours"]=='no') print 'selected' ;?> >no
  99                 <option <? if ($obj["more_often_than_2_hours"]=='yes') print 'selected'; ?>>yes
 100                 </SELECT>
 101         </TD>
 102         <TD >After every meal:</TD>
 103         <TD>
 104                 <SELECT NAME="vomit_after_every_meal">
 105                 <option <? if ($obj["vomit_after_every_meal"]=='n/a') print 'selected' ;?> >n/a
 106                 <option <? if ($obj["vomit_after_every_meal"]=='no') print 'selected' ;?> >no
 107                 <option <? if ($obj["vomit_after_every_meal"]=='yes') print 'selected'; ?>>yes
 108                 </SELECT>
 109         </TD>
 110         <TD >Blood in vomitus:</TD>
 111         <TD>
 112                 <SELECT NAME="blood_in_vomitus">
 113                 <option <? if ($obj["blood_in_vomitus"]=='n/a') print 'selected' ;?> >n/a
 114                 <option <? if ($obj["blood_in_vomitus"]=='no') print 'selected' ;?> >no
 115                 <option <? if ($obj["blood_in_vomitus"]=='yes') print 'selected'; ?>>yes
 116                 </SELECT>
 117         </TD>
 118 </TR>
 119
 120 <TR>
 121         <TD>Takink Medication:</TD>
 122         <TD>
 123                 <SELECT NAME="taking_medication">
 124                 <option <? if ($obj["taking_medication"]=='no') print 'selected'; ?>>no
 125                 <option <? if ($obj["taking_medication"]=='yes') print 'selected'; ?>>yes
 126         </TD>
 127         <TD>Oral Rehidration solution:</TD>
 128         <TD>
 129                 <SELECT NAME="oral_rehydration">
 130                 <option <? if ($obj["taking_oral_rehydration_solution"]=='yes') print 'selected'; ?>>yes
 131                 <option <? if ($obj["taking_oral_rehydration_solution"]=='no') print 'selected'; ?>>no
 132         </TD>
 133         <TD>Eating Solid Food</TD>
 134         <TD>
 135                 <SELECT NAME="eating_solid_food">
 136                 <option <? if ($obj["eating_solid_food"]=='yes') print 'selected'; ?>>yes
 137                 <option <? if ($obj["eating_solid_food"]=='no') print 'selected'; ?>>no
 138         </TD>
 139 </TR>
 140 <TR>
 141         <TD>Fever: </TD>
 142         <TD>
 143                 <SELECT NAME="fever">
 144                 <option <? if ($obj["fever"]=='no') print 'selected' ;?> >no
 145                 <option <? if ($obj["fever"]=='yes') print 'selected'; ?>>yes
 146                 </SELECT>
 147         </TD>
 148         <TD >Pain:</TD>
 149         <TD>
 150                 <SELECT NAME="pain">
 151                 <option <? if ($obj["pain"]=='no pain') print 'selected' ;?> >no pain
 152                 <option <? if ($obj["pain"]=='moderate') print 'selected'; ?>>moderate
 153                 <option <? if ($obj["pain"]=='intense') print 'selected'; ?>>intense
 154                 <option <? if ($obj["pain"]=='severe') print 'selected'; ?>>severe
 155                 </SELECT>
 156         </TD>
 157         <TD >Lethargy:</TD>
 158         <TD>
 159                 <SELECT NAME="lethargy">
 160                 <option <? if ($obj["lethargy"]=='no') print 'selected'; ?>>no
 161                 <option <? if ($obj["lethargy"]=='yes') print 'selected'; ?>>yes
 162                 </SELECT>
 163         </TD>
 164 </TR>
 165 <!-- common -->
 166 <TR>
 167         <TD>Oral hydration capable:</TD>
 168         <TD>
 169                 <SELECT NAME="oral_hydration_capable">
 170                 <option <? if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?>>yes
 171                 <option <? if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?>>no
 172                 </SELECT>
 173         </TD>
 174         <TD>Urine output at least every 6 hrs.</TD>
 175         <TD>
 176                 <SELECT NAME="urine_output_last_6_hours">
 177                 <option <? if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?>>yes
 178                 <option <? if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?>>no
 179                 </SELECT>
 180         <TD>With Pain?:</TD>
 181         <TD>
 182                 <SELECT NAME="pain_with_urination">
 183                 <option <? if ($obj["pain_with_urination"]=='no') print 'selected'; ?>>no
 184                 <option <? if ($obj["pain_with_urination"]=='yes') print 'selected'; ?>>yes
 185                 </SELECT>
 186         </TD>
 187 </TR>
 188 <TR>
 189         <TD>Cough or difficulty breathing:</TD>
 190         <TD>
 191                 <SELECT NAME="cough_or_breathing_difficulty">
 192                 <option <? if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?>>no
 193                 <option <? if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?>>yes
 194                 </SELECT>
 195         </TD>
 196         <TD>Sleeps confortably?:</TD>
 197         <TD>
 198                 <SELECT NAME="able_to_sleep">
 199                 <option <? if ($obj["able_to_sleep"]=='yes') print 'selected'; ?>>yes
 200                 <option <? if ($obj["able_to_sleep"]=='no') print 'selected'; ?>>no
 201                 </SELECT>
 202         </TD>
 203 </TR>
 204 <TR>
 205         <TD>Nasal Discharge:</TD>
 206         <TD>
 207                 <SELECT NAME="nasal_discharge">
 208                 <option <? if ($obj["nasal_discharge"]=='no') print 'selected'; ?>>no
 209                 <option <? if ($obj["nasal_discharge"]=='yes') print 'selected'; ?>>yes
 210                 </SELECT>
 211         </TD>
 212         <TD>Prior Hospitalization</TD>
 213         <TD>
 214                 <SELECT NAME="previous_hospitalization">
 215                 <option <? if ($obj["previous_hospitalization"]=='no') print 'selected'; ?>>no
 216                 <option <? if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?>>yes
 217                 </SELECT>
 218         </TD>
 219         <TD>Siblings affected?:</TD>
 220         <TD>
 221                 <SELECT NAME="siblings_affected">
 222                 <option <? if ($obj["siblings_affected"]=='no') print 'selected'; ?>>no
 223                 <option <? if ($obj["siblings_affected"]=='yes') print 'selected'; ?>>yes
 224                 </SELECT>
 225         </TD>
 226 </TR>
 227 <TR>
 228         <TD valign="top">Immunization up to date:</TD>
 229         <TD valign="top">
 230                 <SELECT NAME="immunization_up_to_date">
 231                 <option <? if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?>>yes
 232                 <option <? if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?>>no
 233                 </SELECT>
 234         </TD>
 235         <TD colspan=4 align=left valign=top>Notes:
 236         <TEXTAREA NAME="notes" ROWS="3" COLS="40"><? if ($obj["notes"]!='') print $obj["notes"]; ?></TEXTAREA></TD>
 237 </TR>
 238 </TABLE>
 239
 240