contrib/forms/vitalsigns/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: vitalsigns");
   6 ?>
   7 <html><head>
   8 <?php html_header_show();?>
   9 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  10 </head>
  11 <body class="body_top">
  12 <form method=post action="<?php echo $rootdir;?>/forms/vitalsigns/save.php?mode=new" name="my_form">
  13 <span class="title">Vital Signs</span><br><br>
  14 <span class=bold>Blood Pressure</span><br>
  15
  16 <table width=100%>
  17 <tr>
  18 <td>
  19 <span class=text>Standing: </span><input size=3 type=entry name="standing_bp_1" value="" >
  20 <input size=3 type=entry name="standing_bp_2" value="" >
  21 </td>
  22 <td>
  23 <span class=text>Sitting: </span><input size=3 type=entry name="sitting_bp_1" value="" >
  24 <input size=3 type=entry name="sitting_bp_2" value="" >
  25 </td>
  26 <td>
  27 <span class=text>Supine: </span><input size=3 type=entry name="supine_bp_1" value="" >
  28 <input size=3 type=entry name="supine_bp_2" value="" >
  29 </td>
  30 <td>
  31 <span class=text>Systolic: </span><input size=3 type=entry name="systolic_bp_1" value="" >
  32 <input size=3 type=entry name="systolic_bp_2" value="" >
  33 </td>
  34 <td>
  35 <span class=text>Diastolic: </span><input size=3 type=entry name="diastolic_bp_1" value="" >
  36 <input size=3 type=entry name="diastolic_bp_2" value="" >
  37 </td>
  38 </tr>
  39 </table>
  40
  41 <table><tr>
  42 <tr><td><span class=text>Heart Rate (Beats/Minute): </span></td><td><input size=3 type=entry name="heart_rate_beats_per_minute" value="" ></td>
  43 <td><span class=text>Respiration (Breaths/Minute): </span></td><td><input size=3 type=entry name="respiration_beats_per_minute" value="" ></td></tr>
  44 </table>
  45
  46 <table>
  47 <tr>
  48 <td><span class=text>Temperature: </span><input size=3 type=entry name="temperature_c" value="" ><span class=text> (C)</span></td>
  49 <td><input size=3 type=entry name="temperature_f" value="" ><span class=text> (F)</span></td>
  50 <td><span class=text>Temperature Method: </span><input type=entry name="temperature_method" value="" ></td>
  51
  52 </tr><tr>
  53
  54 <td><span class=text>Height (Feet): </span><input size=3 type=entry name="height_feet" value="" ></td>
  55 <td><span class=text>Height (Inches): </span><input size=3 type=entry name="height_inches" value="" ></td>
  56 <td><span class=text>Height (Centimeters): </span><input size=3 type=entry name="height_centimeters" value="" ></td>
  57
  58 </tr><tr>
  59
  60 <td><span class=text>Weight (Lbs): </span><input size=3 type=entry name="weight_lbs" value="" ></td>
  61 <td><span class=text>Weight (Ozs): </span><input size=3 type=entry name="weight_ozs" value="" ></td>
  62 <td><span class=text>Weight (Kgs): </span><input size=3 type=entry name="weight_kgs" value="" ></td>
  63
  64 </tr><tr>
  65
  66 </tr></table>
  67
  68 <span class=text>Body Mass Index: </span><input size=5 type=entry name="body_mass_index" value="" >
  69 <span class=text>Figure Shape (If Overweight): </span><input type=entry name="figure_shape" value="" >
  70
  71 <br>
  72 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea>
  73
  74 <br>
  75 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  76 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  77 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save]</a>
  78 </form>
  79 <?php
  80 formFooter();
  81 ?>