interface/forms/bronchitis/view.php

   1 <!-- Form created by Nikolai Vitsyn by 2004/01/23 -->
   2 <?php
   3 include_once("../../globals.php");
   4 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   5 ?>
   6 <html><head>
   7 <?php html_header_show();?>
   8 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body class="body_top">
  11 <?php
  12 include_once("$srcdir/api.inc");
  13 $obj = formFetch("form_bronchitis", $_GET["id"]);
  14 ?>
  15 <form method=post action="<?php echo $rootdir?>/forms/bronchitis/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  16 <span class="title"><?php xl('Bronchitis Form','e'); ?></span><br><br>
  17
  18 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?>]</a>
  19 <br>
  20 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link"
  21  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes','e'); ?>]</a>
  22 <br></br>
  23
  24 <span class=text><?php xl('Onset of Ilness: ','e'); ?></span><input type=entry name="bronchitis_date_of_illness" value="<?php echo stripslashes($obj{"bronchitis_date_of_illness"});?>" ><br></br>
  25
  26 <span class=text><?php xl('HPI:','e'); ?> </span><br><textarea cols=67 rows=8 wrap=virtual name="bronchitis_hpi" ><?php echo stripslashes($obj{"bronchitis_hpi"});?></textarea><br></br>
  27
  28
  29 <table><th colspan="5">"<?php xl('Other Pertinent Symptoms','e'); ?> ":</th>
  30 <tr>
  31 <td width="60" align="right"><?php xl('Fever:','e'); ?> </td>
  32 <td><input type=checkbox name="bronchitis_ops_fever" <?php if ($obj{"bronchitis_ops_fever"} == "on")
  33 {echo "checked";};?>><span class=text></span><br>
  34
  35 <td width="140" align="right"><?php xl('Cough:','e'); ?> </td>
  36 <td><input type=checkbox name="bronchitis_ops_cough" <?php if ($obj{"bronchitis_ops_cough"} == "on")
  37 {echo "checked";};?>><span class=text></span><br>
  38
  39 <td width="170" align="right"><?php xl('Dizziness:','e'); ?> </td>
  40 <td><input type=checkbox name="bronchitis_ops_dizziness" <?php if ($obj{"bronchitis_ops_dizziness"} == "on")
  41 {echo "checked";};?>><span class=text></span><br>
  42 </tr>
  43
  44 <tr>
  45 <td width="60" align="right"><?php xl('Chest Pain:','e'); ?> </td>
  46 <td><input type=checkbox name="bronchitis_ops_chest_pain" <?php if ($obj{"bronchitis_ops_chest_pain"} == "on")
  47 {echo "checked";};?>><span class=text></span><br>
  48 <td width="130" align="right"><?php xl('Dyspnea:','e'); ?> </td>
  49 <td><input type=checkbox name="bronchitis_ops_dyspnea" <?php if ($obj{"bronchitis_ops_dyspnea"} == "on")
  50 {echo "checked";};?>><span class=text></span><br>
  51 <td width="180" align="right"><?php xl('Sweating:','e'); ?> </td>
  52 <td><input type=checkbox name="bronchitis_ops_sweating" <?php if ($obj{"bronchitis_ops_sweating"} == "on")
  53 {echo "checked";};?>><span class=text></span><br>
  54 </tr>
  55
  56 <tr>
  57 <td width="60" align="right"><?php xl('Wheezing:','e'); ?> </td>
  58 <td><input type=checkbox name="bronchitis_ops_wheezing" <?php if ($obj{"bronchitis_ops_wheezing"} == "on")
  59 {echo "checked";};?>><span class=text></span><br>
  60
  61 <td width="130" align="right"><?php xl('Malaise:','e'); ?> </td>
  62 <td><input type=checkbox name="bronchitis_ops_malaise" <?php if ($obj{"bronchitis_ops_malaise"} == "on")
