7 * @link http://www.open-emr.org
8 * @author andres_paglayan <andres_paglayan>
9 * @author cornfeed <jdough823@gmail.com>
10 * @author fndtn357 <fndtn357@gmail.com>
11 * @author sunsetsystems <sunsetsystems>
12 * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
13 * @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
14 * @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
15 * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
16 * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
20 <!-- Form generated from formsWiz
-->
22 require_once("../../globals.php");
23 require_once("$srcdir/api.inc.php");
25 use OpenEMR\Core\Header
;
27 formHeader("Form: hearingtest");
30 <?php Header
::setupHeader(); ?
>
32 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
33 <form method
=post action
="<?php echo $rootdir;?>/forms/hearingtest/save.php?mode=new" name
="my_form">
34 <span
class="title">Hearing Test
</span
><br
/><br
/>
35 <input type
=checkbox name
='with_hearing_aid' ><span
class=text
>With hearing Aid?
</span
><br
/>
39 <span
class=text
>Right Ear
250: </span
><input type
="text" name
="right_ear_250" value
="" ><br
/>
40 <span
class=text
>Right Ear
500: </span
><input type
="text" name
="right_ear_500" value
="" ><br
/>
41 <span
class=text
>Right Ear
1000: </span
><input type
="text" name
="right_ear_1000" value
="" ><br
/>
42 <span
class=text
>Right Ear
2000: </span
><input type
="text" name
="right_ear_2000" value
="" ><br
/>
43 <span
class=text
>Right Ear
3000: </span
><input type
="text" name
="right_ear_3000" value
="" ><br
/>
44 <span
class=text
>Right Ear
4000: </span
><input type
="text" name
="right_ear_4000" value
="" ><br
/>
45 <span
class=text
>Right Ear
5000: </span
><input type
="text" name
="right_ear_5000" value
="" ><br
/>
46 <span
class=text
>Right Ear
6000: </span
><input type
="text" name
="right_ear_6000" value
="" ><br
/>
49 <span
class=text
>Left Ear
250: </span
><input type
="text" name
="left_ear_250" value
="" ><br
/>
50 <span
class=text
>Left Ear
500: </span
><input type
="text" name
="left_ear_500" value
="" ><br
/>
51 <span
class=text
>Left Ear
1000: </span
><input type
="text" name
="left_ear_1000" value
="" ><br
/>
52 <span
class=text
>Left Ear
2000: </span
><input type
="text" name
="left_ear_2000" value
="" ><br
/>
53 <span
class=text
>Left Ear
3000: </span
><input type
="text" name
="left_ear_3000" value
="" ><br
/>
54 <span
class=text
>Left Ear
4000: </span
><input type
="text" name
="left_ear_4000" value
="" ><br
/>
55 <span
class=text
>Left Ear
5000: </span
><input type
="text" name
="left_ear_5000" value
="" ><br
/>
56 <span
class=text
>Left Ear
6000: </span
><input type
="text" name
="left_ear_6000" value
="" ><br
/>
64 <span
class=text
>Additional Notes
: </span
><br
/><textarea cols
=40 rows
=8 name
="additional_notes" ></textarea
>
69 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
71 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick
="top.restoreSession()">[Don
't Save]</a>