contrib/forms/reviewofs/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  cfapress <cfapress>
   9  * @author  Robert Down <robertdown@live.com>
  10  * @author  sunsetsystems <sunsetsystems>
  11  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  12  * @copyright Copyright (c) 2008 cfapress <cfapress>
  13  * @copyright Copyright (c) 2017 Robert Down <robertdown@live.com>
  14  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  15  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  16  */
  17 ?>
  18 <?php
  19 include_once("../../globals.php");
  20 ?>
  21 <html><head>
  22 <?php html_header_show();?>
  23 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  24 </head>
  25 <body class="body_top">
  26 <?php
  27 include_once("$srcdir/api.inc");
  28 $obj = formFetch("form_reviewofs", $_GET["id"]);
  29 ?>
  30 <form method=post action="<?php echo $rootdir?>/forms/reviewofs/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  31 <span class="title">Review of Systems Checks</span><Br><br>
  32
  33 <table>
  34 <tr>
  35 <td valign=top>
  36 <span class=bold>General</span><br>
  37 <input type=checkbox name="fever"  <?php if ($obj{"fever"} == "on") {
  38     echo "checked";
  39 };?>><span class=text>Fever</span><br>
  40 <input type=checkbox name="chills"  <?php if ($obj{"chills"} == "on") {
  41     echo "checked";
  42 };?>><span class=text>Chills</span><br>
  43 <input type=checkbox name="night_sweats"  <?php if ($obj{"night_sweats"} == "on") {
  44     echo "checked";
  45 };?>><span class=text>Night Sweats</span><br>
  46 <input type=checkbox name="weight_loss"  <?php if ($obj{"weight_loss"} == "on") {
  47     echo "checked";
  48 };?>><span class=text>Weight Loss</span><br>
  49 <input type=checkbox name="poor_appetite"  <?php if ($obj{"poor_appetite"} == "on") {
  50     echo "checked";
  51 };?>><span class=text>Poor Appetite</span><br>
  52 <input type=checkbox name="insomnia"  <?php if ($obj{"insomnia"} == "on") {
  53     echo "checked";
  54 };?>><span class=text>Insomnia</span><br>
  55 <input type=checkbox name="fatigued"  <?php if ($obj{"fatigued"} == "on") {
  56     echo "checked";
  57 };?>><span class=text>Fatigued</span><br>
  58 <input type=checkbox name="depressed"  <?php if ($obj{"depressed"} == "on") {
  59     echo "checked";
  60 };?>><span class=text>Depressed</span><br>
  61 <input type=checkbox name="hyperactive"  <?php if ($obj{"hyperactive"} == "on") {
  62     echo "checked";
  63 };?>><span class=text>Hyperactive</span><br>
  64 <input type=checkbox name="exposure_to_foreign_countries"  <?php if ($obj{"exposure_to_foreign_countries"} == "on") {
  65     echo "checked";
  66 };?>><span class=text>Exposure to Foreign Countries</span><br>
  67 <span class=bold>Skin</span><br>
  68 <input type=checkbox name="rashes"  <?php if ($obj{"rashes"} == "on") {
  69     echo "checked";
  70 };?>><span class=text>Rashes</span><br>
  71 <input type=checkbox name="infections"  <?php if ($obj{"infections"} == "on") {
  72     echo "checked";
  73 };?>><span class=text>Infections</span><br>
  74 <input type=checkbox name="ulcerations"  <?php if ($obj{"ulcerations"} == "on") {
  75     echo "checked";
  76 };?>><span class=text>Ulcerations</span><br>
  77 <input type=checkbox name="pemphigus"  <?php if ($obj{"pemphigus"} == "on") {
  78     echo "checked";
  79 };?>><span class=text>Pemphigus</span><br>
