contrib/forms/reviewofs/view.php

   1 <!-- Forms generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <?php html_header_show();?>
   7 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
   8 </head>
   9 <body class="body_top">
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_reviewofs", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?php echo $rootdir?>/forms/reviewofs/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  15 <span class="title">Review of Systems Checks</span><Br><br>
  16
  17 <table>
  18 <tr>
  19 <td valign=top>
  20 <span class=bold>General</span><br>
  21 <input type=checkbox name="fever"  <?php if ($obj{"fever"} == "on") {echo "checked";};?>><span class=text>Fever</span><br>
  22 <input type=checkbox name="chills"  <?php if ($obj{"chills"} == "on") {echo "checked";};?>><span class=text>Chills</span><br>
  23 <input type=checkbox name="night_sweats"  <?php if ($obj{"night_sweats"} == "on") {echo "checked";};?>><span class=text>Night Sweats</span><br>
  24 <input type=checkbox name="weight_loss"  <?php if ($obj{"weight_loss"} == "on") {echo "checked";};?>><span class=text>Weight Loss</span><br>
  25 <input type=checkbox name="poor_appetite"  <?php if ($obj{"poor_appetite"} == "on") {echo "checked";};?>><span class=text>Poor Appetite</span><br>
  26 <input type=checkbox name="insomnia"  <?php if ($obj{"insomnia"} == "on") {echo "checked";};?>><span class=text>Insomnia</span><br>
  27 <input type=checkbox name="fatigued"  <?php if ($obj{"fatigued"} == "on") {echo "checked";};?>><span class=text>Fatigued</span><br>
  28 <input type=checkbox name="depressed"  <?php if ($obj{"depressed"} == "on") {echo "checked";};?>><span class=text>Depressed</span><br>
  29 <input type=checkbox name="hyperactive"  <?php if ($obj{"hyperactive"} == "on") {echo "checked";};?>><span class=text>Hyperactive</span><br>
  30 <input type=checkbox name="exposure_to_foreign_countries"  <?php if ($obj{"exposure_to_foreign_countries"} == "on") {echo "checked";};?>><span class=text>Exposure to Foreign Countries</span><br>
  31 <span class=bold>Skin</span><br>
  32 <input type=checkbox name="rashes"  <?php if ($obj{"rashes"} == "on") {echo "checked";};?>><span class=text>Rashes</span><br>
  33 <input type=checkbox name="infections"  <?php if ($obj{"infections"} == "on") {echo "checked";};?>><span class=text>Infections</span><br>
  34 <input type=checkbox name="ulcerations"  <?php if ($obj{"ulcerations"} == "on") {echo "checked";};?>><span class=text>Ulcerations</span><br>
  35 <input type=checkbox name="pemphigus"  <?php if ($obj{"pemphigus"} == "on") {echo "checked";};?>><span class=text>Pemphigus</span><br>
  36 <input type=checkbox name="herpes"  <?php if ($obj{"herpes"} == "on") {echo "checked";};?>><span class=text>Herpes</span><br>
  37 </td>
  38 <td valign=top>
  39 <span class=bold>HEENT</span><br>
  40 <input type=checkbox name="cataracts"  <?php if ($obj{"cataracts"} == "on") {echo "checked";};?>><span class=text>Cataracts</span><br>
  41 <input type=checkbox name="cataract_surgery"  <?php if ($obj{"cataract_surgery"} == "on") {echo "checked";};?>><span class=text>Cataract Surgery</span><br>
  42 <input type=checkbox name="glaucoma"  <?php if ($obj{"glaucoma"} == "on") {echo "checked";};?>><span class=text>Glaucoma</span><br>
  43 <input type=checkbox name="double_vision"  <?php if ($obj{"double_vision"} == "on") {echo "checked";};?>><span class=text>Double Vision</span><br>
  44 <input type=checkbox name="blurred_vision"  <?php if ($obj{"blurred_vision"} == "on") {echo "checked";};?>><span class=text>Blurred Vision</span><br>
