contrib/forms/example2/print.php

   1 <?php
   2 /*
   3  * Sports Physical Form created by Jason Morrill: January 2009
   4  */
   5
   6 include_once("../../globals.php");
   7 include_once("$srcdir/api.inc");
   8
   9 /** CHANGE THIS - name of the database table associated with this form **/
  10 $table_name = "form_example";
  11
  12 /** CHANGE THIS name to the name of your form **/
  13 $form_name = "My Example Form";
  14
  15 /** CHANGE THIS to match the folder you created for this form **/
  16 $form_folder = "example";
  17
  18 formHeader("Form: ".$form_name);
  19 $returnurl = 'encounter_top.php';
  20
  21 /* load the saved record */
  22 $record = formFetch($table_name, $_GET["id"]);
  23
  24 /* remove the time-of-day from the date fields */
  25 if ($record['form_date'] != "") {
  26     $dateparts = explode(" ", $record['form_date']);
  27     $record['form_date'] = $dateparts[0];
  28 }
  29
  30 if ($record['dob'] != "") {
  31     $dateparts = explode(" ", $record['dob']);
  32     $record['dob'] = $dateparts[0];
  33 }
  34
  35 if ($record['sig_date'] != "") {
  36     $dateparts = explode(" ", $record['sig_date']);
  37     $record['sig_date'] = $dateparts[0];
  38 }
  39 ?>
  40
  41 <html><head>
  42 <?php html_header_show();?>
  43
  44 <!-- supporting javascript code -->
  45 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-min-3-1-1/index.js"></script>
  46 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/textformat.js"></script>
  47
  48 <!-- page styles -->
  49 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  50 <link rel="stylesheet" href="../../forms/<?php echo $form_folder; ?>/style.css" type="text/css">
  51
  52 </head>
  53
  54 <body class="body_top">
  55
  56 Printed on <?php echo date("F d, Y", time()); ?>
  57
  58 <form method=post action="">
  59 <span class="title"><?php xl($form_name, 'e'); ?></span><br>
  60
  61 <!-- container for the main body of the form -->
  62 <div id="print_form_container">
  63
  64 <div id="print_general">
  65 <table>
  66 <tr><td>
  67 Date:
  68    <input type='text' size='10' name='form_date' id='form_date'
  69     value='<?php echo stripslashes($record['form_date']);?>'
  70     title='<?php xl('yyyy-mm-dd', 'e'); ?>'
  71     />
  72 </td></tr>
  73 <tr><td>
  74 Name: <input id="name" name="name" type="text" size="50" maxlength="250" value="<?php echo stripslashes($record['name']);?>">
  75 Date of Birth:
  76    <input type='text' size='10' name='dob' id='dob'
  77     value='<?php echo stripslashes($record['dob']);?>'
  78     title='<?php xl('yyyy-mm-dd Date of Birth', 'e'); ?>'
  79     />
  80 </td></tr>
  81 <tr><td>
  82 Phone: <input name="phone" id="phone" type="text" size="15" maxlength="15" value="<?php echo stripslashes($record['phone']);?>">
  83 </td></tr>
  84 <tr><td>
  85 Address: <input name="address" id="address" type="text" size="80" maxlength="250" value="<?php echo stripslashes($record['address']);?>">
  86 </td></tr>
  87 </table>
  88 </div>
  89
  90 <div id="print_bottom">
  91 Use this space to express notes <br>
  92 <textarea name="notes" id="notes" cols="80" rows="4"><?php echo stripslashes($record['notes']);?></textarea>
  93 <br><br>
  94 <div style="text-align:right;">
  95 Signature?
  96 <input type="radio" id="sig" name="sig" value="y" <?php if ($record["sig"] == 'y') {
  97     echo "CHECKED";
  98 } ?>>Yes
  99 /
 100 <input type="radio" id="sig" name="sig" value="n" <?php if ($record["sig"] == 'n') {
 101     echo "CHECKED";
 102 } ?>>No
 103 &nbsp;&nbsp;
 104 Date of signature:
 105    <input type='text' size='10' name='sig_date' id='sig_date'
 106     value='<?php echo stripslashes($record['sig_date']);?>'
 107     title='<?php xl('yyyy-mm-dd', 'e'); ?>' />
 108 </div>
 109 </div>
 110
 111 </div> <!-- end form_container -->
 112
 113 </form>
 114
 115 </body>
 116
 117 <script language="javascript">
 118 window.print();
 119 window.close();
 120 </script>
 121
 122 </html>