  80 <input type=checkbox name="herpes"  <?php if ($obj{"herpes"} == "on") {
  81     echo "checked";
  82 };?>><span class=text>Herpes</span><br>
  83 </td>
  84 <td valign=top>
  85 <span class=bold>HEENT</span><br>
  86 <input type=checkbox name="cataracts"  <?php if ($obj{"cataracts"} == "on") {
  87     echo "checked";
  88 };?>><span class=text>Cataracts</span><br>
  89 <input type=checkbox name="cataract_surgery"  <?php if ($obj{"cataract_surgery"} == "on") {
  90     echo "checked";
  91 };?>><span class=text>Cataract Surgery</span><br>
  92 <input type=checkbox name="glaucoma"  <?php if ($obj{"glaucoma"} == "on") {
  93     echo "checked";
  94 };?>><span class=text>Glaucoma</span><br>
  95 <input type=checkbox name="double_vision"  <?php if ($obj{"double_vision"} == "on") {
  96     echo "checked";
  97 };?>><span class=text>Double Vision</span><br>
  98 <input type=checkbox name="blurred_vision"  <?php if ($obj{"blurred_vision"} == "on") {
  99     echo "checked";
 100 };?>><span class=text>Blurred Vision</span><br>
 101 <input type=checkbox name="poor_hearing"  <?php if ($obj{"poor_hearing"} == "on") {
 102     echo "checked";
 103 };?>><span class=text>Poor Hearing</span><br>
 104 <input type=checkbox name="headaches"  <?php if ($obj{"headaches"} == "on") {
 105     echo "checked";
 106 };?>><span class=text>Headaches</span><br>
 107 <input type=checkbox name="ringing_in_ears"  <?php if ($obj{"ringing_in_ears"} == "on") {
 108     echo "checked";
 109 };?>><span class=text>Ringing in Ears</span><br>
 110 <input type=checkbox name="bloody_nose"  <?php if ($obj{"bloody_nose"} == "on") {
 111     echo "checked";
 112 };?>><span class=text>Bloody Nose</span><br>
 113 <input type=checkbox name="sinusitis"  <?php if ($obj{"sinusitis"} == "on") {
 114     echo "checked";
 115 };?>><span class=text>Sinusitis</span><br>
 116 <input type=checkbox name="sinus_surgery"  <?php if ($obj{"sinus_surgery"} == "on") {
 117     echo "checked";
 118 };?>><span class=text>Sinus Surgery</span><br>
 119 <input type=checkbox name="dry_mouth"  <?php if ($obj{"dry_mouth"} == "on") {
 120     echo "checked";
 121 };?>><span class=text>Dry Mouth</span><br>
 122 <input type=checkbox name="strep_throat"  <?php if ($obj{"strep_throat"} == "on") {
 123     echo "checked";
 124 };?>><span class=text>Strep Throat</span><br>
 125 <input type=checkbox name="tonsillectomy"  <?php if ($obj{"tonsillectomy"} == "on") {
 126     echo "checked";
 127 };?>><span class=text>Tonsillectomy</span><br>
 128 <input type=checkbox name="swollen_lymph_nodes"  <?php if ($obj{"swollen_lymph_nodes"} == "on") {
 129     echo "checked";
 130 };?>><span class=text>Swollen Lymph Nodes</span><br>
 131 <input type=checkbox name="throat_cancer"  <?php if ($obj{"throat_cancer"} == "on") {
 132     echo "checked";
 133 };?>><span class=text>Throat Cancer</span><br>
 134 <input type=checkbox name="throat_cancer_surgery"  <?php if ($obj{"throat_cancer_surgery"} == "on") {
 135     echo "checked";
 136 };?>><span class=text>Throat Cancer Surgery</span><br>
 137 </td>
 138 <td valign=top>
 139 <span class=bold>Cardiovascular</span><br>
 140 <input type=checkbox name="heart_attack"  <?php if ($obj{"heart_attack"} == "on") {
 141     echo "checked";
 142 };?>><span class=text>Heart Attack</span><br>
 143 <input type=checkbox name="irregular_heart_beat"  <?php if ($obj{"irregular_heart_beat"} == "on") {