  63 {echo "checked";};?>><span class=text></span><br>
  64 </tr>
  65
  66 <tr>
  67 <td width="60" align="right"><?php xl('Sputum:','e'); ?> </td>
  68 <td><input type=checkbox name="bronchitis_ops_sputum" <?php if ($obj{"bronchitis_ops_sputum"} == "on")
  69 {echo "checked";};?>><span class=text></span><br></td>
  70
  71 <td width="130" align="right"><?php xl('Appearance:','e'); ?>  <span class="text"></span></td>
  72 <td><input type=entry name="bronchitis_ops_appearance" value="<?php echo
  73 stripslashes($obj{"bronchitis_ops_appearance"});?>" size="15"></td>
  74 </tr>
  75 </table>
  76
  77 <table><tr>
  78 <td width="227" align="right"><?php xl('All Reviewed and Negative:','e'); ?> </td>
  79 <td><input type=checkbox name="bronchitis_ops_all_reviewed" <?php if ($obj{"bronchitis_ops_all_reviewed"} == "on")
  80 {echo "checked";};?>><span class=text></span><br>
  81 </tr>
  82 </table>
  83 <br></br>
  84
  85 <table >
  86 <tr>
  87 <td width="60" align="right"><?php xl('Review of PMH:','e'); ?> </td>
  88 <td><input type=checkbox name="bronchitis_review_of_pmh" <?php if ($obj{"bronchitis_review_of_pmh"} == "on")
  89 {echo "checked";};?>><span class=text></span><br></td>
  90 <td align="right"><?php xl('Medications:','e'); ?> </td>
  91 <td><input type=checkbox name="bronchitis_review_of_medications" <?php if ($obj{"bronchitis_review_of_medications"} == "on")
  92 {echo "checked";};?>><span class=text></span><br></td>
  93 <td align="right"><?php xl('Allergies:','e'); ?> </td>
  94 <td><input type=checkbox name="bronchitis_review_of_allergies" <?php if ($obj{"bronchitis_review_of_allergies"} == "on")
  95 {echo "checked";};?>><span class=text></span><br></td>
  96 <td align="right"><?php xl('Social History:','e'); ?> </td>
  97 <td><input type=checkbox name="bronchitis_review_of_sh" <?php if ($obj{"bronchitis_review_of_sh"} == "on")
  98 {echo "checked";};?>><span class=text></span><br></td>
  99 <td align="right"><?php xl('Family History:','e'); ?> </td>
 100 <td><input type=checkbox name="bronchitis_review_of_fh" <?php if ($obj{"bronchitis_review_of_fh"} == "on")
 101 {echo "checked";};?>><span class=text></span><br></td>
 102 </tr>
 103 </table>
 104 <br></br>
 105
 106
 107 <table>
 108 <tr>
 109 <td width="60"><?php xl('TM\'S:','e'); ?> </td>
 110 <td align="right"><?php xl('Normal Right:','e'); ?> </td>
 111 <td><input type=checkbox name="bronchitis_tms_normal_right" <?php if ($obj{"bronchitis_tms_normal_right"} == "on")
 112 {echo "checked";};?>><span class=text></span><br>
 113 <td align="right"><?php xl('Left:','e'); ?> </td>
 114 <td><input type=checkbox name="bronchitis_tms_normal_left" <?php if ($obj{"bronchitis_tms_normal_left"} == "on")
 115 {echo "checked";};?>><span class=text></span><br>
 116 <td align="right"><?php xl('NARES: Normal Right','e'); ?> </td>
 117 <td><input type=checkbox name="bronchitis_nares_normal_right" <?php if ($obj{"bronchitis_nares_normal_right"} == "on")
 118 {echo "checked";};?>><span class=text></span><br>
 119 <td align="right"><?php xl('Left:','e'); ?>  </td>
 120 <td><input type=checkbox name="bronchitis_nares_normal_left" <?php if ($obj{"bronchitis_nares_normal_left"} == "on")
