contrib/forms/ped_fever/form.php

   1 <?php
   2
   3 /*
   4 Pediatric Fever form
   5 This form works as new and editing,
   6 */
   7 ?>
   8 <TABLE span class=text>
   9 <th><H2><U>Pediatric Fever Form</U></H2></th>
  10 <TR>
  11     <TD>Fever: </TD>
  12     <TD>
  13     <INPUT TYPE="text" NAME="fever_temp" value="<?php if ($obj["fever_temp"]!='') {
  14         print $obj["fever_temp"];
  15 } ?>">
  16     </TD>
  17     <TD>Measured:</TD>
  18     <TD>
  19         <SELECT NAME="measured">
  20         <option <?php if ($obj["measured"]=='axillary') {
  21             print 'selected' ;
  22 }?> >axillary
  23         <option <?php if ($obj["measured"]=='oral') {
  24             print 'selected' ;
  25 }?> >oral
  26         <option <?php if ($obj["measured"]=='rectal') {
  27             print 'selected' ;
  28 }?> >rectal
  29         <option <?php if ($obj["measured"]=='not measured') {
  30             print 'selected' ;
  31 }?> >not measured
  32         </SELECT>
  33     </TD>
  34     <TD>Duration:</TD>
  35     <TD>
  36         <SELECT NAME="duration">
  37         <option <?php if ($obj["duration"]=='one hour') {
  38             print 'selected';
  39 } ?>>one hour
  40         <option <?php if ($obj["duration"]=='twelve hours') {
  41             print 'selected';
  42 } ?>>twelve hours
  43         <option <?php if ($obj["duration"]=='one day') {
  44             print 'selected';
  45 } ?>>one day
  46         <option <?php if ($obj["duration"]=='two days') {
  47             print 'selected';
  48 } ?>>two days
  49         <option <?php if ($obj["duration"]=='three days') {
  50             print 'selected';
  51 } ?>>three days
  52         <option <?php if ($obj["duration"]=='more than 3 days') {
  53             print 'selected';
  54 } ?>>more than 3 days
  55         </SELECT>
  56     </TD>
  57 </TR>
  58 <TR>
  59     <TD>Takink Medication:</TD>
  60     <TD>
  61         <SELECT NAME="taking_medication">
  62         <option <?php if ($obj["taking_medication"]=='no') {
  63             print 'selected';
  64 } ?>>no
  65         <option <?php if ($obj["taking_medication"]=='yes') {
  66             print 'selected';
  67 } ?>>yes
  68     </TD>
  69     <TD>Responds to Tylenol:</TD>
  70     <TD>
  71         <SELECT NAME="responds_to_tylenol">
  72         <option <?php if ($obj["responds_to_tylenol"]=='n/a') {
  73             print 'selected';
  74 } ?>>n/a
  75         <option <?php if ($obj["responds_to_tylenol"]=='no') {
  76             print 'selected';
  77 } ?>>no
  78         <option <?php if ($obj["responds_to_tylenol"]=='yes') {
  79             print 'selected';
  80 } ?>>yes
  81     </TD>
  82     <TD>Responds to Molrtin</TD>
  83     <TD>
  84         <SELECT NAME="responds_to_moltrin">
  85         <option <?php if ($obj["responds_to_moltrin"]=='n/a') {
  86             print 'selected';
  87 } ?>>n/a
  88         <option <?php if ($obj["responds_to_moltrin"]=='no') {
  89             print 'selected';
  90 } ?>>no
  91         <option <?php if ($obj["responds_to_moltrin"]=='yes') {
  92             print 'selected';
  93 } ?>>yes
  94
  95     </TD>
  96 </TR>
  97 </TR>
  98     <TD >Pain:</TD>
  99     <TD>
 100         <SELECT NAME="pain">
 101         <option <?php if ($obj["pain"]=='no pain') {
 102             print 'selected' ;
 103 }?> >no pain
 104         <option <?php if ($obj["pain"]=='moderate') {
 105             print 'selected';
 106 } ?>>moderate
 107         <option <?php if ($obj["pain"]=='intense') {
 108             print 'selected';
 109 } ?>>intense
 110         <option <?php if ($obj["pain"]=='severe') {
 111             print 'selected';
 112 } ?>>severe
 113         </SELECT>
 114     </TD>
 115     <TD >Lethargy:</TD>
 116     <TD>
 117         <SELECT NAME="lethargy">
 118         <option <?php if ($obj["lethargy"]=='no') {
 119             print 'selected';
 120 } ?>>no
 121         <option <?php if ($obj["lethargy"]=='yes') {
 122             print 'selected';
 123 } ?>>yes
 124         </SELECT>
 125     </TD>
 126     <TD >Vomiting:</TD>