 144     echo "checked";
 145 };?>><span class=text>Irregular Heart Beat</span><br>
 146 <input type=checkbox name="chest_pains"  <?php if ($obj{"chest_pains"} == "on") {
 147     echo "checked";
 148 };?>><span class=text>Chest Pains</span><br>
 149 <input type=checkbox name="shortness_of_breath"  <?php if ($obj{"shortness_of_breath"} == "on") {
 150     echo "checked";
 151 };?>><span class=text>Shortness of Breath</span><br>
 152 <input type=checkbox name="high_blood_pressure"  <?php if ($obj{"high_blood_pressure"} == "on") {
 153     echo "checked";
 154 };?>><span class=text>High Blood Pressure</span><br>
 155 <input type=checkbox name="heart_failure"  <?php if ($obj{"heart_failure"} == "on") {
 156     echo "checked";
 157 };?>><span class=text>Heart Failure</span><br>
 158 <input type=checkbox name="poor_circulation"  <?php if ($obj{"poor_circulation"} == "on") {
 159     echo "checked";
 160 };?>><span class=text>Poor Circulation</span><br>
 161 <input type=checkbox name="vascular_surgery"  <?php if ($obj{"vascular_surgery"} == "on") {
 162     echo "checked";
 163 };?>><span class=text>Vascular Surgery</span><br>
 164 <input type=checkbox name="cardiac_catheterization"  <?php if ($obj{"cardiac_catheterization"} == "on") {
 165     echo "checked";
 166 };?>><span class=text>Cardiac Catheterization</span><br>
 167 <input type=checkbox name="coronary_artery_bypass"  <?php if ($obj{"coronary_artery_bypass"} == "on") {
 168     echo "checked";
 169 };?>><span class=text>Coronary Artery Bypass</span><br>
 170 <input type=checkbox name="heart_transplant"  <?php if ($obj{"heart_transplant"} == "on") {
 171     echo "checked";
 172 };?>><span class=text>Heart Transplant</span><br>
 173 <input type=checkbox name="stress_test"  <?php if ($obj{"stress_test"} == "on") {
 174     echo "checked";
 175 };?>><span class=text>Stress Test</span><br>
 176 <span class=bold>Endocrine</span><br>
 177 <input type=checkbox name="insulin_dependent_diabetes"  <?php if ($obj{"insulin_dependent_diabetes"} == "on") {
 178     echo "checked";
 179 };?>><span class=text>Insulin Dependent Diabetes</span><br>
 180 <input type=checkbox name="noninsulin_dependent_diabetes"  <?php if ($obj{"noninsulin_dependent_diabetes"} == "on") {
 181     echo "checked";
 182 };?>><span class=text>Non-Insulin Dependent Diabetes</span><br>
 183 <input type=checkbox name="hypothyroidism"  <?php if ($obj{"hypothyroidism"} == "on") {
 184     echo "checked";
 185 };?>><span class=text>Hypothyroidism</span><br>
 186 <input type=checkbox name="hyperthyroidism"  <?php if ($obj{"hyperthyroidism"} == "on") {
 187     echo "checked";
 188 };?>><span class=text>Hyperthyroidism</span><br>
 189 <input type=checkbox name="cushing_syndrom"  <?php if ($obj{"cushing_syndrom"} == "on") {
 190     echo "checked";
 191 };?>><span class=text>Cushing Syndrom</span><br>
 192 <input type=checkbox name="addison_syndrom"  <?php if ($obj{"addison_syndrom"} == "on") {
 193     echo "checked";
 194 };?>><span class=text>Addison Syndrom</span><br>
 195 </td>
 196 <td valign=top>
 197 <span class=bold>Pulmonary</span><br>
 198 <input type=checkbox name="emphysema"  <?php if ($obj{"emphysema"} == "on") {
 199     echo "checked";
 200 };?>><span class=text>Emphysema</span><br>
 201 <input type=checkbox name="chronic_bronchitis"  <?php if ($obj{"chronic_bronchitis"} == "on") {
