contrib/forms/reviewofs/view.php

   1 <?php
   2
   3 /**
   4  * Generated DocBlock
   5  *
   6  * @package OpenEMR
   7  * @link    http://www.open-emr.org
   8  * @author  andres_paglayan <andres_paglayan>
   9  * @author  cfapress <cfapress>
  10  * @author  Robert Down <robertdown@live.com>
  11  * @author  sunsetsystems <sunsetsystems>
  12  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  13  * @copyright Copyright (c) 2008 cfapress <cfapress>
  14  * @copyright Copyright (c) 2017-2022 Robert Down <robertdown@live.com>
  15  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  16  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  17  */
  18
  19 ?>
  20 <?php
  21 require_once("../../globals.php");
  22
  23 use OpenEMR\Core\Header;
  24
  25 ?>
  26 <html><head>
  27     <?php Header::setupHeader(); ?>
  28 </head>
  29 <body class="body_top">
  30 <?php
  31 require_once("$srcdir/api.inc.php");
  32 $obj = formFetch("form_reviewofs", $_GET["id"]);
  33 ?>
  34 <form method=post action="<?php echo $rootdir?>/forms/reviewofs/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form">
  35 <span class="title">Review of Systems Checks</span><br /><br />
  36
  37 <table>
  38 <tr>
  39 <td valign=top>
  40 <span class=bold>General</span><br />
  41 <input type=checkbox name="fever"  <?php if ($obj["fever"] == "on") {
  42     echo "checked";
  43                                    };?>><span class=text>Fever</span><br />
  44 <input type=checkbox name="chills"  <?php if ($obj["chills"] == "on") {
  45     echo "checked";
  46                                     };?>><span class=text>Chills</span><br />
  47 <input type=checkbox name="night_sweats"  <?php if ($obj["night_sweats"] == "on") {
  48     echo "checked";
  49                                           };?>><span class=text>Night Sweats</span><br />
  50 <input type=checkbox name="weight_loss"  <?php if ($obj["weight_loss"] == "on") {
  51     echo "checked";
  52                                          };?>><span class=text>Weight Loss</span><br />
  53 <input type=checkbox name="poor_appetite"  <?php if ($obj["poor_appetite"] == "on") {
  54     echo "checked";
  55                                            };?>><span class=text>Poor Appetite</span><br />
  56 <input type=checkbox name="insomnia"  <?php if ($obj["insomnia"] == "on") {
  57     echo "checked";
  58                                       };?>><span class=text>Insomnia</span><br />
  59 <input type=checkbox name="fatigued"  <?php if ($obj["fatigued"] == "on") {
  60     echo "checked";
  61                                       };?>><span class=text>Fatigued</span><br />
  62 <input type=checkbox name="depressed"  <?php if ($obj["depressed"] == "on") {
  63     echo "checked";
  64                                        };?>><span class=text>Depressed</span><br />
  65 <input type=checkbox name="hyperactive"  <?php if ($obj["hyperactive"] == "on") {
  66     echo "checked";
  67                                          };?>><span class=text>Hyperactive</span><br />
  68 <input type=checkbox name="exposure_to_foreign_countries"  <?php if ($obj["exposure_to_foreign_countries"] == "on") {
  69     echo "checked";
  70                                                            };?>><span class=text>Exposure to Foreign Countries</span><br />
  71 <span class=bold>Skin</span><br />
  72 <input type=checkbox name="rashes"  <?php if ($obj["rashes"] == "on") {
  73     echo "checked";
  74                                     };?>><span class=text>Rashes</span><br />
  75 <input type=checkbox name="infections"  <?php if ($obj["infections"] == "on") {
  76     echo "checked";
  77                                         };?>><span class=text>Infections</span><br />
  78 <input type=checkbox name="ulcerations"  <?php if ($obj["ulcerations"] == "on") {
  79     echo "checked";
  80                                          };?>><span class=text>Ulcerations</span><br />
  81 <input type=checkbox name="pemphigus"  <?php if ($obj["pemphigus"] == "on") {
  82     echo "checked";
