contrib/forms/ped_GI/form.php

   1 <?php
   2
   3 /*
   4 Pediatric GI assesment
   5 This form works as new and editing,
   6 */
   7 ?>
   8 <TABLE span class=text>
   9 <th><H2><U>Pediatric GI Form</U></H2></th>
  10
  11 <TR>
  12         <TD>Has Diarrhea:</TD>
  13         <TD>
  14                 <SELECT NAME="diarrhea">
  15                 <option <?php if ($obj["diarrhea"]=='no') print 'selected'; ?>>no
  16                 <option <?php if ($obj["diarrhea"]=='yes') print 'selected'; ?>>yes
  17                 </SELECT>
  18         </TD>
  19         <TD>Every bowel movement:</TD>
  20         <TD>
  21                 <SELECT NAME="with_every_bowel_movement">
  22                 <option <?php if ($obj["with_every_bowel_movement"]=='n/a') print 'selected'; ?>>n/a
  23                 <option <?php if ($obj["with_every_bowel_movement"]=='no') print 'selected'; ?>>no
  24                 <option <?php if ($obj["with_every_bowel_movement"]=='yes') print 'selected'; ?>>yes
  25                 </SELECT>
  26         </TD>
  27         <TD>After Every meal:</TD>
  28         <TD>
  29                 <SELECT NAME="after_every_meal">
  30                 <option <?php if ($obj["after_every_meal"]=='n/a') print 'selected'; ?>>n/a
  31                 <option <?php if ($obj["after_every_meal"]=='no') print 'selected'; ?>>no
  32                 <option <?php if ($obj["after_every_meal"]=='yes') print 'selected'; ?>>yes
  33                 </SELECT>
  34         </TD>
  35 </TD>
  36 <TR>
  37         <TD>Blood or mocus in stool:</TD>
  38         <TD>
  39                 <SELECT NAME="blood_or_mucus_in_stool">
  40                 <option <?php if ($obj["blood_or_mucus_in_stool"]=='no') print 'selected'; ?>>no
  41                 <option <?php if ($obj["blood_or_mucus_in_stool"]=='blood') print 'selected'; ?>>blood
  42                 <option <?php if ($obj["blood_or_mucus_in_stool"]=='mucus') print 'selected'; ?>>mucus
  43                 <option <?php if ($obj["blood_or_mucus_in_stool"]=='both') print 'selected'; ?>>both
  44                 </SELECT>
  45         </TD>
  46         <TD>Onset:</TD>
  47         <TD>
  48                 <SELECT NAME="diarrhea_onset">
  49                 <option <?php if ($obj["diarrhea_onset"]=='one hour') print 'selected'; ?>>one hour
  50                 <option <?php if ($obj["diarrhea_onset"]=='twelve hours') print 'selected'; ?>>twelve hours
  51                 <option <?php if ($obj["diarrhea_onset"]=='one day') print 'selected'; ?>>one day
  52                 <option <?php if ($obj["diarrhea_onset"]=='two days') print 'selected'; ?>>two days
  53                 <option <?php if ($obj["diarrhea_onset"]=='three days') print 'selected'; ?>>three days
  54                 <option <?php if ($obj["diarrhea_onset"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  55                 </SELECT>
  56         </TD>
  57         <TD>Worms:</TD>
  58         <TD>
  59                 <SELECT NAME="worms">
  60                 <option <?php if ($obj["worms"]=='no') print 'selected'; ?>>no
  61                 <option <?php if ($obj["worms"]=='yes') print 'selected'; ?>>yes
  62                 </SELECT>
  63         </TD>
  64 </TR>
  65
  66 <TR>
  67         <TD>Vomiting:</TD>
  68         <TD>
  69                 <SELECT NAME="vomits">
  70                 <option <?php if ($obj["vomits"]=='no') print 'selected'; ?>>no
  71                 <option <?php if ($obj["vomits"]=='yes') print 'selected'; ?>>yes
  72                 </SELECT>
  73         </TD>
  74         <TD>Duration:</TD>
  75         <TD>
  76                 <SELECT NAME="duration">
  77                 <option <?php if ($obj["duration"]=='one hour') print 'selected'; ?>>one hour
  78                 <option <?php if ($obj["duration"]=='twelve hours') print 'selected'; ?>>twelve hours
  79                 <option <?php if ($obj["duration"]=='one day') print 'selected'; ?>>one day