 202     echo "checked";
 203 };?>><span class=text>Chronic Bronchitis</span><br>
 204 <input type=checkbox name="interstitial_lung_disease"  <?php if ($obj{"interstitial_lung_disease"} == "on") {
 205     echo "checked";
 206 };?>><span class=text>Interstitial Lung Disease</span><br>
 207 <input type=checkbox name="shortness_of_breath_2"  <?php if ($obj{"shortness_of_breath_2"} == "on") {
 208     echo "checked";
 209 };?>><span class=text>Shortness of Breath</span><br>
 210 <input type=checkbox name="lung_cancer"  <?php if ($obj{"lung_cancer"} == "on") {
 211     echo "checked";
 212 };?>><span class=text>Lung Cancer</span><br>
 213 <input type=checkbox name="lung_cancer_surgery"  <?php if ($obj{"lung_cancer_surgery"} == "on") {
 214     echo "checked";
 215 };?>><span class=text>Lung Cancer Surgery</span><br>
 216 <input type=checkbox name="pheumothorax"  <?php if ($obj{"pheumothorax"} == "on") {
 217     echo "checked";
 218 };?>><span class=text>Pheumothorax</span><br>
 219 <span class=bold>Genitourinary</span><br>
 220 <input type=checkbox name="kidney_failure"  <?php if ($obj{"kidney_failure"} == "on") {
 221     echo "checked";
 222 };?>><span class=text>Kidney Failure</span><br>
 223 <input type=checkbox name="kidney_stones"  <?php if ($obj{"kidney_stones"} == "on") {
 224     echo "checked";
 225 };?>><span class=text>Kidney Stones</span><br>
 226 <input type=checkbox name="kidney_cancer"  <?php if ($obj{"kidney_cancer"} == "on") {
 227     echo "checked";
 228 };?>><span class=text>Kidney Cancer</span><br>
 229 <input type=checkbox name="kidney_infections"  <?php if ($obj{"kidney_infections"} == "on") {
 230     echo "checked";
 231 };?>><span class=text>Kidney Infections</span><br>
 232 <input type=checkbox name="bladder_infections"  <?php if ($obj{"bladder_infections"} == "on") {
 233     echo "checked";
 234 };?>><span class=text>Bladder Infections</span><br>
 235 <input type=checkbox name="bladder_cancer"  <?php if ($obj{"bladder_cancer"} == "on") {
 236     echo "checked";
 237 };?>><span class=text>Bladder Cancer</span><br>
 238 <input type=checkbox name="prostate_problems"  <?php if ($obj{"prostate_problems"} == "on") {
 239     echo "checked";
 240 };?>><span class=text>Prostate Problems</span><br>
 241 <input type=checkbox name="prostate_cancer"  <?php if ($obj{"prostate_cancer"} == "on") {
 242     echo "checked";
 243 };?>><span class=text>Prostate Cancer</span><br>
 244 <input type=checkbox name="kidney_transplant"  <?php if ($obj{"kidney_transplant"} == "on") {
 245     echo "checked";
 246 };?>><span class=text>Kidney Transplant</span><br>
 247 <input type=checkbox name="sexually_transmitted_disease"  <?php if ($obj{"sexually_transmitted_disease"} == "on") {
 248     echo "checked";
 249 };?>><span class=text>Sexually Transmitted Disease</span><br>
 250 <input type=checkbox name="burning_with_urination"  <?php if ($obj{"burning_with_urination"} == "on") {
 251     echo "checked";
 252 };?>><span class=text>Burning with Urination</span><br>
 253 <input type=checkbox name="discharge_from_urethra"  <?php if ($obj{"discharge_from_urethra"} == "on") {
 254     echo "checked";
 255 };?>><span class=text>Discharge From Urethra</span><br>
 256 </td>
 257 <td valign=top>
 258 <span class=bold>Gastrointestinal</span><br>
 259 <input type=checkbox name="stomach_pains"  <?php if ($obj{"stomach_pains"} == "on") {
