interface/forms/bronchitis/new.php

   1 <!-- Form created by Nikolai Vitsyn: 2004/01/23  -->
   2 <!--                          Update 2004/01/29  -->
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 formHeader("Form: bronchitis");
   7 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   8 ?>
   9 <html><head>
  10 <SCRIPT LANGUAGE="JavaScript">
  11 <!--
  12
  13    function onset_check (form)   {
  14
  15         var d, s = "Today's date is: "; //Declare variables.
  16         d = new Date(); //Create Date object.
  17         s += (d.getMonth() + 1) + "-"; //Get month
  18         s += d.getDate() + "-"; //Get day
  19         s += d.getYear(); //Get year.
  20
  21     onset_str = form.bronchitis_date_of_illness.value;
  22     if (onset_str == "") {
  23     alert("No valid date into Onset of illness field!!! Enter date as YYYY-MM-DD");
  24     alert(d);
  25
  26         return;
  27       }
  28     if (onset_str.length != 10) {
  29      alert("Your date should be 10 characters");
  30         return;
  31       }
  32     alert("OK, Bye!!!");
  33     return;
  34    }
  35 </SCRIPT>
  36
  37 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  38 </head>
  39 <body <?echo $top_bg_line;?>
  40 topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  41
  42 <form method=post action="<?echo $rootdir;?>/forms/bronchitis/save.php?mode=new" name="my_form">
  43 <br></br>
  44 <span class="title" ><?php xl('Bronchitis Form','e'); ?></span>
  45 <br></br>
  46
  47 <a href="javascript:document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
  48 <br>
  49 <a href="<?echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link" style="color: #483D8B">[<?php xl('Don\'t Save','e'); ?>]</a>
  50 <br></br>
  51 <span class="text" ><?php xl('Onset of Illness:','e'); ?> </span><input type="entry" name="bronchitis_date_of_illness" value=""></input>
  52 <br></br>
  53
  54 <span class="text" ><?php xl('HPI:','e'); ?>:</span><br></br>
  55 <textarea name="bronchitis_hpi" rows="4" cols="67" wrap="virtual name"></textarea>
  56 <br></br>
  57
  58 <table ><th colspan="5"><?php xl('Other Pertinent Symptoms:','e'); ?></th>
  59 <tr>
  60 <td width="80" align="right"><?php xl('Fever:','e'); ?></td>
  61 <td><input type="checkbox" name="bronchitis_ops_fever"></input></td>
  62 <td width="100" align="right"><?php xl('Cough:','e'); ?></td>
  63 <td><input type="checkbox" name="bronchitis_ops_cough"></input></td>
  64 <td width="60" align="right"><?php xl('Dizziness:','e'); ?></td>
  65 <td><input type="checkbox" name="bronchitis_ops_dizziness"></input></td>
  66 </tr>
  67 <tr>
  68 <td width="80" align="right"><?php xl('Chest Pain:','e'); ?></td>
  69 <td><input type="checkbox" name="bronchitis_ops_chest_pain"></input></td>
  70 <td width="100" align="right"><?php xl('Dyspnea:','e'); ?></td>
  71 <td><input type="checkbox" name="bronchitis_ops_dyspnea"></input></td>
  72 <td width="60" align="right"><?php xl('Sweating:','e'); ?></td>
  73 <td><input type="checkbox" name="bronchitis_ops_sweating"></input></td>
  74 </tr>
  75 <tr>
  76 <td width="80" align="right"><?php xl('Wheezing:','e'); ?></td>
  77 <td><input type="checkbox" name="bronchitis_ops_wheezing"></input></td>
  78 <td width="100" align="right"><?php xl('Malaise:','e'); ?></td>
  79 <td><input type="checkbox" name="bronchitis_ops_malaise"></input></td>
  80 </tr>
  81 <tr>
  82 <td width="80" align="right"><?php xl('Sputum:','e'); ?></td>
  83 <td><input type="checkbox" name="bronchitis_ops_sputum"></input></td>
  84 <td width="100" align="right"><?php xl('Appearance:','e'); ?></td>
  85 <td><input type="text" name="bronchitis_ops_appearance" size="10" value="<?php xl('none','e'); ?>"></input></td>
  86 </tr>
  87 </table>
  88
  89 <table>
  90 <tr>
  91 <td width="205" align="right"><?php xl('All Reviewed and Negative:','e'); ?></td>
