interface/forms/bronchitis/view.php

   1 <!-- Form created by Nikolai Vitsyn by 2004/01/23 -->
   2 <?php
   3 include_once("../../globals.php");
   4 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   5 ?>
   6 <html><head>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_bronchitis", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?echo $rootdir?>/forms/bronchitis/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  15 <span class="title"><?php xl('Bronchitis Form','e'); ?></span><br><br>
  16
  17 <a href="javascript:document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
  18 <br>
  19 <a href="<?echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link">[<?php xl('Don\'t Save Changes','e'); ?>]</a>
  20 <br></br>
  21
  22 <span class=text><?php xl('Onset of Ilness: ','e'); ?></span><input type=entry name="bronchitis_date_of_illness" value="<?echo stripslashes($obj{"bronchitis_date_of_illness"});?>" ><br></br>
  23
  24 <span class=text><?php xl('HPI:','e'); ?> </span><br><textarea cols=67 rows=8 wrap=virtual name="bronchitis_hpi" ><?echo stripslashes($obj{"bronchitis_hpi"});?></textarea><br></br>
  25
  26
  27 <table><th colspan="5">"<?php xl('Other Pertinent Symptoms','e'); ?> ":</th>
  28 <tr>
  29 <td width="60" align="right"><?php xl('Fever:','e'); ?> </td>
  30 <td><input type=checkbox name="bronchitis_ops_fever" <?if ($obj{"bronchitis_ops_fever"} == "on")
  31 {echo "checked";};?>><span class=text></span><br>
  32
  33 <td width="140" align="right"><?php xl('Cough:','e'); ?> </td>
  34 <td><input type=checkbox name="bronchitis_ops_cough" <?if ($obj{"bronchitis_ops_cough"} == "on")
  35 {echo "checked";};?>><span class=text></span><br>
  36
  37 <td width="170" align="right"><?php xl('Dizziness:','e'); ?> </td>
  38 <td><input type=checkbox name="bronchitis_ops_dizziness" <?if ($obj{"bronchitis_ops_dizziness"} == "on")
  39 {echo "checked";};?>><span class=text></span><br>
  40 </tr>
  41
  42 <tr>
  43 <td width="60" align="right"><?php xl('Chest Pain:','e'); ?> </td>
  44 <td><input type=checkbox name="bronchitis_ops_chest_pain" <?if ($obj{"bronchitis_ops_chest_pain"} == "on")
  45 {echo "checked";};?>><span class=text></span><br>
  46 <td width="130" align="right"><?php xl('Dyspnea:','e'); ?> </td>
  47 <td><input type=checkbox name="bronchitis_ops_dyspnea" <?if ($obj{"bronchitis_ops_dyspnea"} == "on")
  48 {echo "checked";};?>><span class=text></span><br>
  49 <td width="180" align="right"><?php xl('Sweating:','e'); ?> </td>
  50 <td><input type=checkbox name="bronchitis_ops_sweating" <?if ($obj{"bronchitis_ops_sweating"} == "on")
  51 {echo "checked";};?>><span class=text></span><br>
  52 </tr>
  53
  54 <tr>
  55 <td width="60" align="right"><?php xl('Wheezing:','e'); ?> </td>
  56 <td><input type=checkbox name="bronchitis_ops_wheezing" <?if ($obj{"bronchitis_ops_wheezing"} == "on")
  57 {echo "checked";};?>><span class=text></span><br>
  58
  59 <td width="130" align="right"><?php xl('Malaise:','e'); ?> </td>
  60 <td><input type=checkbox name="bronchitis_ops_malaise" <?if ($obj{"bronchitis_ops_malaise"} == "on")
  61 {echo "checked";};?>><span class=text></span><br>
  62 </tr>
  63
  64 <tr>
  65 <td width="60" align="right"><?php xl('Sputum:','e'); ?> </td>
  66 <td><input type=checkbox name="bronchitis_ops_sputum" <?if ($obj{"bronchitis_ops_sputum"} == "on")
  67 {echo "checked";};?>><span class=text></span><br></td>
  68
  69 <td width="130" align="right"><?php xl('Appearance:','e'); ?>  <span class="text"></span></td>
  70 <td><input type=entry name="bronchitis_ops_appearance" value="<?echo
  71 stripslashes($obj{"bronchitis_ops_appearance"});?>" size="15"></td>