 260     echo "checked";
 261 };?>><span class=text>Stomach Pains</span><br>
 262 <input type=checkbox name="peptic_ulcer_disease"  <?php if ($obj{"peptic_ulcer_disease"} == "on") {
 263     echo "checked";
 264 };?>><span class=text>Peptic Ulcer Disease</span><br>
 265 <input type=checkbox name="gastritis"  <?php if ($obj{"gastritis"} == "on") {
 266     echo "checked";
 267 };?>><span class=text>Gastritis</span><br>
 268 <input type=checkbox name="endoscopy"  <?php if ($obj{"endoscopy"} == "on") {
 269     echo "checked";
 270 };?>><span class=text>Endoscopy</span><br>
 271 <input type=checkbox name="polyps"  <?php if ($obj{"polyps"} == "on") {
 272     echo "checked";
 273 };?>><span class=text>Polyps</span><br>
 274 <input type=checkbox name="colonoscopy"  <?php if ($obj{"colonoscopy"} == "on") {
 275     echo "checked";
 276 };?>><span class=text>colonoscopy</span><br>
 277 <input type=checkbox name="colon_cancer"  <?php if ($obj{"colon_cancer"} == "on") {
 278     echo "checked";
 279 };?>><span class=text>Colon Cancer</span><br>
 280 <input type=checkbox name="colon_cancer_surgery"  <?php if ($obj{"colon_cancer_surgery"} == "on") {
 281     echo "checked";
 282 };?>><span class=text>Colon Cancer Surgery</span><br>
 283 <input type=checkbox name="ulcerative_colitis"  <?php if ($obj{"ulcerative_colitis"} == "on") {
 284     echo "checked";
 285 };?>><span class=text>Ulcerative Colitis</span><br>
 286 <input type=checkbox name="crohns_disease"  <?php if ($obj{"crohns_disease"} == "on") {
 287     echo "checked";
 288 };?>><span class=text>Crohn's Disease</span><br>
 289 <input type=checkbox name="appendectomy"  <?php if ($obj{"appendectomy"} == "on") {
 290     echo "checked";
 291 };?>><span class=text>Appendectomy</span><br>
 292 <input type=checkbox name="divirticulitis"  <?php if ($obj{"divirticulitis"} == "on") {
 293     echo "checked";
 294 };?>><span class=text>Divirticulitis</span><br>
 295 <input type=checkbox name="divirticulitis_surgery"  <?php if ($obj{"divirticulitis_surgery"} == "on") {
 296     echo "checked";
 297 };?>><span class=text>Divirticulitis Surgery</span><br>
 298 <input type=checkbox name="gall_stones"  <?php if ($obj{"gall_stones"} == "on") {
 299     echo "checked";
 300 };?>><span class=text>Gall Stones</span><br>
 301 <input type=checkbox name="cholecystectomy"  <?php if ($obj{"cholecystectomy"} == "on") {
 302     echo "checked";
 303 };?>><span class=text>Cholecystectomy</span><br>
 304 <input type=checkbox name="hepatitis"  <?php if ($obj{"hepatitis"} == "on") {
 305     echo "checked";
 306 };?>><span class=text>Hepatitis</span><br>
 307 <input type=checkbox name="cirrhosis_of_the_liver"  <?php if ($obj{"cirrhosis_of_the_liver"} == "on") {
 308     echo "checked";
 309 };?>><span class=text>Cirrhosis of the Liver</span><br>
 310 <input type=checkbox name="splenectomy"  <?php if ($obj{"splenectomy"} == "on") {
 311     echo "checked";
 312 };?>><span class=text>Splenectomy</span><br>
 313 </td>
 314 <td valign=top>
 315 <span class=bold>Musculoskeletal</span><br>
 316 <input type=checkbox name="osetoarthritis"  <?php if ($obj{"osetoarthritis"} == "on") {
 317     echo "checked";
 318 };?>><span class=text>Osetoarthritis</span><br>
 319 <input type=checkbox name="rheumotoid_arthritis"  <?php if ($obj{"rheumotoid_arthritis"} == "on") {
 320     echo "checked";
 321 };?>><span class=text>Rheumotoid Arthritis</span><br>