  92 <td><input type="checkbox" name="bronchitis_ops_all_reviewed"></input></td>
  93 </tr>
  94 </table>
  95 <br></br>
  96
  97
  98 <table >
  99 <tr>
 100 <td width="60"><?php xl('Review of PMH:','e'); ?></td>
 101 <td align="right"></td>
 102 <td><input type="checkbox" name="bronchitis_review_of_pmh"></input></td>
 103 <td align="right"><?php xl('Medications:','e'); ?></td>
 104 <td><input type="checkbox" name="bronchitis_review_of_medications"></input></td>
 105 <td align="right"><?php xl('Allergies:','e'); ?></td>
 106 <td><input type="checkbox" name="bronchitis_review_of_allergies"></input></td>
 107 <td align="right"><?php xl('Social History:','e'); ?></td>
 108 <td><input type="checkbox" name="bronchitis_review_of_sh"></input></td>
 109 <td align="right"><?php xl('Family History:','e'); ?></td>
 110 <td><input type="checkbox" name="bronchitis_review_of_fh"></input></td>
 111 </tr>
 112 </table>
 113 <br></br>
 114
 115 <table>
 116 <tr>
 117 <td width="60"><?php xl('TM\'S:','e'); ?></td>
 118 <td align="right"><?php xl('Normal Right:','e'); ?></td>
 119 <td><input type="checkbox" name="bronchitis_tms_normal_right"></input></td>
 120 <td align="right"><?php xl('Left:','e'); ?></td>
 121 <td><input type="checkbox" name="bronchitis_tms_normal_left"></input></td>
 122
 123 <td width="80"><?php xl('NARES:','e'); ?> </td>
 124 <td align="right"><?php xl('Normal Right','e'); ?></td>
 125 <td><input type="checkbox" name="bronchitis_nares_normal_right"></input></td>
 126 <td align="right"><?php xl('Left:','e'); ?></td>
 127 <td><input type="checkbox" name="bronchitis_nares_normal_left"></input></td>
 128 </tr>
 129
 130 <tr>
 131 <td width="50"></td>
 132 <td align="right"><?php xl('Thickened Right:','e'); ?></td>
 133 <td><input type="checkbox" name="bronchitis_tms_thickened_right"></input></td>
 134 <td align="right"><?php xl('Left:','e'); ?></td>
 135 <td><input type="checkbox" name="bronchitis_tms_thickened_left"></input></td>
 136
 137 <td width="80"></td>
 138 <td align="right"><?php xl('Swelling Right','e'); ?></td>
 139 <td><input type="checkbox" name="bronchitis_nares_swelling_right"></input></td>
 140 <td align="right"><?php xl('Left:','e'); ?></td>
 141 <td><input type="checkbox" name="bronchitis_nares_swelling_left"></input></td>
 142 </tr>
 143
 144 <tr>
 145 <td width="50"></td>
 146 <td align="right"><?php xl('A/F Level Right:','e'); ?></td>
 147 <td><input type="checkbox" name="bronchitis_tms_af_level_right"></input></td>
 148 <td align="right"><?php xl('Left:','e'); ?></td>
 149 <td><input type="checkbox" name="bronchitis_tms_af_level_left"></input></td>
 150
 151 <td width="80"></td>
 152 <td align="right"><?php xl('Discharge Right:','e'); ?></td>
 153 <td><input type="checkbox" name="bronchitis_nares_discharge_right"></input></td>
 154 <td align="right"><?php xl('Left:','e'); ?></td>
 155 <td><input type="checkbox" name="bronchitis_nares_discharge_left"></input></td>
 156 </tr>
 157
 158 <tr>
 159 <td width="50"></td>
 160 <td align="right"><?php xl('Retracted Right:','e'); ?></td>
 161 <td><input type="checkbox" name="bronchitis_tms_retracted_right"></input></td>
 162 <td align="right"><?php xl('Left:','e'); ?></td>
 163 <td><input type="checkbox" name="bronchitis_tms_retracted_left"></input></td>
 164 </tr>
 165
 166 <tr>
 167 <td width="50"></td>
 168 <td align="right"><?php xl('Bulging Right:','e'); ?></td>
 169 <td><input type="checkbox" name="bronchitis_tms_bulging_right"></input></td>
 170 <td align="right"><?php xl('Left:','e'); ?></td>
 171 <td><input type="checkbox" name="bronchitis_tms_bulging_left"></input></td>
 172
 173 </tr>
 174
 175 <tr>
 176 <td width="50"></td>
 177 <td align="right"><?php xl('Perforated Right:','e'); ?></td>
 178 <td><input type="checkbox" name="bronchitis_tms_perforated_right"></input></td>
 179 <td align="right"><?php xl('Left:','e'); ?></td>
 180 <td><input type="checkbox" name="bronchitis_tms_perforated_left"></input></td>
