contrib/forms/hearingtest/view.php

   1 <?php
   2 /**
   3  * Generated DocBlock
   4  *
   5  * @package OpenEMR
   6  * @link    http://www.open-emr.org
   7  * @author  andres_paglayan <andres_paglayan>
   8  * @author  cornfeed <jdough823@gmail.com>
   9  * @author  fndtn357 <fndtn357@gmail.com>
  10  * @author  Robert Down <robertdown@live.com>
  11  * @author  sunsetsystems <sunsetsystems>
  12  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  13  * @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
  14  * @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
  15  * @copyright Copyright (c) 2017 Robert Down <robertdown@live.com>
  16  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  17  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  18  */
  19 ?>
  20 <!-- Forms generated from formsWiz -->
  21 <?php
  22 include_once("../../globals.php");
  23 ?>
  24 <html><head>
  25 <?php html_header_show();?>
  26 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  27 </head>
  28 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  29 <?php
  30 include_once("$srcdir/api.inc");
  31 $obj = formFetch("form_hearingtest", $_GET["id"]);
  32 ?>
  33 <form method=post action="<?php echo $rootdir?>/forms/hearingtest/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  34 <span class="title">Hearing Test</span><Br><br>
  35 <input type=checkbox name="with_hearing_aid"  <?php if ($obj{"with_hearing_aid"} == "on") {
  36     echo "checked";
  37 };?>><span class=text>With hearing Aid?</span><br>
  38 <table>
  39 <tr>
  40 <td>
  41 <span class=text>Right Ear 250: </span><input type=entry name="right_ear_250" value="<?php echo $obj{"right_ear_250"};?>" ><br>
  42 <span class=text>Right Ear 500: </span><input type=entry name="right_ear_500" value="<?php echo $obj{"right_ear_500"};?>" ><br>
  43 <span class=text>Right Ear 1000: </span><input type=entry name="right_ear_1000" value="<?php echo $obj{"right_ear_1000"};?>" ><br>
  44 <span class=text>Right Ear 2000: </span><input type=entry name="right_ear_2000" value="<?php echo $obj{"right_ear_2000"};?>" ><br>
  45 <span class=text>Right Ear 3000: </span><input type=entry name="right_ear_3000" value="<?php echo $obj{"right_ear_3000"};?>" ><br>
  46 <span class=text>Right Ear 4000: </span><input type=entry name="right_ear_4000" value="<?php echo $obj{"right_ear_4000"};?>" ><br>
  47 <span class=text>Right Ear 5000: </span><input type=entry name="right_ear_5000" value="<?php echo $obj{"right_ear_5000"};?>" ><br>
  48 <span class=text>Right Ear 6000: </span><input type=entry name="right_ear_6000" value="<?php echo $obj{"right_ear_6000"};?>" ><br>
  49 </td>
  50 <td>
  51 <span class=text>Left Ear 250: </span><input type=entry name="left_ear_250" value="<?php echo $obj{"left_ear_250"};?>" ><br>
  52 <span class=text>Left Ear 500: </span><input type=entry name="left_ear_500" value="<?php echo $obj{"left_ear_500"};?>" ><br>
  53 <span class=text>Left Ear 1000: </span><input type=entry name="left_ear_1000" value="<?php echo $obj{"left_ear_1000"};?>" ><br>
  54 <span class=text>Left Ear 2000: </span><input type=entry name="left_ear_2000" value="<?php echo $obj{"left_ear_2000"};?>" ><br>
  55 <span class=text>Left Ear 3000: </span><input type=entry name="left_ear_3000" value="<?php echo $obj{"left_ear_3000"};?>" ><br>
  56 <span class=text>Left Ear 4000: </span><input type=entry name="left_ear_4000" value="<?php echo $obj{"left_ear_4000"};?>" ><br>
  57 <span class=text>Left Ear 5000: </span><input type=entry name="left_ear_5000" value="<?php echo $obj{"left_ear_5000"};?>" ><br>
  58 <span class=text>Left Ear 6000: </span><input type=entry name="left_ear_6000" value="<?php echo $obj{"left_ear_6000"};?>" ><br>
  59 </td>
  60 </tr>
  61 </table>
  62 <br>
  63 <table>
  64 <tr>
  65 <td valign=top>
  66 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?php echo $obj{"additional_notes"};?></textarea><br>
  67 </td>
  68 </tr>
  69 </table>
  70
  71 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  72 <br>
  73 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
  74 </form>
  75 <?php
  76 formFooter();
  77 ?>