  72 </tr>
  73 </table>
  74
  75 <table><tr>
  76 <td width="227" align="right"><?php xl('All Reviewed and Negative:','e'); ?> </td>
  77 <td><input type=checkbox name="bronchitis_ops_all_reviewed" <?if ($obj{"bronchitis_ops_all_reviewed"} == "on")
  78 {echo "checked";};?>><span class=text></span><br>
  79 </tr>
  80 </table>
  81 <br></br>
  82
  83 <table >
  84 <tr>
  85 <td width="60" align="right"><?php xl('Review of PMH:','e'); ?> </td>
  86 <td><input type=checkbox name="bronchitis_review_of_pmh" <?if ($obj{"bronchitis_review_of_pmh"} == "on")
  87 {echo "checked";};?>><span class=text></span><br></td>
  88 <td align="right"><?php xl('Medications:','e'); ?> </td>
  89 <td><input type=checkbox name="bronchitis_review_of_medications" <?if ($obj{"bronchitis_review_of_medications"} == "on")
  90 {echo "checked";};?>><span class=text></span><br></td>
  91 <td align="right"><?php xl('Allergies:','e'); ?> </td>
  92 <td><input type=checkbox name="bronchitis_review_of_allergies" <?if ($obj{"bronchitis_review_of_allergies"} == "on")
  93 {echo "checked";};?>><span class=text></span><br></td>
  94 <td align="right"><?php xl('Social History:','e'); ?> </td>
  95 <td><input type=checkbox name="bronchitis_review_of_sh" <?if ($obj{"bronchitis_review_of_sh"} == "on")
  96 {echo "checked";};?>><span class=text></span><br></td>
  97 <td align="right"><?php xl('Family History:','e'); ?> </td>
  98 <td><input type=checkbox name="bronchitis_review_of_fh" <?if ($obj{"bronchitis_review_of_fh"} == "on")
  99 {echo "checked";};?>><span class=text></span><br></td>
 100 </tr>
 101 </table>
 102 <br></br>
 103
 104
 105 <table>
 106 <tr>
 107 <td width="60"><?php xl('TM\'S:','e'); ?> </td>
 108 <td align="right"><?php xl('Normal Right:','e'); ?> </td>
 109 <td><input type=checkbox name="bronchitis_tms_normal_right" <?if ($obj{"bronchitis_tms_normal_right"} == "on")
 110 {echo "checked";};?>><span class=text></span><br>
 111 <td align="right"><?php xl('Left:','e'); ?> </td>
 112 <td><input type=checkbox name="bronchitis_tms_normal_left" <?if ($obj{"bronchitis_tms_normal_left"} == "on")
 113 {echo "checked";};?>><span class=text></span><br>
 114 <td align="right"><?php xl('NARES: Normal Right','e'); ?> </td>
 115 <td><input type=checkbox name="bronchitis_nares_normal_right" <?if ($obj{"bronchitis_nares_normal_right"} == "on")
 116 {echo "checked";};?>><span class=text></span><br>
 117 <td align="right"><?php xl('Left:','e'); ?>  </td>
 118 <td><input type=checkbox name="bronchitis_nares_normal_left" <?if ($obj{"bronchitis_nares_normal_left"} == "on")
 119 {echo "checked";};?>><span class=text></span><br>
 120 </tr>
 121
 122 <tr>
 123 <td width="60"></td>
 124 <td align="right"> <?php xl('Thickened Right:','e'); ?> </td>
 125 <td><input type=checkbox name="bronchitis_tms_thickened_right" <?if ($obj{"bronchitis_tms_thickened_right"} == "on")
 126 {echo "checked";};?>><span class=text></span><br>
 127 <td align="right"><?php xl('Left:','e'); ?> </td>
 128 <td><input type=checkbox name="bronchitis_tms_thickened_left" <?if ($obj{"bronchitis_tms_thickened_left"} == "on")
 129 {echo "checked";};?>><span class=text></span><br>
 130
 131 <td align="right"><?php xl('Swelling Right','e'); ?> </td>
 132 <td><input type=checkbox name="bronchitis_nares_swelling_right" <?if ($obj{"bronchitis_nares_swelling_right"} == "on")
 133 {echo "checked";};?>><span class=text></span><br>
 134 <td align="right"><?php xl('Left: ','e'); ?> </td>
 135 <td><input type=checkbox name="bronchitis_nares_swelling_left" <?if ($obj{"bronchitis_nares_swelling_left"} == "on")
 136 {echo "checked";};?>><span class=text></span><br>
 137 </tr>
 138
 139 <tr>
 140 <td width="60"></td>
