1 <!-- Form generated from formsWiz
-->
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: hearingtest");
8 <?php
html_header_show();?
>
9 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
11 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
12 <form method
=post action
="<?php echo $rootdir;?>/forms/hearingtest/save.php?mode=new" name
="my_form">
13 <span
class="title">Hearing Test
</span
><br
><br
>
14 <input type
=checkbox name
='with_hearing_aid' ><span
class=text
>With hearing Aid?
</span
><br
>
18 <span
class=text
>Right Ear
250: </span
><input type
=entry name
="right_ear_250" value
="" ><br
>
19 <span
class=text
>Right Ear
500: </span
><input type
=entry name
="right_ear_500" value
="" ><br
>
20 <span
class=text
>Right Ear
1000: </span
><input type
=entry name
="right_ear_1000" value
="" ><br
>
21 <span
class=text
>Right Ear
2000: </span
><input type
=entry name
="right_ear_2000" value
="" ><br
>
22 <span
class=text
>Right Ear
3000: </span
><input type
=entry name
="right_ear_3000" value
="" ><br
>
23 <span
class=text
>Right Ear
4000: </span
><input type
=entry name
="right_ear_4000" value
="" ><br
>
24 <span
class=text
>Right Ear
5000: </span
><input type
=entry name
="right_ear_5000" value
="" ><br
>
25 <span
class=text
>Right Ear
6000: </span
><input type
=entry name
="right_ear_6000" value
="" ><br
>
28 <span
class=text
>Left Ear
250: </span
><input type
=entry name
="left_ear_250" value
="" ><br
>
29 <span
class=text
>Left Ear
500: </span
><input type
=entry name
="left_ear_500" value
="" ><br
>
30 <span
class=text
>Left Ear
1000: </span
><input type
=entry name
="left_ear_1000" value
="" ><br
>
31 <span
class=text
>Left Ear
2000: </span
><input type
=entry name
="left_ear_2000" value
="" ><br
>
32 <span
class=text
>Left Ear
3000: </span
><input type
=entry name
="left_ear_3000" value
="" ><br
>
33 <span
class=text
>Left Ear
4000: </span
><input type
=entry name
="left_ear_4000" value
="" ><br
>
34 <span
class=text
>Left Ear
5000: </span
><input type
=entry name
="left_ear_5000" value
="" ><br
>
35 <span
class=text
>Left Ear
6000: </span
><input type
=entry name
="left_ear_6000" value
="" ><br
>
43 <span
class=text
>Additional Notes
: </span
><br
><textarea cols
=40 rows
=8 name
="additional_notes" ></textarea
>
48 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
50 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick
="top.restoreSession()">[Don
't Save]</a>