 121 {echo "checked";};?>><span class=text></span><br>
 122 </tr>
 123
 124 <tr>
 125 <td width="60"></td>
 126 <td align="right"> <?php xl('Thickened Right:','e'); ?> </td>
 127 <td><input type=checkbox name="bronchitis_tms_thickened_right" <?php if ($obj{"bronchitis_tms_thickened_right"} == "on")
 128 {echo "checked";};?>><span class=text></span><br>
 129 <td align="right"><?php xl('Left:','e'); ?> </td>
 130 <td><input type=checkbox name="bronchitis_tms_thickened_left" <?php if ($obj{"bronchitis_tms_thickened_left"} == "on")
 131 {echo "checked";};?>><span class=text></span><br>
 132
 133 <td align="right"><?php xl('Swelling Right','e'); ?> </td>
 134 <td><input type=checkbox name="bronchitis_nares_swelling_right" <?php if ($obj{"bronchitis_nares_swelling_right"} == "on")
 135 {echo "checked";};?>><span class=text></span><br>
 136 <td align="right"><?php xl('Left: ','e'); ?> </td>
 137 <td><input type=checkbox name="bronchitis_nares_swelling_left" <?php if ($obj{"bronchitis_nares_swelling_left"} == "on")
 138 {echo "checked";};?>><span class=text></span><br>
 139 </tr>
 140
 141 <tr>
 142 <td width="60"></td>
 143 <td align="right"><?php xl('A/F Level Right:','e'); ?> </td>
 144 <td><input type=checkbox name="bronchitis_tms_af_level_right" <?php if ($obj{"bronchitis_tms_af_level_right"} == "on")
 145 {echo "checked";};?>><span class=text></span><br>
 146 <td align="right"><?php xl('Left:','e'); ?> </td>
 147 <td><input type=checkbox name="bronchitis_tms_af_level_left" <?php if ($obj{"bronchitis_tms_af_level_left"} == "on")
 148 {echo "checked";};?>><span class=text></span><br>
 149
 150 <td align="right"><?php xl('Discharge Right','e'); ?> </td>
 151 <td><input type=checkbox name="bronchitis_nares_discharge_right" <?php if ($obj{"bronchitis_nares_discharge_right"} == "on")
 152 {echo "checked";};?>><span class=text></span><br>
 153 <td align="right"><?php xl('Left: ','e'); ?> </td>
 154 <td><input type=checkbox name="bronchitis_nares_discharge_left" <?php if ($obj{"bronchitis_nares_discharge_left"} == "on")
 155 {echo "checked";};?>><span class=text></span><br>
 156 </tr>
 157
 158 <tr>
 159 <td width="60"></td>
 160 <td align="right"><?php xl('Retracted Right:','e'); ?> </td>
 161 <td><input type=checkbox name="bronchitis_tms_retracted_right" <?php if ($obj{"bronchitis_tms_retracted_right"} == "on")
 162 {echo "checked";};?>><span class=text></span><br>
 163 <td align="right"><?php xl('Left:','e'); ?> </td>
 164 <td><input type=checkbox name="bronchitis_tms_retracted_left" <?php if ($obj{"bronchitis_tms_retracted_left"} == "on")
 165 {echo "checked";};?>><span class=text></span><br>
 166 </tr>
 167
 168 <tr>
 169 <td width="60"></td>
 170 <td align="right"><?php xl('Bulging Right:','e'); ?> </td>
 171 <td><input type=checkbox name="bronchitis_tms_bulging_right" <?php if ($obj{"bronchitis_tms_bulging_right"} == "on")
 172 {echo "checked";};?>><span class=text></span><br>
 173 <td align="right"><?php xl('Left:','e'); ?> </td>
 174 <td><input type=checkbox name="bronchitis_tms_bulging_left" <?php if ($obj{"bronchitis_tms_bulging_left"} == "on")
 175 {echo "checked";};?>><span class=text></span><br>
 176 </tr>
 177
 178 <tr>
 179 <td width="60"></td>