 322 <input type=checkbox name="lupus"  <?php if ($obj{"lupus"} == "on") {
 323     echo "checked";
 324 };?>><span class=text>Lupus</span><br>
 325 <input type=checkbox name="ankylosing_sondlilitis"  <?php if ($obj{"ankylosing_sondlilitis"} == "on") {
 326     echo "checked";
 327 };?>><span class=text>Ankylosing Sondlilitis</span><br>
 328 <input type=checkbox name="swollen_joints"  <?php if ($obj{"swollen_joints"} == "on") {
 329     echo "checked";
 330 };?>><span class=text>Swollen Joints</span><br>
 331 <input type=checkbox name="stiff_joints"  <?php if ($obj{"stiff_joints"} == "on") {
 332     echo "checked";
 333 };?>><span class=text>Stiff Joints</span><br>
 334 <input type=checkbox name="broken_bones"  <?php if ($obj{"broken_bones"} == "on") {
 335     echo "checked";
 336 };?>><span class=text>Broken Bones</span><br>
 337 <input type=checkbox name="neck_problems"  <?php if ($obj{"neck_problems"} == "on") {
 338     echo "checked";
 339 };?>><span class=text>Neck Problems</span><br>
 340 <input type=checkbox name="back_problems"  <?php if ($obj{"back_problems"} == "on") {
 341     echo "checked";
 342 };?>><span class=text>Back Problems</span><br>
 343 <input type=checkbox name="back_surgery"  <?php if ($obj{"back_surgery"} == "on") {
 344     echo "checked";
 345 };?>><span class=text>Back Surgery</span><br>
 346 <input type=checkbox name="scoliosis"  <?php if ($obj{"scoliosis"} == "on") {
 347     echo "checked";
 348 };?>><span class=text>Scoliosis</span><br>
 349 <input type=checkbox name="herniated_disc"  <?php if ($obj{"herniated_disc"} == "on") {
 350     echo "checked";
 351 };?>><span class=text>Herniated Disc</span><br>
 352 <input type=checkbox name="shoulder_problems"  <?php if ($obj{"shoulder_problems"} == "on") {
 353     echo "checked";
 354 };?>><span class=text>Shoulder Problems</span><br>
 355 <input type=checkbox name="elbow_problems"  <?php if ($obj{"elbow_problems"} == "on") {
 356     echo "checked";
 357 };?>><span class=text>Elbow Problems</span><br>
 358 <input type=checkbox name="wrist_problems"  <?php if ($obj{"wrist_problems"} == "on") {
 359     echo "checked";
 360 };?>><span class=text>Wrist Problems</span><br>
 361 <input type=checkbox name="hand_problems"  <?php if ($obj{"hand_problems"} == "on") {
 362     echo "checked";
 363 };?>><span class=text>Hand Problems</span><br>
 364 <input type=checkbox name="hip_problems"  <?php if ($obj{"hip_problems"} == "on") {
 365     echo "checked";
 366 };?>><span class=text>Hip Problems</span><br>
 367 <input type=checkbox name="knee_problems"  <?php if ($obj{"knee_problems"} == "on") {
 368     echo "checked";
 369 };?>><span class=text>Knee Problems</span><br>
 370 <input type=checkbox name="ankle_problems"  <?php if ($obj{"ankle_problems"} == "on") {
 371     echo "checked";
 372 };?>><span class=text>Ankle Problems</span><br>
 373 <input type=checkbox name="foot_problems"  <?php if ($obj{"foot_problems"} == "on") {
 374     echo "checked";
 375 };?>><span class=text>Foot Problems</span><br>
 376 </td>
 377 </tr>
 378 </table>
 379
 380 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?php echo $obj{"additional_notes"};?></textarea><br>
 381 <br>
 382 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 383 <br>
 384 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 385 </form>
 386 <?php
 387 formFooter();
 388 ?>