6 # this file made by andres@paglayan.com on 2004-05-03
8 # custom file for WHS forms.
10 # Habit form, part of main intake
20 include_once("../../globals.php");
22 include_once("../../../library/api.inc");
31 <?php
html_header_show();?
>
33 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
41 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
45 <!--REM note that every input method has the same name
as a valid column
, this will make things easier in save
.php
-->
49 <!-- main form starts here
-->
53 <form method
='post' action
="<?php echo $rootdir;?>/forms/habits/save.php?mode=new" name
='habits_form'>
63 <TABLE span
class=text
>
65 <th
><H2
><U
>Habits
</U
></H2
></th
>
69 <TD
><b
>Caffeine
:</b
></TD
>
71 <TD
><INPUT TYPE
="checkbox" NAME
="coffee" VALUE
="YES"> Coffee
 
; 
;</TD
>
73 <TD
><INPUT TYPE
="checkbox" NAME
="tea" VALUE
="YES"> Tea
</TD
>
75 <TD
><INPUT TYPE
="checkbox" NAME
="soft_drinks" VALUE
="YES"> Soft Drinks
</TD
>
77 <TD
><INPUT TYPE
="checkbox" NAME
="other_caffeine" VALUE
="YES"> Other
</TD
>
79 <TD
><INPUT TYPE
="text" NAME
="caffeine_per_day" SIZE
="2"> # per day</TD>
85 <TD
><B
>Salt Usage
:</B
></TD
>
87 <TD
><INPUT TYPE
="radio" NAME
="salt_usage" VALUE
="Heavy"> Heavy
</TD
>
89 <TD
><INPUT TYPE
="radio" NAME
="salt_usage" VALUE
="Moderate"> Moderate
</TD
>
91 <TD
><INPUT TYPE
="radio" NAME
="salt_usage" VALUE
="Light"> Light
</TD
>
93 <TD
><INPUT TYPE
="radio" NAME
="salt_usage" VALUE
="No salt"> No added salt
</TD
>
101 <TD
><B
>Sugar Usage
</B
></TD
>
103 <TD
><INPUT TYPE
="radio" NAME
="sugar_usage" VALUE
="Heavy"> Heavy
</TD
>
105 <TD
><INPUT TYPE
="radio" NAME
="sugar_usage" VALUE
="Moderate"> Moderate
</TD
>
107 <TD
><INPUT TYPE
="radio" NAME
="sugar_usage" VALUE
="Light"> Light
</TD
>
109 <TD
><INPUT TYPE
="radio" NAME
="sugar_usage" VALUE
="No sugar"> No added sugar
</TD
>
117 <TD colspan
="2"><B
>You feel your diet is
:</B
> </TD
>
119 <TD
><INPUT TYPE
="radio" NAME
="diet" VALUE
="Healthy"> Healthy
</TD
>
121 <TD
><INPUT TYPE
="radio" NAME
="diet" VALUE
="Fair"> Fair
</TD
>
123 <TD
><INPUT TYPE
="radio" NAME
="diet" VALUE
="Poor"> Poor
</TD
>
131 <TD
><B
>Coments
:</B
> </TD
>
133 <TD Colspan
="5"><INPUT TYPE
="text" size
="50" NAME
="diet_comments"></TD
>
139 <TD
><B
>Alcohol
:</B
> </TD
>
141 <TD colspan
="2"><INPUT TYPE
="text" size
="2" NAME
="alc_per_day"> Glasses per day
</TD
>
143 <TD colspan
="2"><INPUT TYPE
="text" size
="2" NAME
="alc_per_week"> Glasses per week
</TD
>
151 <TD colspan
="2"><B
>Recreational Drugs
:</B
> </TD
>
153 <TD colspan
="2">Which Drugs?
<INPUT TYPE
="text" size
="20" NAME
="recr_drugs"></TD
>
155 <TD colspan
="2">How often?
<INPUT TYPE
="text" size
="20" NAME
="recr_drugs_often"></TD
>
161 <TD colspan
="4"><B
>Do you feel you have a problem with alcohol
or drugs?
</B
>
163 <SELECT NAME
="alc_drug_problem"><option
><option
>YES
<OPTION
>NO
</SELECT
>
167 <TD colspan
="2">Explain
:<INPUT TYPE
="text" size
="20" NAME
="alc_drug_problem_explain"></TD
>
173 <TD colspan
="2"><B
>Tobacco
:</B
> </TD
>
175 <TD colspan
="2">Do you smoke?
<SELECT NAME
="current_smoke"><option
><option
>YES
<OPTION
>NO
</SELECT
> </TD
>
177 <TD colspan
="2">Have you ever smoked?
<SELECT NAME
="ever_smoked"><option
><option
>YES
<OPTION
>NO
</SELECT
> </TD
>
183 <TD
><INPUT TYPE
="text" size
="2" NAME
="cig_per_day_now"> per day now
.</TD
>
185 <TD colspan
="2"><INPUT TYPE
="text" size
="2" NAME
="cig_per_day_past"> per day in the past
.</TD
>
187 <TD colspan
="3">How long have you been smoking?
<INPUT TYPE
="text" size
="2" NAME
="how_long_smoke">Years
</TD
>
193 <TD colspan
="4">If you no longer smoke
, when did you quit?
<INPUT TYPE
="text" size
="10" maxlength
="10" NAME
="smoke_quit" VALUE
="mm/dd/yyyy" maxlength
="10">
201 <TD colspan
="2">Would you like to quit?
<SELECT NAME
="like_to_quit"><option
><option
>YES
<OPTION
>NO
</SELECT
></TD
>
207 <TD
><B
>exercise
:</B
></TD
>
209 <TD colspan
="2">Do you exercise regularly?
<SELECT NAME
="exercise_reg"><option
><option
>YES
<OPTION
>NO
</SELECT
></TD
>
211 <TD colspan
="3">What types?
<INPUT TYPE
="text" size
="40" NAME
="exercise_types"></TD
>
219 <TD colspan
="2">How many times per week?
<INPUT TYPE
="text" size
="2" NAME
="exercise_per_week"></TD
>
221 <TD colspan
="2">For how long each time?
<INPUT TYPE
="text" size
="3" NAME
="exercise_minutes">Minutes
</TD
>
227 <TD
><B
>Seat belt
use:</B
></TD
>
229 <TD colspan
="5"><SELECT NAME
="seat_belt"><option
><option
>Always
<OPTION
>Usually
<OPTION
>Seldom
<OPTION
>Never
</SELECT
></TD
>
235 <TD colspan
="5">Have you ever been pushed
, shoved
, slapped
, hit
, or verbally abused by anyone?
</TD
>
237 <TD
><SELECT NAME
="ever_been_molested"><option
><option
>YES
<OPTION
>NO
</SELECT
></TD
>
243 <TD colspan
="5">Have you ever pushed
, shoved
, slapped
, hit
, or verbally abused another individual?
</TD
>
245 <TD
><SELECT NAME
="ever_molested_other"><option
><option
>YES
<OPTION
>NO
</SELECT
></TD
>
263 <a href
="javascript:top.restoreSession();document.habits_form.submit();" class="link_submit">[Save
]</a
>
269 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick
="top.restoreSession()">[Don
't Save]</a>
289 <!-- ends main form -->