 180 <td align="right"><?php xl('Perforated Right:','e'); ?> </td>
 181 <td><input type=checkbox name="bronchitis_tms_perforated_right" <?php if ($obj{"bronchitis_tms_perforated_right"} == "on")
 182 {echo "checked";};?>><span class=text></span><br>
 183 <td align="right"><?php xl('Left:','e'); ?> </td>
 184 <td><input type=checkbox name="bronchitis_tms_perforated_left" <?php if ($obj{"bronchitis_tms_perforated_left"} == "on")
 185 {echo "checked";};?>><span class=text></span><br>
 186 </tr>
 187 </table>
 188
 189 <table><tr>
 190 <td width="127"></td>
 191 <td align="right"><?php xl('Not Examined:','e'); ?> </td>
 192 <td><input type=checkbox name="bronchitis_tms_nares_not_examined" <?php if ($obj{"bronchitis_tms_nares_not_examined"} == "on")
 193 {echo "checked";};?>><span class=text></span><br>
 194 </tr></table>
 195 <br></br>
 196
 197 <table>
 198 <tr>
 199 <td width="90"><?php xl('SINUS TENDERNESS:','e'); ?> </td>
 200 <td align="right"><?php xl('No Sinus Tenderness:','e'); ?> </td>
 201 <td><input type=checkbox name="bronchitis_no_sinus_tenderness" <?php if ($obj{"bronchitis_no_sinus_tenderness"} == "on")
 202 {echo "checked";};?>><span class=text></span><br>
 203 <td width="90"><?php xl('OROPHARYNX: ','e'); ?> </td>
 204 <td align="right"><?php xl('Normal Oropharynx:','e'); ?> </td>
 205 <td><input type=checkbox name="bronchitis_oropharynx_normal"<?php if ($obj{"bronchitis_oropharynx_normal"} == "on")
 206 {echo "checked";};?>><span class=text></span><br>
 207 </tr>
 208
 209 <tr>
 210 <td width="90" align="right"><?php xl('Frontal Right:','e'); ?>  </td>
 211 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_right" <?php if ($obj{"bronchitis_sinus_tenderness_frontal_right"} == "on")
 212 {echo "checked";};?>><span class=text></span><br>
 213 <td align="right"><?php xl('Left:','e'); ?> </td>
 214 <td><input type=checkbox name="bronchitis_sinus_tenderness_frontal_left" <?php if ($obj{"bronchitis_sinus_tenderness_frontal_left"} == "on")
 215 {echo "checked";};?>><span class=text></span><br>
 216 <td align="right"><?php xl('Erythema:','e'); ?> </td>
 217 <td><input type=checkbox name="bronchitis_oropharynx_erythema" <?php if ($obj{"bronchitis_oropharynx_erythema"} == "on")
 218 {echo "checked";};?>><span class=text></span><br>
 219 <td align="right"><?php xl('Exudate:','e'); ?> </td>
 220 <td><input type=checkbox name="bronchitis_oropharynx_exudate" <?php if ($obj{"bronchitis_oropharynx_exudate"} == "on")
 221 {echo "checked";};?>><span class=text></span><br>
 222 <td align="right"><?php xl('Abcess:','e'); ?> </td>
 223 <td><input type=checkbox name="bronchitis_oropharynx_abcess" <?php if ($obj{"bronchitis_oropharynx_abcess"} == "on")
 224 {echo "checked";};?>><span class=text></span><br>
 225 <td align="right"><?php xl('Ulcers:','e'); ?> </td>
 226 <td><input type=checkbox name="bronchitis_oropharynx_ulcers" <?php if ($obj{"bronchitis_oropharynx_ulcers"} == "on")
 227 {echo "checked";};?>><span class=text></span><br>
 228 </tr>
 229
 230 <tr>
 231 <td width ="90" align="right"><?php xl('Maxillary Right:','e'); ?> </td>
 232 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_right" <?php if ($obj{"bronchitis_sinus_tenderness_maxillary_right"} == "on")
 233 {echo "checked";};?>><span class=text></span><br></td>