 141 <td align="right"><?php xl('A/F Level Right:','e'); ?> </td>
 142 <td><input type=checkbox name="bronchitis_tms_af_level_right" <?if ($obj{"bronchitis_tms_af_level_right"} == "on")
 143 {echo "checked";};?>><span class=text></span><br>
 144 <td align="right"><?php xl('Left:','e'); ?> </td>
 145 <td><input type=checkbox name="bronchitis_tms_af_level_left" <?if ($obj{"bronchitis_tms_af_level_left"} == "on")
 146 {echo "checked";};?>><span class=text></span><br>
 147
 148 <td align="right"><?php xl('Discharge Right','e'); ?> </td>
 149 <td><input type=checkbox name="bronchitis_nares_discharge_right" <?if ($obj{"bronchitis_nares_discharge_right"} == "on")
 150 {echo "checked";};?>><span class=text></span><br>
 151 <td align="right"><?php xl('Left: ','e'); ?> </td>
 152 <td><input type=checkbox name="bronchitis_nares_discharge_left" <?if ($obj{"bronchitis_nares_discharge_left"} == "on")
 153 {echo "checked";};?>><span class=text></span><br>
 154 </tr>
 155
 156 <tr>
 157 <td width="60"></td>
 158 <td align="right"><?php xl('Retracted Right:','e'); ?> </td>
 159 <td><input type=checkbox name="bronchitis_tms_retracted_right" <?if ($obj{"bronchitis_tms_retracted_right"} == "on")
 160 {echo "checked";};?>><span class=text></span><br>
 161 <td align="right"><?php xl('Left:','e'); ?> </td>
 162 <td><input type=checkbox name="bronchitis_tms_retracted_left" <?if ($obj{"bronchitis_tms_retracted_left"} == "on")
 163 {echo "checked";};?>><span class=text></span><br>
 164 </tr>
 165
 166 <tr>
 167 <td width="60"></td>
 168 <td align="right"><?php xl('Bulging Right:','e'); ?> </td>
 169 <td><input type=checkbox name="bronchitis_tms_bulging_right" <?if ($obj{"bronchitis_tms_bulging_right"} == "on")
 170 {echo "checked";};?>><span class=text></span><br>
 171 <td align="right"><?php xl('Left:','e'); ?> </td>
 172 <td><input type=checkbox name="bronchitis_tms_bulging_left" <?if ($obj{"bronchitis_tms_bulging_left"} == "on")
 173 {echo "checked";};?>><span class=text></span><br>
 174 </tr>
 175
 176 <tr>
 177 <td width="60"></td>
 178 <td align="right"><?php xl('Perforated Right:','e'); ?> </td>
 179 <td><input type=checkbox name="bronchitis_tms_perforated_right" <?if ($obj{"bronchitis_tms_perforated_right"} == "on")
 180 {echo "checked";};?>><span class=text></span><br>
 181 <td align="right"><?php xl('Left:','e'); ?> </td>
 182 <td><input type=checkbox name="bronchitis_tms_perforated_left" <?if ($obj{"bronchitis_tms_perforated_left"} == "on")
 183 {echo "checked";};?>><span class=text></span><br>
 184 </tr>
 185 </table>
 186
 187 <table><tr>
 188 <td width="127"></td>
 189 <td align="right"><?php xl('Not Examined:','e'); ?> </td>
 190 <td><input type=checkbox name="bronchitis_tms_nares_not_examined" <?if ($obj{"bronchitis_tms_nares_not_examined"} == "on")
 191 {echo "checked";};?>><span class=text></span><br>
 192 </tr></table>
 193 <br></br>
 194
 195 <table>
 196 <tr>
 197 <td width="90"><?php xl('SINUS TENDERNESS:','e'); ?> </td>
 198 <td align="right"><?php xl('No Sinus Tenderness:','e'); ?> </td>
 199 <td><input type=checkbox name="bronchitis_no_sinus_tenderness" <?if ($obj{"bronchitis_no_sinus_tenderness"} == "on")
 200 {echo "checked";};?>><span class=text></span><br>
 201 <td width="90"><?php xl('OROPHARYNX: ','e'); ?> </td>
 202 <td align="right"><?php xl('Normal Oropharynx:','e'); ?> </td>
 203 <td><input type=checkbox name="bronchitis_oropharynx_normal"<?if ($obj{"bronchitis_oropharynx_normal"} == "on")
 204 {echo "checked";};?>><span class=text></span><br>
 205 </tr>
 206
 207 <tr>
 208 <td width="90" align="right"><?php xl('Frontal Right:','e'); ?>  </td>
