interface/forms/ankleinjury/view.php

   1 <!-- Ankle Injury View Form created by Nikolai Vitsyn by 2004/02/19 -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <?php html_header_show();?>
   7 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
   8 </head>
   9 <body class="body_top">
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_ankleinjury", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?php echo $rootdir?>/forms/ankleinjury/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  15 <span class="title"><?php xl('Ankle Evaluation Form','e');?></span><br></br>
  16
  17 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e');?>]</a>
  18 <br>
  19 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  20  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes','e');?>]</a>
  21 <br></br>
  22
  23 <span class=text>Date of Injury: </span><input type=entry name="ankle_date_of_injuary" value="<?php echo stripslashes($obj{"ankle_date_of_injuary"});?>" >
  24 <td align="right"><?php xl('Work related?','e');?>:</td>
  25 <td><input type=checkbox name="ankle_work_related" <?php if ($obj{"ankle_work_related"} == "on")
  26 echo "checked";;?>><span class=text></span><br></td>
  27
  28 <table >
  29 <tr>
  30 <td align="right"><?php xl('Foot:','e');?></td>
  31 <td><input type=radio name="ankle_foot" value="Left" <?php if ($obj{"ankle_foot"} == "Left")
  32 {echo "checked";};?>><span class=text></span><br></td>
  33 <td align="right"><?php xl('Left:','e');?></td>
  34 <td><input type=radio name="ankle_foot" value="Right" <?php if ($obj{"ankle_foot"} == "Right")
  35 {echo "checked";};?>><span class=text></span><br></td>
  36 <td align="right"><?php xl('Right:','e');?></td>
  37 </tr>
  38 </table>
  39
  40 <table >
  41 <tr>
  42 <td align="right"><?php xl('Severity of Pain:','e');?></td>
  43 <td align="right">1:</td>
  44 <td><input type=radio name="ankle_severity_of_pain" value="1" <?php if ($obj{"ankle_severity_of_pain"} == "1")
  45 {echo "checked";};?>><span class=text></span><br></td>
  46
  47 <td align="right">2:</td>
  48 <td><input type=radio name="ankle_severity_of_pain" value="2" <?php if ($obj{"ankle_severity_of_pain"} == "2")
  49 {echo "checked";};?>><span class=text></span><br></td>
  50
  51 <td align="right">3:</td>
  52 <td><input type=radio name="ankle_severity_of_pain" value="3" <?php if ($obj{"ankle_severity_of_pain"} == "3")
  53 {echo "checked";};?>><span class=text></span><br></td>
  54 </tr>
  55 </table>
  56
  57 <table><tr>
  58 <td align="right"><?php xl('Significant Swelling:','e');?></td>
  59 <td><input type=checkbox name="ankle_significant_swelling" <?php if ($obj{"ankle_significant_swelling"} == "on")
  60 {echo "checked";};?>><span class=text></span><br>
  61 </tr>
  62 </table>
  63
  64
  65 <table >
  66 <tr>
  67 <td align="right"><?php xl('Onset of Swelling:','e');?></td>
  68 <td><input type=radio name="ankle_onset_of_swelling" value="within minutes" <?php if ($obj{"ankle_onset_of_swelling"} == "within minutes")
  69 {echo "checked";};?>><span class=text></span><br></td>
  70 <td align="right"><?php xl('within minutes:','e');?></td>
  71 <td><input type=radio name="ankle_onset_of_swelling" value="within hours" <?php if ($obj{"ankle_onset_of_swelling"} == "within hours")
  72 {echo "checked";};?>><span class=text></span><br></td>
  73 <td align="right"><?php xl('within hours:','e');?></td>
  74 </tr>
  75 </table>
  76
  77 <span class="text"><?php xl('How did Injury Occur?:','e');?></span></br>
  78 <textarea name="ankle_how_did_injury_occur" cols ="67" rows="4"  wrap="virtual name">
  79 <?php echo stripslashes($obj{"ankle_how_did_injury_occur"});?></textarea>
  80 <br>
  81
  82 <table><th colspan="5"><?php xl('Ottawa Ankle Rules','e');?></th>
  83 <tr>