 181 </tr>
 182 </table>
 183
 184 <table>
 185 <tr>
 186 <td width="220" align="right"><?php xl('Not Examined:','e'); ?></td>
 187 <td><input type="checkbox" name="bronchitis_tms_nares_not_examined"></input></td>
 188 </tr>
 189 </table>
 190 <br></br>
 191
 192 <table>
 193 <tr>
 194 <td width="90"><?php xl('SINUS TENDERNESS:','e'); ?></td>
 195 <td align="right"><?php xl('No Sinus Tenderness:','e'); ?></td>
 196 <td><input type="checkbox" name="bronchitis_no_sinus_tenderness"></input></td>
 197 <td align="right"></td>
 198
 199 <td width="90"><?php xl('OROPHARYNX: ','e'); ?></td>
 200 <td align="right"><?php xl('Normal Oropharynx:','e'); ?></td>
 201 <td><input type="checkbox" name="bronchitis_oropharynx_normal"></input></td>
 202 <td align="right"></td>
 203 </tr>
 204
 205 <tr>
 206 <td width="50"></td>
 207 <td align="right"><?php xl('Frontal Right:','e'); ?></td>
 208 <td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_right"></input></td>
 209 <td align="right"><?php xl('Left:','e'); ?></td>
 210 <td><input type="checkbox" name="bronchitis_sinus_tenderness_frontal_left"></input></td>
 211 <td align="right"><?php xl('Erythema:','e'); ?></td>
 212 <td><input type="checkbox" name="bronchitis_oropharynx_erythema"></input></td>
 213 <td align="right"><?php xl('Exudate:','e'); ?></td>
 214 <td><input type="checkbox" name="bronchitis_oropharynx_exudate"></input></td>
 215 <td align="right"><?php xl('Abcess:','e'); ?></td>
 216 <td><input type="checkbox" name="bronchitis_oropharynx_abcess"></input></td>
 217 <td align="right"><?php xl('Ulcers:','e'); ?></td>
 218 <td><input type="checkbox" name="bronchitis_oropharynx_ulcers"></input></td>
 219 </tr>
 220
 221 <tr>
 222 <td width="50"></td>
 223 <td align="right"><?php xl('Maxillary Right:','e'); ?></td>
 224 <td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_right"></input></td>
 225 <td align="right"><?php xl('Left:','e'); ?></td>
 226 <td><input type="checkbox" name="bronchitis_sinus_tenderness_maxillary_left"></input></td>
 227
 228 <td width="120" align="right"><?php xl('Appearance:','e'); ?></td>
 229 <td><input type="text" name="bronchitis_oropharynx_appearance" size="10" value="normal"></input></td>
 230 </tr>
 231 </table>
 232
 233 <table>
 234 <tr>
 235 <td width="238" align="right" ><?php xl('Not Examined:','e'); ?> </td>
 236 <td><input type="checkbox" name="bronchitis_sinus_tenderness_not_examined"></input></td>
 237 <td width="268" align="right" ><?php xl('Not Examined:','e'); ?> </td>
 238 <td><input type="checkbox" name="bronchitis_oropharynx_not_examined"></input></td>
 239 </tr>
 240 </table>
 241 <br></br>
 242
 243 <table>
 244 <tr>
 245 <td width="60"><?php xl('HEART:','e');?></td>
 246 <td align="right"><?php xl('laterally displaced PMI:','e'); ?></td>
 247 <td><input type="checkbox" name="bronchitis_heart_pmi"></input></td>
 248 <td align="right"><?php xl('S3:','e'); ?></td>
 249 <td><input type="checkbox" name="bronchitis_heart_s3"></input></td>
 250 <td align="right"><?php xl('S4:','e'); ?></td>
 251 <td><input type="checkbox" name="bronchitis_heart_s4"></input></td>
 252 </tr>
 253 <tr>
 254 <td width="60"></td>
 255 <td align="right"><?php xl('Click:','e'); ?></td>
 256 <td><input type="checkbox" name="bronchitis_heart_click"></input></td>
 257 <td align="right"><?php xl('Rub:','e'); ?></td>
 258 <td><input type="checkbox" name="bronchitis_heart_rub"></input></td>
 259 </tr>
 260 </table>
 261
 262 <table>
 263 <tr>
 264 <td width="60"></td>
 265 <td><?php xl('Murmur:','e'); ?></td>
 266 <td><input type="text" name="bronchitis_heart_murmur" size="10" value="none"></input></td>
 267 <td><?php xl('Grade:','e'); ?></td>
 268 <td><input type="text" name="bronchitis_heart_grade" size="10" value="n/a"></input></td>
 269 <td><?php xl('Location:','e'); ?></td>
 270 <td><input type="text" name="bronchitis_heart_location" size="10" value="n/a"></input></td>