  83                                        };?>><span class=text>Pemphigus</span><br />
  84 <input type=checkbox name="herpes"  <?php if ($obj["herpes"] == "on") {
  85     echo "checked";
  86                                     };?>><span class=text>Herpes</span><br />
  87 </td>
  88 <td valign=top>
  89 <span class=bold>HEENT</span><br />
  90 <input type=checkbox name="cataracts"  <?php if ($obj["cataracts"] == "on") {
  91     echo "checked";
  92                                        };?>><span class=text>Cataracts</span><br />
  93 <input type=checkbox name="cataract_surgery"  <?php if ($obj["cataract_surgery"] == "on") {
  94     echo "checked";
  95                                               };?>><span class=text>Cataract Surgery</span><br />
  96 <input type=checkbox name="glaucoma"  <?php if ($obj["glaucoma"] == "on") {
  97     echo "checked";
  98                                       };?>><span class=text>Glaucoma</span><br />
  99 <input type=checkbox name="double_vision"  <?php if ($obj["double_vision"] == "on") {
 100     echo "checked";
 101                                            };?>><span class=text>Double Vision</span><br />
 102 <input type=checkbox name="blurred_vision"  <?php if ($obj["blurred_vision"] == "on") {
 103     echo "checked";
 104                                             };?>><span class=text>Blurred Vision</span><br />
 105 <input type=checkbox name="poor_hearing"  <?php if ($obj["poor_hearing"] == "on") {
 106     echo "checked";
 107                                           };?>><span class=text>Poor Hearing</span><br />
 108 <input type=checkbox name="headaches"  <?php if ($obj["headaches"] == "on") {
 109     echo "checked";
 110                                        };?>><span class=text>Headaches</span><br />
 111 <input type=checkbox name="ringing_in_ears"  <?php if ($obj["ringing_in_ears"] == "on") {
 112     echo "checked";
 113                                              };?>><span class=text>Ringing in Ears</span><br />
 114 <input type=checkbox name="bloody_nose"  <?php if ($obj["bloody_nose"] == "on") {
 115     echo "checked";
 116                                          };?>><span class=text>Bloody Nose</span><br />
 117 <input type=checkbox name="sinusitis"  <?php if ($obj["sinusitis"] == "on") {
 118     echo "checked";
 119                                        };?>><span class=text>Sinusitis</span><br />
 120 <input type=checkbox name="sinus_surgery"  <?php if ($obj["sinus_surgery"] == "on") {
 121     echo "checked";
 122                                            };?>><span class=text>Sinus Surgery</span><br />
 123 <input type=checkbox name="dry_mouth"  <?php if ($obj["dry_mouth"] == "on") {
 124     echo "checked";
 125                                        };?>><span class=text>Dry Mouth</span><br />
 126 <input type=checkbox name="strep_throat"  <?php if ($obj["strep_throat"] == "on") {
 127     echo "checked";
 128                                           };?>><span class=text>Strep Throat</span><br />
 129 <input type=checkbox name="tonsillectomy"  <?php if ($obj["tonsillectomy"] == "on") {
 130     echo "checked";
 131                                            };?>><span class=text>Tonsillectomy</span><br />
 132 <input type=checkbox name="swollen_lymph_nodes"  <?php if ($obj["swollen_lymph_nodes"] == "on") {
 133     echo "checked";
 134                                                  };?>><span class=text>Swollen Lymph Nodes</span><br />
 135 <input type=checkbox name="throat_cancer"  <?php if ($obj["throat_cancer"] == "on") {
 136     echo "checked";
 137                                            };?>><span class=text>Throat Cancer</span><br />
 138 <input type=checkbox name="throat_cancer_surgery"  <?php if ($obj["throat_cancer_surgery"] == "on") {
 139     echo "checked";
 140                                                    };?>><span class=text>Throat Cancer Surgery</span><br />
 141 </td>
 142 <td valign=top>
 143 <span class=bold>Cardiovascular</span><br />
 144 <input type=checkbox name="heart_attack"  <?php if ($obj["heart_attack"] == "on") {