  45 <input type=checkbox name="poor_hearing"  <?php if ($obj{"poor_hearing"} == "on") {echo "checked";};?>><span class=text>Poor Hearing</span><br>
  46 <input type=checkbox name="headaches"  <?php if ($obj{"headaches"} == "on") {echo "checked";};?>><span class=text>Headaches</span><br>
  47 <input type=checkbox name="ringing_in_ears"  <?php if ($obj{"ringing_in_ears"} == "on") {echo "checked";};?>><span class=text>Ringing in Ears</span><br>
  48 <input type=checkbox name="bloody_nose"  <?php if ($obj{"bloody_nose"} == "on") {echo "checked";};?>><span class=text>Bloody Nose</span><br>
  49 <input type=checkbox name="sinusitis"  <?php if ($obj{"sinusitis"} == "on") {echo "checked";};?>><span class=text>Sinusitis</span><br>
  50 <input type=checkbox name="sinus_surgery"  <?php if ($obj{"sinus_surgery"} == "on") {echo "checked";};?>><span class=text>Sinus Surgery</span><br>
  51 <input type=checkbox name="dry_mouth"  <?php if ($obj{"dry_mouth"} == "on") {echo "checked";};?>><span class=text>Dry Mouth</span><br>
  52 <input type=checkbox name="strep_throat"  <?php if ($obj{"strep_throat"} == "on") {echo "checked";};?>><span class=text>Strep Throat</span><br>
  53 <input type=checkbox name="tonsillectomy"  <?php if ($obj{"tonsillectomy"} == "on") {echo "checked";};?>><span class=text>Tonsillectomy</span><br>
  54 <input type=checkbox name="swollen_lymph_nodes"  <?php if ($obj{"swollen_lymph_nodes"} == "on") {echo "checked";};?>><span class=text>Swollen Lymph Nodes</span><br>
  55 <input type=checkbox name="throat_cancer"  <?php if ($obj{"throat_cancer"} == "on") {echo "checked";};?>><span class=text>Throat Cancer</span><br>
  56 <input type=checkbox name="throat_cancer_surgery"  <?php if ($obj{"throat_cancer_surgery"} == "on") {echo "checked";};?>><span class=text>Throat Cancer Surgery</span><br>
  57 </td>
  58 <td valign=top>
  59 <span class=bold>Cardiovascular</span><br>
  60 <input type=checkbox name="heart_attack"  <?php if ($obj{"heart_attack"} == "on") {echo "checked";};?>><span class=text>Heart Attack</span><br>
  61 <input type=checkbox name="irregular_heart_beat"  <?php if ($obj{"irregular_heart_beat"} == "on") {echo "checked";};?>><span class=text>Irregular Heart Beat</span><br>
  62 <input type=checkbox name="chest_pains"  <?php if ($obj{"chest_pains"} == "on") {echo "checked";};?>><span class=text>Chest Pains</span><br>
  63 <input type=checkbox name="shortness_of_breath"  <?php if ($obj{"shortness_of_breath"} == "on") {echo "checked";};?>><span class=text>Shortness of Breath</span><br>
  64 <input type=checkbox name="high_blood_pressure"  <?php if ($obj{"high_blood_pressure"} == "on") {echo "checked";};?>><span class=text>High Blood Pressure</span><br>
  65 <input type=checkbox name="heart_failure"  <?php if ($obj{"heart_failure"} == "on") {echo "checked";};?>><span class=text>Heart Failure</span><br>
  66 <input type=checkbox name="poor_circulation"  <?php if ($obj{"poor_circulation"} == "on") {echo "checked";};?>><span class=text>Poor Circulation</span><br>
  67 <input type=checkbox name="vascular_surgery"  <?php if ($obj{"vascular_surgery"} == "on") {echo "checked";};?>><span class=text>Vascular Surgery</span><br>
  68 <input type=checkbox name="cardiac_catheterization"  <?php if ($obj{"cardiac_catheterization"} == "on") {echo "checked";};?>><span class=text>Cardiac Catheterization</span><br>
  69 <input type=checkbox name="coronary_artery_bypass"  <?php if ($obj{"coronary_artery_bypass"} == "on") {echo "checked";};?>><span class=text>Coronary Artery Bypass</span><br>
  70 <input type=checkbox name="heart_transplant"  <?php if ($obj{"heart_transplant"} == "on") {echo "checked";};?>><span class=text>Heart Transplant</span><br>
