contrib/forms/example2/new.php

   1 <?php
   2 /*
   3  * The page shown when the user requests a new form
   4  */
   5
   6 include_once("../../globals.php");
   7 include_once("$srcdir/api.inc");
   8
   9 /** CHANGE THIS name to the name of your form **/
  10 $form_name = "My Example Form";
  11
  12 /** CHANGE THIS to match the folder you created for this form **/
  13 $form_folder = "example";
  14
  15 formHeader("Form: ".$forn_name);
  16
  17 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
  18 ?>
  19
  20 <html><head>
  21 <?php html_header_show();?>
  22
  23 <!-- other supporting javascript code -->
  24 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/js/jquery.js"></script>
  25 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/textformat.js"></script>
  26
  27 <!-- page styles -->
  28 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  29 <link rel="stylesheet" href="../../forms/<?php echo $form_folder; ?>/style.css" type="text/css">
  30
  31 <!-- pop up calendar -->
  32 <style type="text/css">@import url(<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar.css);</style>
  33 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar.js"></script>
  34 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar_en.js"></script>
  35 <script type="text/javascript" src="<?php echo $GLOBALS['webroot'] ?>/library/dynarch_calendar_setup.js"></script>
  36
  37 <script language="JavaScript">
  38 // this line is to assist the calendar text boxes
  39 var mypcc = '<?php echo $GLOBALS['phone_country_code'] ?>';
  40 </script>
  41
  42 </head>
  43
  44 <body class="body_top">
  45
  46 <?php echo date("F d, Y", time()); ?>
  47
  48 <form method=post action="<?php echo $rootdir;?>/forms/<?php echo $form_folder; ?>/save.php?mode=new" name="my_form">
  49 <span class="title"><?php xl($form_name, 'e'); ?></span><br>
  50
  51 <!-- Save/Cancel buttons -->
  52 <input type="button" class="save" value="<?php xl('Save','e'); ?>"> &nbsp;
  53 <input type="button" class="dontsave" value="<?php xl('Don\'t Save','e'); ?>"> &nbsp;
  54
  55 <!-- container for the main body of the form -->
  56 <div id="form_container">
  57
  58 <div id="general">
  59 <table>
  60 <tr><td>
  61 Date:
  62    <input type='text' size='10' name='form_date' id='form_date'
  63     value='<?php echo date('Y-m-d', time()); ?>'
  64     title='<?php xl('yyyy-mm-dd','e'); ?>'
  65     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
  66    <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
  67     id='img_form_date' border='0' alt='[?]' style='cursor:pointer;cursor:hand'
  68     title='<?php xl('Click here to choose a date','e'); ?>'>
  69 </td></tr>
  70 <tr><td>
  71 Name: <input id="name" name="name" type="text" size="50" maxlength="250">
  72 Date of Birth:
  73    <input type='text' size='10' name='dob' id='dob'
  74     value='<?php echo $date ?>'
  75     title='<?php xl('yyyy-mm-dd Date of Birth','e'); ?>'
  76     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc);' />
  77    <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
  78     id='img_dob' border='0' alt='[?]' style='cursor:pointer;cursor:hand'
  79     title='<?php xl('Click here to choose a date','e'); ?>'>
  80 </td></tr>
  81 <tr><td>
  82 Phone: <input name="phone" id="phone" type="text" size="15" maxlength="15">
  83 </td></tr>
  84 <tr><td>
  85 Address: <input name="address" id="address" type="text" size="80" maxlength="250">
  86 </td></tr>
  87 </table>
  88 </div>
  89
  90 <div id="bottom">
  91 Use this space to express notes <br>
  92 <textarea name="notes" id="notes" cols="80" rows="4"></textarea>
  93 <br><br>
  94 <div style="text-align:right;">
  95 Signature?
  96 <input type="radio" id="sig" name="sig" value="y">Yes
  97 /
  98 <input type="radio" id="sig" name="sig" value="n">No
  99 &nbsp;&nbsp;
 100 Date of signature:
 101    <input type='text' size='10' name='sig_date' id='sig_date'
 102     value='<?php echo date('Y-m-d', time()); ?>'
 103     title='<?php xl('yyyy-mm-dd','e'); ?>'
 104     onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' />
 105    <img src='../../pic/show_calendar.gif' align='absbottom' width='24' height='22'
 106     id='img_sig_date' border='0' alt='[?]' style='cursor:pointer;cursor:hand'
 107     title='<?php xl('Click here to choose a date','e'); ?>'>
 108 </div>
 109 </div>
 110
 111 </div> <!-- end form_container -->
 112
 113 <!-- Save/Cancel buttons -->
 114 <input type="button" class="save" value="<?php xl('Save','e'); ?>"> &nbsp;
 115 <input type="button" class="dontsave" value="<?php xl('Don\'t Save','e'); ?>"> &nbsp;
 116 </form>
 117
 118 </body>
 119
 120 <script language="javascript">
 121 /* required for popup calendar */
 122 Calendar.setup({inputField:"dob", ifFormat:"%Y-%m-%d", button:"img_dob"});
 123 Calendar.setup({inputField:"form_date", ifFormat:"%Y-%m-%d", button:"img_form_date"});
 124 Calendar.setup({inputField:"sig_date", ifFormat:"%Y-%m-%d", button:"img_sig_date"});
 125
 126 // jQuery stuff to make the page a little easier to use
 127
 128 $(document).ready(function(){
 129     $(".save").click(function() { top.restoreSession(); document.my_form.submit(); });
 130     $(".dontsave").click(function() { location.href='<?php echo "$rootdir/patient_file/encounter/$returnurl";?>'; });
 131 });
 132 </script>
 133
 134 </html>
 135