  84 <td align="right"><?php xl('Bone Tenderness:','e');?></td>
  85 <td align="right"><?php xl('Medial malleolus:','e');?></td>
  86 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Medial malleolus" <?php if ($obj{"ankle_ottawa_bone_tenderness"} == "Medial malleolus")
  87 {echo "checked";};?>><span class=text></span><br></td>
  88 <td align="right"><?php xl('Lateral malleolus:','e');?></td>
  89 <td><input type=radio name="ankle_ottawa_bone_tenderness"  value="Lateral malleolus" <?php if ($obj{"ankle_ottawa_bone_tenderness"} == "Lateral malleolus")
  90 {echo "checked";};?>><span class=text></span><br></td>
  91 <td align="right"><?php xl('Base of fifth (5th) Metarsal:','e');?></td>
  92 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Base of fifth (5th) Metarsal" <?php if ($obj{"ankle_ottawa_bone_tenderness"} == "Base of fifth (5th) Metarsal")
  93 {echo "checked";};?>><span class=text></span><br></td>
  94 <td align="right"><?php xl('At the Navicular:','e');?></td>
  95 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="At the Navicular" <?php if ($obj{"ankle_ottawa_bone_tenderness"} == "At the Navicular")
  96 {echo "checked";};?>><span class=text></span><br></td>
  97 </tr>
  98 </table>
  99
 100 <table >
 101 <tr>
 102 <td align="right"><?php xl('Able to Bear Weight four (4) steps:','e');?></td>
 103 <td align="right"><?php xl('Yes:','e');?></td>
 104 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="Yes" <?php if ($obj{"ankle_able_to_bear_weight_steps"} == "Yes")
 105 {echo "checked";};?>><span class=text></span><br></td>
 106 <td align="right"><?php xl('No:','e');?></td>
 107 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="No" <?php if ($obj{"ankle_able_to_bear_weight_steps"} == "No")
 108 {echo "checked";};?>><span class=text></span><br></td>
 109 </tr>
 110 </table>
 111
 112 <table>
 113 <tr><th><?php xl('X-Ray Interpretation:','e');?></th> <th><?php xl('Additional X-RAY Notes:','e');?></th></tr>
 114 <tr>
 115 <td>
 116 <input type=entry name="ankle_x_ray_interpretation" value="<?php echo
 117 stripslashes($obj{"ankle_x_ray_interpretation"});?>" size="50">
 118 </td>
 119 <td rowspan=2>
 120 <textarea name="ankle_additional_x_ray_notes" cols ="30" rows="1" wrap="virtual name">
 121 <?php echo stripslashes($obj{"ankle_additional_x_ray_notes"});?></textarea>
 122 <td>
 123 </tr>
 124 </table>
 125
 126 <table>
 127 <tr><th><?php xl('Diagnosis:','e');?></th><th><?php xl('Additional Diagnosis:','e');?></th></tr>
 128 <tr>
 129 <td><input type=entry name="ankle_diagnosis1" value="<?php echo
 130 stripslashes($obj{"ankle_diagnosis1"});?>" size="50">
 131 </td>
 132 <td rowspan=2>
 133 <textarea name="ankle_additional_diagnisis" rows="2" cols="30" wrap="virtual name">
 134 <?php echo stripslashes($obj{"ankle_additional_diagnisis"});?></textarea>
 135 </td>
 136
 137 <tr>
 138 <td><input type=entry name="ankle_diagnosis2" value="<?php echo
 139 stripslashes($obj{"ankle_diagnosis2"});?>" size="50"></td>
 140 </tr>
 141 <td><input type=entry name="ankle_diagnosis3" value="<?php echo
 142 stripslashes($obj{"ankle_diagnosis3"});?>" size="50"></td>
 143 </tr>
 144 <td><input type=entry name="ankle_diagnosis4" value="<?php echo
 145 stripslashes($obj{"ankle_diagnosis4"});?>" size="50"></td>
 146 </tr>
 147 </table>
 148
 149 <table><tr><th><?php xl('Plan:','e');?></th><tr>
 150 <tr><td>
 151 <textarea name="ankle_plan" rows="4" cols="67" wrap="virtual name">
 152 <?php echo stripslashes($obj{"ankle_plan"});?></textarea>
 153 </td></tr></table>
 154
 155 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e');?>]</a>
 156 <br>
 157 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
 158  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes','e');?>]</a>
 159 </form>
 160 <?php
 161 formFooter();
 162 ?>