 127     <TD>
 128         <SELECT NAME="vomiting">
 129         <option <?php if ($obj["vomiting"]=='no') {
 130             print 'selected';
 131 } ?>>no
 132         <option <?php if ($obj["vomiting"]=='yes') {
 133             print 'selected';
 134 } ?>>yes
 135         </SELECT>
 136     </TD>
 137 </TR>
 138
 139 <TR>
 140     <TD colspan=2 >Able to take oral hydration:</TD>
 141     <TD>
 142         <SELECT NAME="oral_hydration_capable">
 143         <option <?php if ($obj["oral_hydration_capable"]=='yes') {
 144             print 'selected';
 145 } ?>>yes
 146         <option <?php if ($obj["oral_hydration_capable"]=='no') {
 147             print 'selected';
 148 } ?>>no
 149         </SELECT>
 150     </TD>
 151     <TD colspan=2 >Urine output at least every 6 hrs.</TD>
 152     <TD>
 153         <SELECT NAME="urine_output_last_6_hours">
 154         <option <?php if ($obj["urine_output_last_6_hours"]=='yes') {
 155             print 'selected';
 156 } ?>>yes
 157         <option <?php if ($obj["urine_output_last_6_hours"]=='no') {
 158             print 'selected';
 159 } ?>>no
 160         </SELECT>
 161         With Pain?:
 162         <SELECT NAME="pain_with_urination">
 163         <option <?php if ($obj["pain_with_urination"]=='no') {
 164             print 'selected';
 165 } ?>>no
 166         <option <?php if ($obj["pain_with_urination"]=='yes') {
 167             print 'selected';
 168 } ?>>yes
 169         </SELECT>
 170
 171     </TD>
 172 </TR>
 173 <TR>
 174     <TD colspan=2 >Cough or difficulty breathing:</TD>
 175     <TD>
 176         <SELECT NAME="cough_or_breathing_difficulty">
 177         <option <?php if ($obj["cough_or_breathing_difficulty"]=='no') {
 178             print 'selected';
 179 } ?>>no
 180         <option <?php if ($obj["cough_or_breathing_difficulty"]=='yes') {
 181             print 'selected';
 182 } ?>>yes
 183         </SELECT>
 184     </TD>
 185     <TD colspan=2 >Able to sleep confortably</TD>
 186     <TD>
 187         <SELECT NAME="able_to_sleep">
 188         <option <?php if ($obj["able_to_sleep"]=='yes') {
 189             print 'selected';
 190 } ?>>yes
 191         <option <?php if ($obj["able_to_sleep"]=='no') {
 192             print 'selected';
 193 } ?>>no
 194         </SELECT>
 195     </TD>
 196 </TR>
 197 <TR>
 198     <TD>Nasal Discharge:</TD>
 199     <TD>
 200         <SELECT NAME="nasal_discharge">
 201         <option <?php if ($obj["nasal_discharge"]=='no') {
 202             print 'selected';
 203 } ?>>no
 204         <option <?php if ($obj["nasal_discharge"]=='yes') {
 205             print 'selected';
 206 } ?>>yes
 207         </SELECT>
 208     </TD>
 209     <TD>Prior Hospitalization</TD>
 210     <TD>
 211         <SELECT NAME="previous_hospitalization">
 212         <option <?php if ($obj["previous_hospitalization"]=='no') {
 213             print 'selected';
 214 } ?>>no
 215         <option <?php if ($obj["previous_hospitalization"]=='yes') {
 216             print 'selected';
 217 } ?>>yes
 218         </SELECT>
 219     </TD>
 220     <TD>Siblings affected?:</TD>
 221     <TD>
 222         <SELECT NAME="siblings_affected">
 223         <option <?php if ($obj["siblings_affected"]=='no') {
 224             print 'selected';
 225 } ?>>no
 226         <option <?php if ($obj["siblings_affected"]=='yes') {
 227             print 'selected';
 228 } ?>>yes
 229         </SELECT>
 230     </TD>
 231 </TR>
 232 <TR>
 233     <TD colspan=2 valign="top">Immunization up to date:
 234         <SELECT NAME="immunization_up_to_date">
 235         <option <?php if ($obj["immunization_up_to_date"]=='yes') {
 236             print 'selected';
 237 } ?>>yes
 238         <option <?php if ($obj["immunization_up_to_date"]=='no') {
 239             print 'selected';
 240 } ?>>no
 241         </SELECT>
 242     </TD>
 243     <TD colspan=4 align=left valign=top>Notes:
 244     <TEXTAREA NAME="notes" ROWS="3" COLS="40">
 245     <?php if ($obj["notes"]!='') {
 246         print $obj["notes"];
 247 } ?>
 248     </TEXTAREA></TD>
 249 </TR>
 250 </TABLE>
 251
 252