interface/forms/newpatient/new.php

   1 <?
   2 include_once("../../globals.php");
   3 include_once("$srcdir/calendar.inc");
   4
   5 $months = array("01","02","03","04","05","06","07","08","09","10","11","12");
   6 $days = array("01","02","03","04","05","06","07","08","09","10","11","12","13","14","15","16","17",
   7         "18","19","20","21","22","23","24","25","26","27","28","29","30","31");
   8 $years = array("2004","2005","2006","2007");
   9 ?>
  10
  11 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  12
  13 <html>
  14 <head>
  15 <title>New Encounter</title>
  16
  17 </head>
  18 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0 onload="javascript:document.new_encounter.reason.focus();">
  19
  20 <form method=post action="<?echo $rootdir?>/forms/newpatient/save.php" name=new_encounter target=Main>
  21 <input type=hidden name=mode value='new'>
  22 <span class=title>New Encounter Form</span>
  23 <br>
  24
  25 <table>
  26
  27 <tr><td><select name='facility'>
  28 <?
  29 $dres = sqlStatement("select facility from users where username='".$_SESSION{"authUser"}."'");
  30 $drow = sqlFetchArray($dres);
  31 $fres = sqlStatement("select * from facility order by name");
  32 if ($fres) {
  33 for ($iter = 0; $frow = sqlFetchArray($fres); $iter++)
  34                 $result[$iter] = $frow;
  35 foreach($result as $iter) {
  36 ?>
  37 <option value="<?echo $iter{name};?>" <?if ($drow{facility} == $iter{name}) {echo "selected";};?>><?echo $iter{name};?></option>
  38 <?
  39 }
  40 }
  41 ?>
  42 </select></td><td></td></tr>
  43
  44 <tr><td><span class=text>Chief Complaint:</span></td><td></td></tr>
  45 <tr><td><textarea name='reason' cols='40' rows='6' wrap='virtual'></textarea></td></td></tr>
  46
  47 <tr><td><span class='text'>Date Of Service:</span></td>
  48 <td><select name='month'>
  49 <?
  50 foreach($months as $month){
  51 ?>
  52 <option value="<?echo $month;?>" <?if($month == date("m")) echo "selected";?>><?echo $month?></option>
  53 <?
  54 }
  55 ?>
  56 </select>
  57 <select name='day'>
  58 <?
  59 foreach($days as $day){
  60 ?>
  61 <option value="<?echo $day;?>" <?if($day == date("d")) echo "selected";?>><?echo $day?></option>
  62 <?
  63 }
  64 ?>
  65 </select>
  66 <select name='year'>
  67 <?
  68 foreach($years as $year){
  69 ?>
  70 <option value="<?echo $year;?>" <?if($year == date("Y")) echo "selected";?>><?echo $year?></option>
  71 <?
  72 }
  73 ?>
  74 </select></td></tr>
  75
  76 <tr><td><span class='text'>Date of onset or hospitalization:</span></td>
  77 <td><select name='onset_month'>
  78 <?
  79 foreach($months as $month){
  80 ?>
  81 <option value="<?echo $month;?>" <?if($month == date("m")) echo "selected";?>><?echo $month?></option>
  82 <?
  83 }
  84 ?>
  85 </select>
  86 <select name='onset_day'>
  87 <?
  88 foreach($days as $day){
  89 ?>
  90 <option value="<?echo $day;?>" <?if($day == date("d")) echo "selected";?>><?echo $day?></option>
  91 <?
  92 }
  93 ?>
  94 </select>
  95 <select name='onset_year'>
  96 <?
  97 foreach($years as $year){
  98 ?>
  99 <option value="<?echo $year;?>" <?if($year == date("Y")) echo "selected";?>><?echo $year?></option>
 100 <?
 101 }
 102 ?>
 103 </select></td></tr>
 104
 105 </table>
 106
 107 <a href="javascript:document.new_encounter.submit();" class="link_submit">[Save]</a>
 108 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 109 <?
 110 if (isset($_GET["autoloaded"]) && $_GET["autoloaded"] == "1") {
 111 } else {
 112 ?>
 113 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link">[Don't Save]</a>
 114 <?
 115 }
 116 ?>
 117
 118 </form>
 119
 120 </body>
 121 </html>