  71 <input type=checkbox name="stress_test"  <?php if ($obj{"stress_test"} == "on") {echo "checked";};?>><span class=text>Stress Test</span><br>
  72 <span class=bold>Endocrine</span><br>
  73 <input type=checkbox name="insulin_dependent_diabetes"  <?php if ($obj{"insulin_dependent_diabetes"} == "on") {echo "checked";};?>><span class=text>Insulin Dependent Diabetes</span><br>
  74 <input type=checkbox name="noninsulin_dependent_diabetes"  <?php if ($obj{"noninsulin_dependent_diabetes"} == "on") {echo "checked";};?>><span class=text>Non-Insulin Dependent Diabetes</span><br>
  75 <input type=checkbox name="hypothyroidism"  <?php if ($obj{"hypothyroidism"} == "on") {echo "checked";};?>><span class=text>Hypothyroidism</span><br>
  76 <input type=checkbox name="hyperthyroidism"  <?php if ($obj{"hyperthyroidism"} == "on") {echo "checked";};?>><span class=text>Hyperthyroidism</span><br>
  77 <input type=checkbox name="cushing_syndrom"  <?php if ($obj{"cushing_syndrom"} == "on") {echo "checked";};?>><span class=text>Cushing Syndrom</span><br>
  78 <input type=checkbox name="addison_syndrom"  <?php if ($obj{"addison_syndrom"} == "on") {echo "checked";};?>><span class=text>Addison Syndrom</span><br>
  79 </td>
  80 <td valign=top>
  81 <span class=bold>Pulmonary</span><br>
  82 <input type=checkbox name="emphysema"  <?php if ($obj{"emphysema"} == "on") {echo "checked";};?>><span class=text>Emphysema</span><br>
  83 <input type=checkbox name="chronic_bronchitis"  <?php if ($obj{"chronic_bronchitis"} == "on") {echo "checked";};?>><span class=text>Chronic Bronchitis</span><br>
  84 <input type=checkbox name="interstitial_lung_disease"  <?php if ($obj{"interstitial_lung_disease"} == "on") {echo "checked";};?>><span class=text>Interstitial Lung Disease</span><br>
  85 <input type=checkbox name="shortness_of_breath_2"  <?php if ($obj{"shortness_of_breath_2"} == "on") {echo "checked";};?>><span class=text>Shortness of Breath</span><br>
  86 <input type=checkbox name="lung_cancer"  <?php if ($obj{"lung_cancer"} == "on") {echo "checked";};?>><span class=text>Lung Cancer</span><br>
  87 <input type=checkbox name="lung_cancer_surgery"  <?php if ($obj{"lung_cancer_surgery"} == "on") {echo "checked";};?>><span class=text>Lung Cancer Surgery</span><br>
  88 <input type=checkbox name="pheumothorax"  <?php if ($obj{"pheumothorax"} == "on") {echo "checked";};?>><span class=text>Pheumothorax</span><br>
  89 <span class=bold>Genitourinary</span><br>
  90 <input type=checkbox name="kidney_failure"  <?php if ($obj{"kidney_failure"} == "on") {echo "checked";};?>><span class=text>Kidney Failure</span><br>
  91 <input type=checkbox name="kidney_stones"  <?php if ($obj{"kidney_stones"} == "on") {echo "checked";};?>><span class=text>Kidney Stones</span><br>
  92 <input type=checkbox name="kidney_cancer"  <?php if ($obj{"kidney_cancer"} == "on") {echo "checked";};?>><span class=text>Kidney Cancer</span><br>
  93 <input type=checkbox name="kidney_infections"  <?php if ($obj{"kidney_infections"} == "on") {echo "checked";};?>><span class=text>Kidney Infections</span><br>
  94 <input type=checkbox name="bladder_infections"  <?php if ($obj{"bladder_infections"} == "on") {echo "checked";};?>><span class=text>Bladder Infections</span><br>
  95 <input type=checkbox name="bladder_cancer"  <?php if ($obj{"bladder_cancer"} == "on") {echo "checked";};?>><span class=text>Bladder Cancer</span><br>
  96 <input type=checkbox name="prostate_problems"  <?php if ($obj{"prostate_problems"} == "on") {echo "checked";};?>><span class=text>Prostate Problems</span><br>
