1 <!-- Form generated from formsWiz
-->
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: pain");
8 <?php
html_header_show();?
>
9 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
11 <body
class="body_top">
12 <form method
=post action
="<?php echo $rootdir;?>/forms/pain/save.php?mode=new" name
="my_form">
13 <span
class="title">Pain Evaluation
</span
><br
><br
>
16 <input type
=checkbox name
='dull' ><span
class=text
>Dull
</span
>
17 <input type
=checkbox name
='colicky' ><span
class=text
>Colicky
</span
>
18 <input type
=checkbox name
='sharp' ><span
class=text
>Sharp
</span
>
19 <span
class=text
>Duration of Pain
: </span
><input type
=entry name
="duration_of_pain" value
="" ><br
>
22 <span
class=text
>History of Pain
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="history_of_pain" ></textarea
><br
>
27 <td
><span
class=text
>Accompanying Symptoms Vomitting
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_vomitting" value
="" ></td
>
29 <td
><span
class=text
>Accompanying Symptoms Nausea
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_nausea" value
="" ></td
>
31 <td
><span
class=text
>Accompanying Symptoms Headache
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_headache" value
="" ></td
>
34 <span
class=text
>Accompanying Symptoms Other
: </span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="accompanying_symptoms_other" ></textarea
><br
>
39 <span
class=text
>Pain Referred to Other Sites?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="pain_referred_to_other_sites" ></textarea
>
41 <span
class=text
>What Relieves Pain?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="what_relieves_pain" ></textarea
>
43 <span
class=text
>What Makes Pain
Worse (Movement
/Positions
/Activities
)?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="what_makes_pain_worse" ></textarea
>
45 <span
class=text
>Additional Notes
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="additional_notes" ></textarea
>
49 <a href
="javascript:document.my_form.submit();" class="link_submit">[Save
]</a
>
51 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[Don
't Save]</a>