 234 <td align="right"><?php xl('Left:','e'); ?> </td>
 235 <td><input type=checkbox name="bronchitis_sinus_tenderness_maxillary_left" <?php if ($obj{"bronchitis_sinus_tenderness_maxillary_left"} == "on")
 236 {echo "checked";};?>><span class=text></span><br></td>
 237 <td width="130" align="right"><?php xl('Appearance:','e'); ?>  <span class="text"></span></td>
 238 <td><input type=entry name="bronchitis_oropharynx_appearance" value="<?php echo
 239 stripslashes($obj{"bronchitis_oropharynx_appearance"});?>" size="15"></td>
 240 </tr>
 241 </table>
 242
 243 <table>
 244 <tr>
 245 <td width="256" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 246 <td><input type=checkbox name="bronchitis_sinus_tenderness_not_examined" <?php if ($obj{"bronchitis_sinus_tenderness_not_examined"} == "on")
 247 {echo "checked";};?>><span class=text></span><br>
 248 <td width="208" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 249 <td><input type=checkbox name="bronchitis_oropharynx_not_examined" <?php if ($obj{"bronchitis_oropharynx_not_examined"} == "on")
 250 {echo "checked";};?>><span class=text></span><br>
 251 </tr>
 252 </table>
 253 <br></br>
 254
 255 <table>
 256 <tr>
 257 <td width="60"><?php xl('HEART:','e'); ?> </td>
 258 <td align="right"><?php xl('laterally displaced PMI:','e'); ?> </td>
 259 <td><input type=checkbox name="bronchitis_heart_pmi" <?php if ($obj{"bronchitis_heart_pmi"} == "on")
 260 {echo "checked";};?>><span class=text></span><br>
 261 <td align="right"><?php xl('S3:','e'); ?> </td>
 262 <td><input type=checkbox name="bronchitis_heart_s3" <?php if ($obj{"bronchitis_heart_s3"} == "on")
 263 {echo "checked";};?>><span class=text></span><br>
 264 <td align="right"><?php xl('S4:','e'); ?> </td>
 265 <td><input type=checkbox name="bronchitis_heart_s4" <?php if ($obj{"bronchitis_heart_s4"} == "on")
 266 {echo "checked";};?>><span class=text></span><br>
 267 </tr>
 268
 269 <tr>
 270 <td width="60"></td>
 271 <td align="right"><?php xl('Click:','e'); ?> </td>
 272 <td><input type=checkbox name="bronchitis_heart_click" <?php if ($obj{"bronchitis_heart_click"} == "on")
 273 {echo "checked";};?>><span class=text></span><br>
 274 <td align="right"><?php xl('Rub:','e'); ?> </td>
 275 <td><input type=checkbox name="bronchitis_heart_rub" <?php if ($obj{"bronchitis_heart_rub"} == "on")
 276 {echo "checked";};?>><span class=text></span><br>
 277 </tr>
 278 </table>
 279
 280 <table><tr>
 281 <td width="200" align="right"><?php xl('Murmur:','e'); ?>  <span class="text"></span></td>
 282 <td><input type=entry name="bronchitis_heart_murmur" value="<?php echo
 283 stripslashes($obj{"bronchitis_heart_murmur"});?>" size="15"></td>
 284
 285 <td><span class="text"><?php xl('Grade:','e'); ?>  </span></td><td>
 286 <input type=entry name="bronchitis_heart_grade" value="<?php echo
 287 stripslashes($obj{"bronchitis_heart_grade"});?>" size="15"></td>
 288
 289 <td><span class="text"><?php xl('Location:','e'); ?>  </span></td><td>
 290 <input type=entry name="bronchitis_heart_location" value="<?php echo
 291 stripslashes($obj{"bronchitis_heart_location"});?>" size="15"></td>
 292 </tr>
 293 </table>
 294
 295 <table><tr>
 296 <td width="205" align="right"><?php xl('Normal Cardiac Exam:','e'); ?>  </td>