  97 <input type=checkbox name="prostate_cancer"  <?php if ($obj{"prostate_cancer"} == "on") {echo "checked";};?>><span class=text>Prostate Cancer</span><br>
  98 <input type=checkbox name="kidney_transplant"  <?php if ($obj{"kidney_transplant"} == "on") {echo "checked";};?>><span class=text>Kidney Transplant</span><br>
  99 <input type=checkbox name="sexually_transmitted_disease"  <?php if ($obj{"sexually_transmitted_disease"} == "on") {echo "checked";};?>><span class=text>Sexually Transmitted Disease</span><br>
 100 <input type=checkbox name="burning_with_urination"  <?php if ($obj{"burning_with_urination"} == "on") {echo "checked";};?>><span class=text>Burning with Urination</span><br>
 101 <input type=checkbox name="discharge_from_urethra"  <?php if ($obj{"discharge_from_urethra"} == "on") {echo "checked";};?>><span class=text>Discharge From Urethra</span><br>
 102 </td>
 103 <td valign=top>
 104 <span class=bold>Gastrointestinal</span><br>
 105 <input type=checkbox name="stomach_pains"  <?php if ($obj{"stomach_pains"} == "on") {echo "checked";};?>><span class=text>Stomach Pains</span><br>
 106 <input type=checkbox name="peptic_ulcer_disease"  <?php if ($obj{"peptic_ulcer_disease"} == "on") {echo "checked";};?>><span class=text>Peptic Ulcer Disease</span><br>
 107 <input type=checkbox name="gastritis"  <?php if ($obj{"gastritis"} == "on") {echo "checked";};?>><span class=text>Gastritis</span><br>
 108 <input type=checkbox name="endoscopy"  <?php if ($obj{"endoscopy"} == "on") {echo "checked";};?>><span class=text>Endoscopy</span><br>
 109 <input type=checkbox name="polyps"  <?php if ($obj{"polyps"} == "on") {echo "checked";};?>><span class=text>Polyps</span><br>
 110 <input type=checkbox name="colonoscopy"  <?php if ($obj{"colonoscopy"} == "on") {echo "checked";};?>><span class=text>colonoscopy</span><br>
 111 <input type=checkbox name="colon_cancer"  <?php if ($obj{"colon_cancer"} == "on") {echo "checked";};?>><span class=text>Colon Cancer</span><br>
 112 <input type=checkbox name="colon_cancer_surgery"  <?php if ($obj{"colon_cancer_surgery"} == "on") {echo "checked";};?>><span class=text>Colon Cancer Surgery</span><br>
 113 <input type=checkbox name="ulcerative_colitis"  <?php if ($obj{"ulcerative_colitis"} == "on") {echo "checked";};?>><span class=text>Ulcerative Colitis</span><br>
 114 <input type=checkbox name="crohns_disease"  <?php if ($obj{"crohns_disease"} == "on") {echo "checked";};?>><span class=text>Crohn's Disease</span><br>
 115 <input type=checkbox name="appendectomy"  <?php if ($obj{"appendectomy"} == "on") {echo "checked";};?>><span class=text>Appendectomy</span><br>
 116 <input type=checkbox name="divirticulitis"  <?php if ($obj{"divirticulitis"} == "on") {echo "checked";};?>><span class=text>Divirticulitis</span><br>
 117 <input type=checkbox name="divirticulitis_surgery"  <?php if ($obj{"divirticulitis_surgery"} == "on") {echo "checked";};?>><span class=text>Divirticulitis Surgery</span><br>
 118 <input type=checkbox name="gall_stones"  <?php if ($obj{"gall_stones"} == "on") {echo "checked";};?>><span class=text>Gall Stones</span><br>
 119 <input type=checkbox name="cholecystectomy"  <?php if ($obj{"cholecystectomy"} == "on") {echo "checked";};?>><span class=text>Cholecystectomy</span><br>
 120 <input type=checkbox name="hepatitis"  <?php if ($obj{"hepatitis"} == "on") {echo "checked";};?>><span class=text>Hepatitis</span><br>
 121 <input type=checkbox name="cirrhosis_of_the_liver"  <?php if ($obj{"cirrhosis_of_the_liver"} == "on") {echo "checked";};?>><span class=text>Cirrhosis of the Liver</span><br>