 271 </tr>
 272 </table>
 273
 274 <table>
 275 <tr>
 276 <td width="203" align="right" ><?php xl('Normal Cardiac Exam: ','e'); ?></td>
 277 <td><input type="checkbox" name="bronchitis_heart_normal"></input></td>
 278 <td width="93" align="right"><?php xl('Not Examined:','e'); ?> </td>
 279 <td><input type="checkbox" name="bronchitis_heart_not_examined"></input></td>
 280 </tr>
 281 </table>
 282 <br></br>
 283
 284 <table>
 285 <tr>
 286 <td width="60"><?php xl('LUNGS:','e'); ?></td>
 287 <td width="106"><?php xl('Breath Sounds:','e'); ?></td>
 288 <td align="right"> <?php xl('normal:','e'); ?></td>
 289 <td><input type="checkbox" name="bronchitis_lungs_bs_normal"></input></td>
 290 <td align="right"><?php xl('reduced:','e'); ?></td>
 291 <td><input type="checkbox" name="bronchitis_lungs_bs_reduced"></input></td>
 292 <td align="right"><?php xl('increased:','e'); ?></td>
 293 <td><input type="checkbox" name="bronchitis_lungs_bs_increased"></input></td>
 294 </tr>
 295
 296 <tr>
 297 <td width="60"></td>
 298 <td><?php xl('Crackles:','e'); ?></td>
 299 <td align="right"><?php xl('LLL:','e'); ?></td>
 300 <td><input type="checkbox" name="bronchitis_lungs_crackles_lll"></input></td>
 301 <td align="right"><?php xl('RLL:','e'); ?></td>
 302 <td><input type="checkbox" name="bronchitis_lungs_crackles_rll"></input></td>
 303 <td align="right"><?php xl('Bilateral:','e'); ?></td>
 304 <td><input type="checkbox" name="bronchitis_lungs_crackles_bll"></input></td>
 305 </tr>
 306
 307 <tr>
 308 <td width="60"></td>
 309 <td><?php xl('Rubs:','e'); ?></td>
 310 <td align="right"><?php xl('LLL:','e'); ?></td>
 311 <td><input type="checkbox" name="bronchitis_lungs_rubs_lll"></input></td>
 312 <td align="right"><?php xl('RLL:','e'); ?></td>
 313 <td><input type="checkbox" name="bronchitis_lungs_rubs_rll"></input></td>
 314 <td align="right"><?php xl('Bilateral:','e'); ?></td>
 315 <td><input type="checkbox" name="bronchitis_lungs_rubs_bll"></input></td>
 316 </tr>
 317
 318 <tr>
 319 <td width="60"></td>
 320 <td><?php xl('Wheezes:','e'); ?></td>
 321 <td align="right"><?php xl('LLL:','e'); ?></td>
 322 <td><input type="checkbox" name="bronchitis_lungs_wheezes_lll"></input></td>
 323 <td align="right"><?php xl('RLL:','e'); ?></td>
 324 <td><input type="checkbox" name="bronchitis_lungs_wheezes_rll"></input></td>
 325 <td align="right"><?php xl('Bilateral:','e'); ?></td>
 326 <td><input type="checkbox" name="bronchitis_lungs_wheezes_bll"></input></td>
 327 <td align="right"><?php xl('Diffuse:','e'); ?></td>
 328 <td><input type="checkbox" name="bronchitis_lungs_wheezes_dll"></input></td>
 329 </tr>
 330 </table>
 331
 332 <table>
 333 <tr>
 334 <td width="218" align="right" ><?php xl('Normal Lung Exam: ','e'); ?></td>
 335 <td><input type="checkbox" name="bronchitis_lungs_normal_exam"></input></td>
 336 <td width="140" align="right" ><?php xl('Not Examined: ','e'); ?></td>
 337 <td><input type="checkbox" name="bronchitis_lungs_not_examined"></input></td>
 338 </tr>
 339 </table>
 340 <br></br>
 341
 342 <span class="text" ><?php xl('Diagnostic Tests:','e'); ?></span><br></br>
 343 <textarea name="bronchitis_diagnostic_tests" rows="4" cols="67" wrap="virtual name"></textarea>
 344 <br></br>
 345
 346 <span class="text" ><?php xl('Diagnosis:','e'); ?> </span>
 347 <table><tr>
 348    <td>
 349    <select name="diagnosis1_bronchitis_form" >
 350       <option value="None"><?php xl('None','e'); ?></option>
 351       <option value="465.9, URI"><?php xl('465.9, URI','e'); ?></option>
 352       <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS','e'); ?></option>
 353       <option value="493.92, Astma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.','e'); ?></option>
 354       <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic','e'); ?></option>
 355       <option value="496.0, COPD"><?php xl('496.0, COPD','e'); ?></option>