 209 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_right" <?if ($obj{"bronchitis_sinus_tenderness_frontal_right"} == "on")
 210 {echo "checked";};?>><span class=text></span><br>
 211 <td align="right"><?php xl('Left:','e'); ?> </td>
 212 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_left" <?if ($obj{"bronchitis_sinus_tenderness_frontal_left"} == "on")
 213 {echo "checked";};?>><span class=text></span><br>
 214 <td align="right"><?php xl('Erythema:','e'); ?> </td>
 215 <td><input type=checkbox name="bronchitis_oropharynx_erythema" <?if ($obj{"bronchitis_oropharynx_erythema"} == "on")
 216 {echo "checked";};?>><span class=text></span><br>
 217 <td align="right"><?php xl('Exudate:','e'); ?> </td>
 218 <td><input type=checkbox name="bronchitis_oropharynx_exudate" <?if ($obj{"bronchitis_oropharynx_exudate"} == "on")
 219 {echo "checked";};?>><span class=text></span><br>
 220 <td align="right"><?php xl('Abcess:','e'); ?> </td>
 221 <td><input type=checkbox name="bronchitis_oropharynx_abcess" <?if ($obj{"bronchitis_oropharynx_abcess"} == "on")
 222 {echo "checked";};?>><span class=text></span><br>
 223 <td align="right"><?php xl('Ulcers:','e'); ?> </td>
 224 <td><input type=checkbox name="bronchitis_oropharynx_ulcers" <?if ($obj{"bronchitis_oropharynx_ulcers"} == "on")
 225 {echo "checked";};?>><span class=text></span><br>
 226 </tr>
 227
 228 <tr>
 229 <td width ="90" align="right"><?php xl('Maxillary Right:','e'); ?> </td>
 230 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_right" <?if ($obj{"bronchitis_sinus_tenderness_maxillary_right"} == "on")
 231 {echo "checked";};?>><span class=text></span><br></td>
 232 <td align="right"><?php xl('Left:','e'); ?> </td>
 233 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_left" <?if ($obj{"bronchitis_sinus_tenderness_maxillary_left"} == "on")
 234 {echo "checked";};?>><span class=text></span><br></td>
 235 <td width="130" align="right"><?php xl('Appearance:','e'); ?>  <span class="text"></span></td>
 236 <td><input type=entry name="bronchitis_oropharynx_appearance" value="<?echo
 237 stripslashes($obj{"bronchitis_oropharynx_appearance"});?>" size="15"></td>
 238 </tr>
 239 </table>
 240
 241 <table>
 242 <tr>
 243 <td width="256" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 244 <td><input type=checkbox name="bronchitis_sinus_tenderness_not_examined" <?if ($obj{"bronchitis_sinus_tenderness_not_examined"} == "on")
 245 {echo "checked";};?>><span class=text></span><br>
 246 <td width="208" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 247 <td><input type=checkbox name="bronchitis_oropharynx_not_examined" <?if ($obj{"bronchitis_oropharynx_not_examined"} == "on")
 248 {echo "checked";};?>><span class=text></span><br>
 249 </tr>
 250 </table>
 251 <br></br>
 252
 253 <table>
 254 <tr>
 255 <td width="60"><?php xl('HEART:','e'); ?> </td>
 256 <td align="right"><?php xl('laterally displaced PMI:','e'); ?> </td>
 257 <td><input type=checkbox name="bronchitis_heart_pmi" <?if ($obj{"bronchitis_heart_pmi"} == "on")
 258 {echo "checked";};?>><span class=text></span><br>
 259 <td align="right"><?php xl('S3:','e'); ?> </td>
 260 <td><input type=checkbox name="bronchitis_heart_s3" <?if ($obj{"bronchitis_heart_s3"} == "on")
 261 {echo "checked";};?>><span class=text></span><br>
 262 <td align="right"><?php xl('S4:','e'); ?> </td>
 263 <td><input type=checkbox name="bronchitis_heart_s4" <?if ($obj{"bronchitis_heart_s4"} == "on")
 264 {echo "checked";};?>><span class=text></span><br>
 265 </tr>
 266
 267 <tr>
 268 <td width="60"></td>
 269 <td align="right"><?php xl('Click:','e'); ?> </td>
 270 <td><input type=checkbox name="bronchitis_heart_click" <?if ($obj{"bronchitis_heart_click"} == "on")