  80                 <option <?php if ($obj["duration"]=='two days') print 'selected'; ?>>two days
  81                 <option <?php if ($obj["duration"]=='three days') print 'selected'; ?>>three days
  82                 <option <?php if ($obj["duration"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  83                 </SELECT>
  84         </TD>
  85         <TD >Proyectile:</TD>
  86         <TD>
  87                 <SELECT NAME="projectile">
  88                 <option <?php if ($obj["projectile"]=='n/a') print 'selected'; ?>>n/a
  89                 <option <?php if ($obj["projectile"]=='no') print 'selected'; ?>>no
  90                 <option <?php if ($obj["projectile"]=='yes') print 'selected'; ?>>yes
  91                 </SELECT>
  92         </TD>
  93 </TR>
  94 <TR>
  95         <TD >+ often than 2 hours:</TD>
  96         <TD>
  97                 <SELECT NAME="more_often_than_2_hours">
  98                 <option <?php if ($obj["more_often_than_2_hours"]=='n/a') print 'selected' ;?> >n/a
  99                 <option <?php if ($obj["more_often_than_2_hours"]=='no') print 'selected' ;?> >no
 100                 <option <?php if ($obj["more_often_than_2_hours"]=='yes') print 'selected'; ?>>yes
 101                 </SELECT>
 102         </TD>
 103         <TD >After every meal:</TD>
 104         <TD>
 105                 <SELECT NAME="vomit_after_every_meal">
 106                 <option <?php if ($obj["vomit_after_every_meal"]=='n/a') print 'selected' ;?> >n/a
 107                 <option <?php if ($obj["vomit_after_every_meal"]=='no') print 'selected' ;?> >no
 108                 <option <?php if ($obj["vomit_after_every_meal"]=='yes') print 'selected'; ?>>yes
 109                 </SELECT>
 110         </TD>
 111         <TD >Blood in vomitus:</TD>
 112         <TD>
 113                 <SELECT NAME="blood_in_vomitus">
 114                 <option <?php if ($obj["blood_in_vomitus"]=='n/a') print 'selected' ;?> >n/a
 115                 <option <?php if ($obj["blood_in_vomitus"]=='no') print 'selected' ;?> >no
 116                 <option <?php if ($obj["blood_in_vomitus"]=='yes') print 'selected'; ?>>yes
 117                 </SELECT>
 118         </TD>
 119 </TR>
 120
 121 <TR>
 122         <TD>Takink Medication:</TD>
 123         <TD>
 124                 <SELECT NAME="taking_medication">
 125                 <option <?php if ($obj["taking_medication"]=='no') print 'selected'; ?>>no
 126                 <option <?php if ($obj["taking_medication"]=='yes') print 'selected'; ?>>yes
 127         </TD>
 128         <TD>Oral Rehidration solution:</TD>
 129         <TD>
 130                 <SELECT NAME="oral_rehydration">
 131                 <option <?php if ($obj["taking_oral_rehydration_solution"]=='yes') print 'selected'; ?>>yes
 132                 <option <?php if ($obj["taking_oral_rehydration_solution"]=='no') print 'selected'; ?>>no
 133         </TD>
 134         <TD>Eating Solid Food</TD>
 135         <TD>
 136                 <SELECT NAME="eating_solid_food">
 137                 <option <?php if ($obj["eating_solid_food"]=='yes') print 'selected'; ?>>yes
 138                 <option <?php if ($obj["eating_solid_food"]=='no') print 'selected'; ?>>no
 139         </TD>
 140 </TR>
 141 <TR>
 142         <TD>Fever: </TD>
 143         <TD>
 144                 <SELECT NAME="fever">
 145                 <option <?php if ($obj["fever"]=='no') print 'selected' ;?> >no
 146                 <option <?php if ($obj["fever"]=='yes') print 'selected'; ?>>yes
 147                 </SELECT>
 148         </TD>
 149         <TD >Pain:</TD>
 150         <TD>
 151                 <SELECT NAME="pain">
 152                 <option <?php if ($obj["pain"]=='no pain') print 'selected' ;?> >no pain
 153                 <option <?php if ($obj["pain"]=='moderate') print 'selected'; ?>>moderate
 154                 <option <?php if ($obj["pain"]=='intense') print 'selected'; ?>>intense
 155                 <option <?php if ($obj["pain"]=='severe') print 'selected'; ?>>severe