 145     echo "checked";
 146                                           };?>><span class=text>Heart Attack</span><br />
 147 <input type=checkbox name="irregular_heart_beat"  <?php if ($obj["irregular_heart_beat"] == "on") {
 148     echo "checked";
 149                                                   };?>><span class=text>Irregular Heart Beat</span><br />
 150 <input type=checkbox name="chest_pains"  <?php if ($obj["chest_pains"] == "on") {
 151     echo "checked";
 152                                          };?>><span class=text>Chest Pains</span><br />
 153 <input type=checkbox name="shortness_of_breath"  <?php if ($obj["shortness_of_breath"] == "on") {
 154     echo "checked";
 155                                                  };?>><span class=text>Shortness of Breath</span><br />
 156 <input type=checkbox name="high_blood_pressure"  <?php if ($obj["high_blood_pressure"] == "on") {
 157     echo "checked";
 158                                                  };?>><span class=text>High Blood Pressure</span><br />
 159 <input type=checkbox name="heart_failure"  <?php if ($obj["heart_failure"] == "on") {
 160     echo "checked";
 161                                            };?>><span class=text>Heart Failure</span><br />
 162 <input type=checkbox name="poor_circulation"  <?php if ($obj["poor_circulation"] == "on") {
 163     echo "checked";
 164                                               };?>><span class=text>Poor Circulation</span><br />
 165 <input type=checkbox name="vascular_surgery"  <?php if ($obj["vascular_surgery"] == "on") {
 166     echo "checked";
 167                                               };?>><span class=text>Vascular Surgery</span><br />
 168 <input type=checkbox name="cardiac_catheterization"  <?php if ($obj["cardiac_catheterization"] == "on") {
 169     echo "checked";
 170                                                      };?>><span class=text>Cardiac Catheterization</span><br />
 171 <input type=checkbox name="coronary_artery_bypass"  <?php if ($obj["coronary_artery_bypass"] == "on") {
 172     echo "checked";
 173                                                     };?>><span class=text>Coronary Artery Bypass</span><br />
 174 <input type=checkbox name="heart_transplant"  <?php if ($obj["heart_transplant"] == "on") {
 175     echo "checked";
 176                                               };?>><span class=text>Heart Transplant</span><br />
 177 <input type=checkbox name="stress_test"  <?php if ($obj["stress_test"] == "on") {
 178     echo "checked";
 179                                          };?>><span class=text>Stress Test</span><br />
 180 <span class=bold>Endocrine</span><br />
 181 <input type=checkbox name="insulin_dependent_diabetes"  <?php if ($obj["insulin_dependent_diabetes"] == "on") {
 182     echo "checked";
 183                                                         };?>><span class=text>Insulin Dependent Diabetes</span><br />
 184 <input type=checkbox name="noninsulin_dependent_diabetes"  <?php if ($obj["noninsulin_dependent_diabetes"] == "on") {
 185     echo "checked";
 186                                                            };?>><span class=text>Non-Insulin Dependent Diabetes</span><br />
 187 <input type=checkbox name="hypothyroidism"  <?php if ($obj["hypothyroidism"] == "on") {
 188     echo "checked";
 189                                             };?>><span class=text>Hypothyroidism</span><br />
 190 <input type=checkbox name="hyperthyroidism"  <?php if ($obj["hyperthyroidism"] == "on") {
 191     echo "checked";
 192                                              };?>><span class=text>Hyperthyroidism</span><br />
 193 <input type=checkbox name="cushing_syndrom"  <?php if ($obj["cushing_syndrom"] == "on") {
 194     echo "checked";
 195                                              };?>><span class=text>Cushing Syndrom</span><br />
 196 <input type=checkbox name="addison_syndrom"  <?php if ($obj["addison_syndrom"] == "on") {
 197     echo "checked";