 271 {echo "checked";};?>><span class=text></span><br>
 272 <td align="right"><?php xl('Rub:','e'); ?> </td>
 273 <td><input type=checkbox name="bronchitis_heart_rub" <?if ($obj{"bronchitis_heart_rub"} == "on")
 274 {echo "checked";};?>><span class=text></span><br>
 275 </tr>
 276 </table>
 277
 278 <table><tr>
 279 <td width="200" align="right"><?php xl('Murmur:','e'); ?>  <span class="text"></span></td>
 280 <td><input type=entry name="bronchitis_heart_murmur" value="<?echo
 281 stripslashes($obj{"bronchitis_heart_murmur"});?>" size="15"></td>
 282
 283 <td><span class="text"><?php xl('Grade:','e'); ?>  </span></td><td>
 284 <input type=entry name="bronchitis_heart_grade" value="<?echo
 285 stripslashes($obj{"bronchitis_heart_grade"});?>" size="15"></td>
 286
 287 <td><span class="text"><?php xl('Location:','e'); ?>  </span></td><td>
 288 <input type=entry name="bronchitis_heart_location" value="<?echo
 289 stripslashes($obj{"bronchitis_heart_location"});?>" size="15"></td>
 290 </tr>
 291 </table>
 292
 293 <table><tr>
 294 <td width="205" align="right"><?php xl('Normal Cardiac Exam:','e'); ?>  </td>
 295 <td><input type=checkbox name="bronchitis_heart_normal" <?if ($obj{"bronchitis_heart_normal"} == "on")
 296 {echo "checked";};?>><span class=text></span><br>
 297 <td width="95" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 298 <td><input type=checkbox name="bronchitis_heart_not_examined" <?if ($obj{"bronchitis_heart_not_examined"} == "on")
 299 {echo "checked";};?>><span class=text></span><br>
 300 </tr></table>
 301 <br></br>
 302
 303 <table><tr>
 304 <td width="60"><?php xl('Lungs:','e'); ?> </td>
 305 <td width="106"><?php xl('Breath Sounds:','e'); ?> </td>
 306 <td align="right"> <?php xl('normal:','e'); ?> </td>
 307 <td><input type=checkbox name="bronchitis_lungs_bs_normal" <?if ($obj{"bronchitis_lungs_bs_normal"} == "on")
 308 {echo "checked";};?>><span class=text></span><br>
 309
 310 <td align="right"><?php xl('reduced:','e'); ?> </td>
 311 <td><input type=checkbox name="bronchitis_lungs_bs_reduced" <?if ($obj{"bronchitis_lungs_bs_reduced"} == "on")
 312 {echo "checked";};?>><span class=text></span><br>
 313
 314 <td align="right"><?php xl('increased:','e'); ?> </td>
 315 <td><input type=checkbox name="bronchitis_lungs_bs_increased" <?if ($obj{"bronchitis_lungs_bs_increased"} == "on")
 316 {echo "checked";};?>><span class=text></span><br>
 317 </tr>
 318
 319 <tr>
 320 <td width="60"></td>
 321 <td><?php xl('Crackles:','e'); ?> </td>
 322 <td align="right"><?php xl(' LLL:','e'); ?> </td>
 323 <td><input type=checkbox name="bronchitis_lungs_crackles_lll" <?if ($obj{"bronchitis_lungs_crackles_lll"} == "on")
 324 {echo "checked";};?>><span class=text></span><br>
 325
 326 <td align="right"><?php xl('RLL:','e'); ?> </td>
 327 <td><input type=checkbox name="bronchitis_lungs_crackles_rll" <?if ($obj{"bronchitis_lungs_crackles_rll"} == "on")
 328 {echo "checked";};?>><span class=text></span><br>
 329
 330 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 331 <td><input type=checkbox name="bronchitis_lungs_crackles_bll" <?if ($obj{"bronchitis_lungs_crackles_bll"} == "on")
 332 {echo "checked";};?>><span class=text></span><br>
 333 </tr>
 334
 335 <tr>
 336 <td width="60"></td>
 337 <td><?php xl('Rubs:','e'); ?> </td>
 338 <td align="right"><?php xl('LLL:','e'); ?> </td>
 339 <td><input type=checkbox name="bronchitis_lungs_rubs_lll" <?if ($obj{"bronchitis_lungs_rubs_lll"} == "on")
 340 {echo "checked";};?>><span class=text></span><br>
 341
 342 <td align="right"><?php xl('RLL:','e'); ?> </td>
 343 <td><input type=checkbox name="bronchitis_lungs_rubs_rll" <?if ($obj{"bronchitis_lungs_rubs_rll"} == "on")