 156                 </SELECT>
 157         </TD>
 158         <TD >Lethargy:</TD>
 159         <TD>
 160                 <SELECT NAME="lethargy">
 161                 <option <?php if ($obj["lethargy"]=='no') print 'selected'; ?>>no
 162                 <option <?php if ($obj["lethargy"]=='yes') print 'selected'; ?>>yes
 163                 </SELECT>
 164         </TD>
 165 </TR>
 166 <!-- common -->
 167 <TR>
 168         <TD>Oral hydration capable:</TD>
 169         <TD>
 170                 <SELECT NAME="oral_hydration_capable">
 171                 <option <?php if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?>>yes
 172                 <option <?php if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?>>no
 173                 </SELECT>
 174         </TD>
 175         <TD>Urine output at least every 6 hrs.</TD>
 176         <TD>
 177                 <SELECT NAME="urine_output_last_6_hours">
 178                 <option <?php if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?>>yes
 179                 <option <?php if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?>>no
 180                 </SELECT>
 181         <TD>With Pain?:</TD>
 182         <TD>
 183                 <SELECT NAME="pain_with_urination">
 184                 <option <?php if ($obj["pain_with_urination"]=='no') print 'selected'; ?>>no
 185                 <option <?php if ($obj["pain_with_urination"]=='yes') print 'selected'; ?>>yes
 186                 </SELECT>
 187         </TD>
 188 </TR>
 189 <TR>
 190         <TD>Cough or difficulty breathing:</TD>
 191         <TD>
 192                 <SELECT NAME="cough_or_breathing_difficulty">
 193                 <option <?php if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?>>no
 194                 <option <?php if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?>>yes
 195                 </SELECT>
 196         </TD>
 197         <TD>Sleeps confortably?:</TD>
 198         <TD>
 199                 <SELECT NAME="able_to_sleep">
 200                 <option <?php if ($obj["able_to_sleep"]=='yes') print 'selected'; ?>>yes
 201                 <option <?php if ($obj["able_to_sleep"]=='no') print 'selected'; ?>>no
 202                 </SELECT>
 203         </TD>
 204 </TR>
 205 <TR>
 206         <TD>Nasal Discharge:</TD>
 207         <TD>
 208                 <SELECT NAME="nasal_discharge">
 209                 <option <?php if ($obj["nasal_discharge"]=='no') print 'selected'; ?>>no
 210                 <option <?php if ($obj["nasal_discharge"]=='yes') print 'selected'; ?>>yes
 211                 </SELECT>
 212         </TD>
 213         <TD>Prior Hospitalization</TD>
 214         <TD>
 215                 <SELECT NAME="previous_hospitalization">
 216                 <option <?php if ($obj["previous_hospitalization"]=='no') print 'selected'; ?>>no
 217                 <option <?php if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?>>yes
 218                 </SELECT>
 219         </TD>
 220         <TD>Siblings affected?:</TD>
 221         <TD>
 222                 <SELECT NAME="siblings_affected">
 223                 <option <?php if ($obj["siblings_affected"]=='no') print 'selected'; ?>>no
 224                 <option <?php if ($obj["siblings_affected"]=='yes') print 'selected'; ?>>yes
 225                 </SELECT>
 226         </TD>
 227 </TR>
 228 <TR>
 229         <TD valign="top">Immunization up to date:</TD>
 230         <TD valign="top">
 231                 <SELECT NAME="immunization_up_to_date">
 232                 <option <?php if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?>>yes
 233                 <option <?php if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?>>no
 234                 </SELECT>
 235         </TD>
 236         <TD colspan=4 align=left valign=top>Notes:
 237         <TEXTAREA NAME="notes" ROWS="3" COLS="40"><?php if ($obj["notes"]!='') print $obj["notes"]; ?></TEXTAREA></TD>
 238 </TR>
 239 </TABLE>
 240
 241