 122 <input type=checkbox name="splenectomy"  <?php if ($obj{"splenectomy"} == "on") {echo "checked";};?>><span class=text>Splenectomy</span><br>
 123 </td>
 124 <td valign=top>
 125 <span class=bold>Musculoskeletal</span><br>
 126 <input type=checkbox name="osetoarthritis"  <?php if ($obj{"osetoarthritis"} == "on") {echo "checked";};?>><span class=text>Osetoarthritis</span><br>
 127 <input type=checkbox name="rheumotoid_arthritis"  <?php if ($obj{"rheumotoid_arthritis"} == "on") {echo "checked";};?>><span class=text>Rheumotoid Arthritis</span><br>
 128 <input type=checkbox name="lupus"  <?php if ($obj{"lupus"} == "on") {echo "checked";};?>><span class=text>Lupus</span><br>
 129 <input type=checkbox name="ankylosing_sondlilitis"  <?php if ($obj{"ankylosing_sondlilitis"} == "on") {echo "checked";};?>><span class=text>Ankylosing Sondlilitis</span><br>
 130 <input type=checkbox name="swollen_joints"  <?php if ($obj{"swollen_joints"} == "on") {echo "checked";};?>><span class=text>Swollen Joints</span><br>
 131 <input type=checkbox name="stiff_joints"  <?php if ($obj{"stiff_joints"} == "on") {echo "checked";};?>><span class=text>Stiff Joints</span><br>
 132 <input type=checkbox name="broken_bones"  <?php if ($obj{"broken_bones"} == "on") {echo "checked";};?>><span class=text>Broken Bones</span><br>
 133 <input type=checkbox name="neck_problems"  <?php if ($obj{"neck_problems"} == "on") {echo "checked";};?>><span class=text>Neck Problems</span><br>
 134 <input type=checkbox name="back_problems"  <?php if ($obj{"back_problems"} == "on") {echo "checked";};?>><span class=text>Back Problems</span><br>
 135 <input type=checkbox name="back_surgery"  <?php if ($obj{"back_surgery"} == "on") {echo "checked";};?>><span class=text>Back Surgery</span><br>
 136 <input type=checkbox name="scoliosis"  <?php if ($obj{"scoliosis"} == "on") {echo "checked";};?>><span class=text>Scoliosis</span><br>
 137 <input type=checkbox name="herniated_disc"  <?php if ($obj{"herniated_disc"} == "on") {echo "checked";};?>><span class=text>Herniated Disc</span><br>
 138 <input type=checkbox name="shoulder_problems"  <?php if ($obj{"shoulder_problems"} == "on") {echo "checked";};?>><span class=text>Shoulder Problems</span><br>
 139 <input type=checkbox name="elbow_problems"  <?php if ($obj{"elbow_problems"} == "on") {echo "checked";};?>><span class=text>Elbow Problems</span><br>
 140 <input type=checkbox name="wrist_problems"  <?php if ($obj{"wrist_problems"} == "on") {echo "checked";};?>><span class=text>Wrist Problems</span><br>
 141 <input type=checkbox name="hand_problems"  <?php if ($obj{"hand_problems"} == "on") {echo "checked";};?>><span class=text>Hand Problems</span><br>
 142 <input type=checkbox name="hip_problems"  <?php if ($obj{"hip_problems"} == "on") {echo "checked";};?>><span class=text>Hip Problems</span><br>
 143 <input type=checkbox name="knee_problems"  <?php if ($obj{"knee_problems"} == "on") {echo "checked";};?>><span class=text>Knee Problems</span><br>
 144 <input type=checkbox name="ankle_problems"  <?php if ($obj{"ankle_problems"} == "on") {echo "checked";};?>><span class=text>Ankle Problems</span><br>
 145 <input type=checkbox name="foot_problems"  <?php if ($obj{"foot_problems"} == "on") {echo "checked";};?>><span class=text>Foot Problems</span><br>
 146 </td>
 147 </tr>
 148 </table>
 149
 150 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?php echo $obj{"additional_notes"};?></textarea><br>
 151 <br>
 152 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 153 <br>
 154 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 155 </form>
 156 <?php
 157 formFooter();
 158 ?>