 344 {echo "checked";};?>><span class=text></span><br>
 345
 346 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 347 <td><input type=checkbox name="bronchitis_lungs_rubs_bll" <?if ($obj{"bronchitis_lungs_rubs_bll"} == "on")
 348 {echo "checked";};?>><span class=text></span><br>
 349 </tr>
 350
 351 <tr>
 352 <td width="60"></td>
 353 <td><?php xl('Wheezes:','e'); ?> </td>
 354 <td align="right"><?php xl('LLL:','e'); ?> </td>
 355 <td><input type=checkbox name="bronchitis_lungs_wheezes_lll" <?if ($obj{"bronchitis_lungs_wheezes_lll"} == "on")
 356 {echo "checked";};?>><span class=text></span><br>
 357
 358 <td align="right"><?php xl('RLL:','e'); ?> </td>
 359 <td><input type=checkbox name="bronchitis_lungs_wheezes_rll" <?if ($obj{"bronchitis_lungs_wheezes_rll"} == "on")
 360 {echo "checked";};?>><span class=text></span><br>
 361
 362 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 363 <td><input type=checkbox name="bronchitis_lungs_wheezes_bll" <?if ($obj{"bronchitis_lungs_wheezes_bll"} == "on")
 364 {echo "checked";};?>><span class=text></span><br>
 365
 366 <td align="right"><?php xl('Diffuse:','e'); ?> </td>
 367 <td><input type=checkbox name="bronchitis_lungs_wheezes_dll" <?if ($obj{"bronchitis_lungs_wheezes_dll"} == "on")
 368 {echo "checked";};?>><span class=text></span><br>
 369 </tr>
 370 </table>
 371
 372
 373 <table><tr>
 374 <td width="218" align="right"><?php xl('Normal Lung Exam:','e'); ?>  </td>
 375 <td><input type=checkbox name="bronchitis_lungs_normal_exam" <?if ($obj{"bronchitis_lungs_normal_exam"} == "on")
 376 {echo "checked";};?>><span class=text></span><br>
 377 <td width="140" align="right"><?php xl('Not Examined','e'); ?> </td>
 378 <td><input type=checkbox name="bronchitis_lungs_not_examined" <?if ($obj{"bronchitis_lungs_not_examined"} == "on")
 379 {echo "checked";};?>><span class=text></span><br>
 380 </tr></table>
 381 <br></br>
 382
 383 <span class="text"><?php xl('Diagnostic Tests:','e'); ?> </span></br>
 384 <textarea name="bronchitis_diagnostic_tests" cols ="67" rows="4"  wrap="virtual name">
 385 <?echo stripslashes($obj{"bronchitis_diagnostic_tests"});?></textarea>
 386 <br></br>
 387
 388 <table><tr>
 389 <span class="text"><?php xl('Diagnosis: ','e'); ?> </span>
 390 <br><input type=entry name="diagnosis1_bronchitis_form" value="<?echo
 391 stripslashes($obj{"diagnosis1_bronchitis_form"});?>" size="40"><br>
 392 </tr>
 393
 394 <tr>
 395 <input type=entry name="diagnosis2_bronchitis_form" value="<?echo
 396 stripslashes($obj{"diagnosis2_bronchitis_form"});?>" size="40"><br>
 397 </tr>
 398
 399 <tr>
 400 <input type=entry name="diagnosis3_bronchitis_form" value="<?echo
 401 stripslashes($obj{"diagnosis3_bronchitis_form"});?>" size="40"><br>
 402 </tr>
 403
 404 <tr>
 405 <input type=entry name="diagnosis4_bronchitis_form" value="<?echo
 406  stripslashes($obj{"diagnosis4_bronchitis_form"});?>" size="40"><br>
 407 </tr>
 408
 409 <table>
 410 <br>
 411 <span class="text"><?php xl('Additional Diagnosis:','e'); ?>  </span></br>
 412 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name">
 413 <?echo stripslashes($obj{"bronchitis_additional_diagnosis"});?></textarea>
 414 <br></br>
 415
 416 <span class="text"><?php xl('Treatment: ','e'); ?> </span></br>
 417 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name">
 418 <?echo stripslashes($obj{"bronchitis_treatment"});?></textarea>
 419 </br>
 420
 421 <a href="javascript:document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?> ]</a>
 422 <br>
 423 <a href="<?echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link">[<?php xl('Don\'t Save Changes','e'); ?> ]</a>
 424
 425 </form>
 426 <?php
 427 formFooter();
 428 ?>