contrib/forms/immunization_record/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <? html_header_show();?>
  23
  24 <title>Form: ACOG Immunization record</title>
  25
  26 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  27
  28 <link rel=stylesheet href="../../acog.css" type="text/css">
  29
  30 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  31
  32 <script language="JavaScript" type="text/JavaScript">
  33
  34 <!--
  35
  36 window.onload = initialize;
  37
  38 //-->
  39
  40 </script>
  41
  42 </head>
  43
  44
  45
  46 <?
  47
  48    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  49
  50    if ($fres){
  51
  52      $patient = sqlFetchArray($fres);
  53
  54    }
  55
  56    $fres=sqlStatement("select * from form_immunization_record where id='".$id."'");
  57
  58    if ($fres){
  59
  60      $ir = sqlFetchArray($fres);
  61
  62    }
  63
  64 ?>
  65
  66 <body <?echo $top_bg_line;?>>
  67
  68
  69
  70
  71
  72 <form action="<?echo $rootdir;?>/forms/immunization_record/save.php?mode=update&id=<? echo $id;?>" method="post" enctype="multipart/form-data" name="my_form">
  73
  74 <? include("../../acog_menu.inc"); ?>
  75
  76 <div class="srvChapter">Immunization record<sup><a href="#" onClick="toolTip('The Immunization Record lists immunization services recommended by ACOG for either routine use or in high-risk patients, as defined in the enclosed table of high-risk factors. space for listing problems and immunization services allows the same form to be used for years.<br><br>For immunizations based on risk refer to the Table of High-Risk Factors')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0"></a></sup></div>
  77
  78 <div style="border: solid 2px black; background-color:#FFFFFF;">
  79
  80   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  81
  82     <tr align="left" valign="bottom">
  83
  84       <td colspan="4" class="fibody2" id="bordR">patient name:
  85
  86         <input name="pname" type="text" class="fullin" id="pname" style="width: 74%" value="<?
  87
  88           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  89
  90           ?>"></td>
  91
  92       <td colspan="2" class="fibody2" id="bordR">Birth date:
  93
  94         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  95
  96           echo $patient{'DOB'};
  97
  98           ?>"></td>
  99
 100       <td colspan="2" class="fibody2">ID No:
 101
 102         <input name="pl_pid" type="text" class="fullin" id="pl_pid" style="width:80%" value="<?
 103
 104           echo $patient{'id'};
 105
 106           ?>"></td>
 107
 108       </tr>
 109
 110     <tr align="center" valign="middle">
 111
 112       <td width="9%" class="ficaption2" id="bordR">age</td>
 113
 114       <td width="13%" class="ficaption2" id="bordR">Tetanus-<br>
 115
 116         Diphteria<br>
 117
 118         booster </td>
 119
 120       <td width="13%" class="ficaption2" id="bordR">Influenza<br>
 121
 122         vaccine </td>
 123
 124       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
 125
 126       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine </td>
 127
 128       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
 129
 130       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
 131
 132       <td width="13%" class="ficaption2">Varicella vaccine </td>
 133
 134     </tr>
 135
 136     <tr align="center" valign="middle">
 137
 138       <td class="fibody2" id="bordR">13-18</td>
 139
 140       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
 141
 142       <td class="fibody2" id="bordR">Based on risk </td>
 143
 144       <td class="fibody2" id="bordR">Based on risk</td>
 145
 146       <td class="fibody2" id="bordR">Based on risk</td>
 147
 148       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
 149
 150       <td class="fibody2" id="bordR">Based on risk</td>
 151
 152       <td class="fibody2">Based on risk</td>
 153
 154     </tr>
 155
 156     <tr align="center" valign="middle">
 157
 158       <td class="fibody2" id="bordR">19-39</td>
 159
 160       <td class="fibody2" id="bordR">Every 10 years </td>