 297 <td><input type=checkbox name="bronchitis_heart_normal" <?php if ($obj{"bronchitis_heart_normal"} == "on")
 298 {echo "checked";};?>><span class=text></span><br>
 299 <td width="95" align="right"><?php xl('Not Examined:','e'); ?>  </td>
 300 <td><input type=checkbox name="bronchitis_heart_not_examined" <?php if ($obj{"bronchitis_heart_not_examined"} == "on")
 301 {echo "checked";};?>><span class=text></span><br>
 302 </tr></table>
 303 <br></br>
 304
 305 <table><tr>
 306 <td width="60"><?php xl('Lungs:','e'); ?> </td>
 307 <td width="106"><?php xl('Breath Sounds:','e'); ?> </td>
 308 <td align="right"> <?php xl('normal:','e'); ?> </td>
 309 <td><input type=checkbox name="bronchitis_lungs_bs_normal" <?php if ($obj{"bronchitis_lungs_bs_normal"} == "on")
 310 {echo "checked";};?>><span class=text></span><br>
 311
 312 <td align="right"><?php xl('reduced:','e'); ?> </td>
 313 <td><input type=checkbox name="bronchitis_lungs_bs_reduced" <?php if ($obj{"bronchitis_lungs_bs_reduced"} == "on")
 314 {echo "checked";};?>><span class=text></span><br>
 315
 316 <td align="right"><?php xl('increased:','e'); ?> </td>
 317 <td><input type=checkbox name="bronchitis_lungs_bs_increased" <?php if ($obj{"bronchitis_lungs_bs_increased"} == "on")
 318 {echo "checked";};?>><span class=text></span><br>
 319 </tr>
 320
 321 <tr>
 322 <td width="60"></td>
 323 <td><?php xl('Crackles:','e'); ?> </td>
 324 <td align="right"><?php xl(' LLL:','e'); ?> </td>
 325 <td><input type=checkbox name="bronchitis_lungs_crackles_lll" <?php if ($obj{"bronchitis_lungs_crackles_lll"} == "on")
 326 {echo "checked";};?>><span class=text></span><br>
 327
 328 <td align="right"><?php xl('RLL:','e'); ?> </td>
 329 <td><input type=checkbox name="bronchitis_lungs_crackles_rll" <?php if ($obj{"bronchitis_lungs_crackles_rll"} == "on")
 330 {echo "checked";};?>><span class=text></span><br>
 331
 332 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 333 <td><input type=checkbox name="bronchitis_lungs_crackles_bll" <?php if ($obj{"bronchitis_lungs_crackles_bll"} == "on")
 334 {echo "checked";};?>><span class=text></span><br>
 335 </tr>
 336
 337 <tr>
 338 <td width="60"></td>
 339 <td><?php xl('Rubs:','e'); ?> </td>
 340 <td align="right"><?php xl('LLL:','e'); ?> </td>
 341 <td><input type=checkbox name="bronchitis_lungs_rubs_lll" <?php if ($obj{"bronchitis_lungs_rubs_lll"} == "on")
 342 {echo "checked";};?>><span class=text></span><br>
 343
 344 <td align="right"><?php xl('RLL:','e'); ?> </td>
 345 <td><input type=checkbox name="bronchitis_lungs_rubs_rll" <?php if ($obj{"bronchitis_lungs_rubs_rll"} == "on")
 346 {echo "checked";};?>><span class=text></span><br>
 347
 348 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 349 <td><input type=checkbox name="bronchitis_lungs_rubs_bll" <?php if ($obj{"bronchitis_lungs_rubs_bll"} == "on")
 350 {echo "checked";};?>><span class=text></span><br>
 351 </tr>
 352
 353 <tr>
 354 <td width="60"></td>
 355 <td><?php xl('Wheezes:','e'); ?> </td>
 356 <td align="right"><?php xl('LLL:','e'); ?> </td>
 357 <td><input type=checkbox name="bronchitis_lungs_wheezes_lll" <?php if ($obj{"bronchitis_lungs_wheezes_lll"} == "on")
 358 {echo "checked";};?>><span class=text></span><br>