 356       <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation','e'); ?></option>
 357       <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute','e'); ?></option>
 358       <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm','e'); ?></option>
 359       <br><br>
 360    </select>
 361    </td>
 362 </tr>
 363 <tr>
 364    <td>
 365    <select name="diagnosis2_bronchitis_form">
 366       <option value="None"><?php xl('None','e'); ?></option>
 367       <option value="465.9, URI"><?php xl('465.9, URI','e'); ?></option>
 368       <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS','e'); ?></option>
 369       <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.','e'); ?></option>
 370       <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic','e'); ?></option>
 371       <option value="496.0, COPD"><?php xl('496.0, COPD','e'); ?></option>
 372       <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation','e'); ?></option>
 373       <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute','e'); ?></option>
 374       <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm','e'); ?></option>
 375       <br><br>
 376    </select>
 377    </td>
 378 </tr>
 379 <tr>
 380    <td>
 381    <select name="diagnosis3_bronchitis_form">
 382       <option value="None"><?php xl('None','e'); ?></option>
 383       <option value="465.9, URI"><?php xl('465.9, URI','e'); ?></option>
 384       <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS','e'); ?></option>
 385       <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.','e'); ?></option>
 386       <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic','e'); ?></option>
 387       <option value="496.0, COPD"><?php xl('496.0, COPD','e'); ?></option>
 388       <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation','e'); ?></option>
 389       <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute','e'); ?></option>
 390       <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm','e'); ?></option>
 391      <br><br>
 392    </select>
 393    </td>
 394 </tr>
 395 <tr>
 396    <td>
 397    <select name="diagnosis4_bronchitis_form">
 398       <option value="None"><?php xl('None','e'); ?></option>
 399       <option value="465.9, URI"><?php xl('465.9, URI','e'); ?></option>
 400       <option value="466.0, Bronchitis, Acute NOS"><?php xl('466.0, Bronchitis, Acute NOS','e'); ?></option>
 401       <option value="493.92, Asthma, Acute Exac."><?php xl('493.92, Asthma, Acute Exac.','e'); ?></option>
 402       <option value="491.8, Bronchitis, Chronic"><?php xl('491.8, Bronchitis, Chronic','e'); ?></option>
 403       <option value="496.0, COPD"><?php xl('496.0, COPD','e'); ?></option>
 404       <option value="491.21,COPD Exacerbation"><?php xl('491.21, COPD Exacerbation','e'); ?></option>
 405       <option value="486.0, Pneumonia, Acute"><?php xl('486.0, Pneumonia, Acute','e'); ?></option>
 406       <option value="519.7, Bronchospasm"><?php xl('519.7, Bronchospasm','e'); ?></option>
 407      <br><br>
 408    </select>
 409    </td>
 410 </tr>
 411 <table>
 412 <br></br>
 413
 414 <span class="text" ><?php xl('Additional Diagnosis:','e'); ?> </span><br></br>
 415 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name"></textarea>
 416 <br></br>
 417
 418 <span class="text" ><?php xl('Treatment:','e'); ?> </span><br></br>
 419 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name"></textarea>
 420
 421 <br></br>
 422 <input type="Button" value="<?php xl('Check Input Data','e'); ?>" style="color: #483D8B" onClick = "onset_check(my_form)"<br>
 423 <br>
 424 <a href="javascript:document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
 425 <br>
 426 <a href="<?echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link" style="color: #483D8B">[<?php xl('Don\'t Save','e'); ?>]</a>
 427 </form>
 428
 429 <?php
 430 formFooter();
 431 ?>