 161
 162       <td class="fibody2" id="bordR">Based on risk</td>
 163
 164       <td class="fibody2" id="bordR">Based on risk</td>
 165
 166       <td class="fibody2" id="bordR">Based on risk</td>
 167
 168       <td class="fibody2" id="bordR">Based on risk</td>
 169
 170       <td class="fibody2" id="bordR">Based on risk</td>
 171
 172       <td class="fibody2">Based on risk</td>
 173
 174     </tr>
 175
 176     <tr align="center" valign="middle">
 177
 178       <td class="fibody2" id="bordR">40-64</td>
 179
 180       <td class="fibody2" id="bordR">Every 10 years</td>
 181
 182       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
 183
 184       <td class="fibody2" id="bordR">Based on risk</td>
 185
 186       <td class="fibody2" id="bordR">Based on risk</td>
 187
 188       <td class="fibody2" id="bordR">Based on risk</td>
 189
 190       <td class="fibody2" id="bordR">Based on risk</td>
 191
 192       <td class="fibody2">Based on risk</td>
 193
 194     </tr>
 195
 196     <tr align="center" valign="middle">
 197
 198       <td class="fibody2" id="bordR">65 and older </td>
 199
 200       <td class="fibody2" id="bordR">Every 10 years</td>
 201
 202       <td class="fibody2" id="bordR">Annually</td>
 203
 204       <td class="fibody2" id="bordR">Once</td>
 205
 206       <td class="fibody2" id="bordR">&nbsp;</td>
 207
 208       <td class="fibody2" id="bordR">Based on risk</td>
 209
 210       <td class="fibody2" id="bordR">Based on risk</td>
 211
 212       <td class="fibody2">Based on risk</td>
 213
 214     </tr>
 215
 216   </table>
 217
 218 </div>
 219
 220 <p>&nbsp;</p>
 221
 222 <div style="border: solid 2px black; background-color:#FFFFFF;">
 223
 224   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 225
 226 <?
 227
 228 $vacci=0;
 229
 230   $vacc_tetanus = explode("|~", $ir["vacc_tetanus"]);
 231
 232   $vacc_influenza = explode("|~", $ir["vacc_influenza"]);
 233
 234   $vacc_pneumococcal = explode("|~", $ir["vacc_pneumococcal"]);
 235
 236   $vacc_mmr = explode("|~", $ir["vacc_mmr"]);
 237
 238   $vacc_hep_a = explode("|~", $ir["vacc_hep_a"]);
 239
 240   $vacc_hep_b = explode("|~", $ir["vacc_hep_b"]);
 241
 242   $vacc_varicella= explode("|~", $ir["vacc_varicella"]);
 243
 244 while ($vacci<20){
 245
 246 print <<<EOL
 247
 248     <tr align="left" valign="bottom">
 249
 250       <td width="9%" class="fibody2" id="bordR">Date</td>
 251
 252       <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2" value="${vacc_tetanus[$vacci]}"></td>
 253
 254       <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2" value="${vacc_influenza[$vacci]}"></td>
 255
 256       <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2" value="${vacc_pneumococcal[$vacci]}"></td>
 257
 258       <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2" value="${vacc_mmr[$vacci]}"></td>
 259
 260       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2" value="${vacc_hep_b[$vacci]}"></td>
 261
 262       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2" value="${vacc_hep_a[$vacci]}"></td>
 263
 264       <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2" value="${vacc_varicella[$vacci]}"></td>
 265
 266     </tr>
 267
 268 EOL;
 269
 270 $vacci++;
 271
 272 }
 273
 274 ?>
 275
 276   </table>
 277
 278 </div>
 279
 280 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 281
 282 <p>&nbsp;</p>
 283
 284 <table width="100%" border="0">
 285
 286   <tr>
 287
 288     <td align="left" width="100"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 289
 290     <td align="left" nowrap> <a href="<? echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<? echo $id; ?>&formname=<? echo $formname; ?>" target="_blank" class="link_submit"
 291
 292      onclick="top.restoreSession()">[Printable form]</a> </td>
 293
 294     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 295
 296      onclick="top.restoreSession()">[Don't Save]</a> </td>
 297
 298   </tr>
 299
 300 </table>
 301
 302 </form>
 303
 304 <?php
 305
 306 formFooter();
 307
 308 ?>
 309
 310 </body>
 311
 312 </html>