 359
 360 <td align="right"><?php xl('RLL:','e'); ?> </td>
 361 <td><input type=checkbox name="bronchitis_lungs_wheezes_rll" <?php if ($obj{"bronchitis_lungs_wheezes_rll"} == "on")
 362 {echo "checked";};?>><span class=text></span><br>
 363
 364 <td align="right"><?php xl('Bilateral:','e'); ?> </td>
 365 <td><input type=checkbox name="bronchitis_lungs_wheezes_bll" <?php if ($obj{"bronchitis_lungs_wheezes_bll"} == "on")
 366 {echo "checked";};?>><span class=text></span><br>
 367
 368 <td align="right"><?php xl('Diffuse:','e'); ?> </td>
 369 <td><input type=checkbox name="bronchitis_lungs_wheezes_dll" <?php if ($obj{"bronchitis_lungs_wheezes_dll"} == "on")
 370 {echo "checked";};?>><span class=text></span><br>
 371 </tr>
 372 </table>
 373
 374
 375 <table><tr>
 376 <td width="218" align="right"><?php xl('Normal Lung Exam:','e'); ?>  </td>
 377 <td><input type=checkbox name="bronchitis_lungs_normal_exam" <?php if ($obj{"bronchitis_lungs_normal_exam"} == "on")
 378 {echo "checked";};?>><span class=text></span><br>
 379 <td width="140" align="right"><?php xl('Not Examined','e'); ?> </td>
 380 <td><input type=checkbox name="bronchitis_lungs_not_examined" <?php if ($obj{"bronchitis_lungs_not_examined"} == "on")
 381 {echo "checked";};?>><span class=text></span><br>
 382 </tr></table>
 383 <br></br>
 384
 385 <span class="text"><?php xl('Diagnostic Tests:','e'); ?> </span></br>
 386 <textarea name="bronchitis_diagnostic_tests" cols ="67" rows="4"  wrap="virtual name">
 387 <?php echo stripslashes($obj{"bronchitis_diagnostic_tests"});?></textarea>
 388 <br></br>
 389
 390 <table><tr>
 391 <span class="text"><?php xl('Diagnosis: ','e'); ?> </span>
 392 <br><input type=entry name="diagnosis1_bronchitis_form" value="<?php echo
 393 stripslashes($obj{"diagnosis1_bronchitis_form"});?>" size="40"><br>
 394 </tr>
 395
 396 <tr>
 397 <input type=entry name="diagnosis2_bronchitis_form" value="<?php echo
 398 stripslashes($obj{"diagnosis2_bronchitis_form"});?>" size="40"><br>
 399 </tr>
 400
 401 <tr>
 402 <input type=entry name="diagnosis3_bronchitis_form" value="<?php echo
 403 stripslashes($obj{"diagnosis3_bronchitis_form"});?>" size="40"><br>
 404 </tr>
 405
 406 <tr>
 407 <input type=entry name="diagnosis4_bronchitis_form" value="<?php echo
 408  stripslashes($obj{"diagnosis4_bronchitis_form"});?>" size="40"><br>
 409 </tr>
 410
 411 <table>
 412 <br>
 413 <span class="text"><?php xl('Additional Diagnosis:','e'); ?>  </span></br>
 414 <textarea name="bronchitis_additional_diagnosis" rows="4" cols="67" wrap="virtual name">
 415 <?php echo stripslashes($obj{"bronchitis_additional_diagnosis"});?></textarea>
 416 <br></br>
 417
 418 <span class="text"><?php xl('Treatment: ','e'); ?> </span></br>
 419 <textarea name="bronchitis_treatment" rows="4" cols="67" wrap="virtual name">
 420 <?php echo stripslashes($obj{"bronchitis_treatment"});?></textarea>
 421 </br>
 422
 423 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php xl('Save','e'); ?> ]</a>
 424 <br>
 425 <a href="<?php echo "$rootdir/patient_file/encounter/$returnurl";?>" class="link"
 426  onclick="top.restoreSession()">[<?php xl('Don\'t Save Changes','e'); ?> ]</a>
 427
 428 </form>
 429 <?php
 430 formFooter();
 431 ?>