 198                                              };?>><span class=text>Addison Syndrom</span><br />
 199 </td>
 200 <td valign=top>
 201 <span class=bold>Pulmonary</span><br />
 202 <input type=checkbox name="emphysema"  <?php if ($obj["emphysema"] == "on") {
 203     echo "checked";
 204                                        };?>><span class=text>Emphysema</span><br />
 205 <input type=checkbox name="chronic_bronchitis"  <?php if ($obj["chronic_bronchitis"] == "on") {
 206     echo "checked";
 207                                                 };?>><span class=text>Chronic Bronchitis</span><br />
 208 <input type=checkbox name="interstitial_lung_disease"  <?php if ($obj["interstitial_lung_disease"] == "on") {
 209     echo "checked";
 210                                                        };?>><span class=text>Interstitial Lung Disease</span><br />
 211 <input type=checkbox name="shortness_of_breath_2"  <?php if ($obj["shortness_of_breath_2"] == "on") {
 212     echo "checked";
 213                                                    };?>><span class=text>Shortness of Breath</span><br />
 214 <input type=checkbox name="lung_cancer"  <?php if ($obj["lung_cancer"] == "on") {
 215     echo "checked";
 216                                          };?>><span class=text>Lung Cancer</span><br />
 217 <input type=checkbox name="lung_cancer_surgery"  <?php if ($obj["lung_cancer_surgery"] == "on") {
 218     echo "checked";
 219                                                  };?>><span class=text>Lung Cancer Surgery</span><br />
 220 <input type=checkbox name="pheumothorax"  <?php if ($obj["pheumothorax"] == "on") {
 221     echo "checked";
 222                                           };?>><span class=text>Pheumothorax</span><br />
 223 <span class=bold>Genitourinary</span><br />
 224 <input type=checkbox name="kidney_failure"  <?php if ($obj["kidney_failure"] == "on") {
 225     echo "checked";
 226                                             };?>><span class=text>Kidney Failure</span><br />
 227 <input type=checkbox name="kidney_stones"  <?php if ($obj["kidney_stones"] == "on") {
 228     echo "checked";
 229                                            };?>><span class=text>Kidney Stones</span><br />
 230 <input type=checkbox name="kidney_cancer"  <?php if ($obj["kidney_cancer"] == "on") {
 231     echo "checked";
 232                                            };?>><span class=text>Kidney Cancer</span><br />
 233 <input type=checkbox name="kidney_infections"  <?php if ($obj["kidney_infections"] == "on") {
 234     echo "checked";
 235                                                };?>><span class=text>Kidney Infections</span><br />
 236 <input type=checkbox name="bladder_infections"  <?php if ($obj["bladder_infections"] == "on") {
 237     echo "checked";
 238                                                 };?>><span class=text>Bladder Infections</span><br />
 239 <input type=checkbox name="bladder_cancer"  <?php if ($obj["bladder_cancer"] == "on") {
 240     echo "checked";
 241                                             };?>><span class=text>Bladder Cancer</span><br />
 242 <input type=checkbox name="prostate_problems"  <?php if ($obj["prostate_problems"] == "on") {
 243     echo "checked";
 244                                                };?>><span class=text>Prostate Problems</span><br />
 245 <input type=checkbox name="prostate_cancer"  <?php if ($obj["prostate_cancer"] == "on") {
 246     echo "checked";
 247                                              };?>><span class=text>Prostate Cancer</span><br />
 248 <input type=checkbox name="kidney_transplant"  <?php if ($obj["kidney_transplant"] == "on") {
 249     echo "checked";
 250                                                };?>><span class=text>Kidney Transplant</span><br />
 251 <input type=checkbox name="sexually_transmitted_disease"  <?php if ($obj["sexually_transmitted_disease"] == "on") {
 252     echo "checked";
 253                                                           };?>><span class=text>Sexually Transmitted Disease</span><br />
 254 <input type=checkbox name="burning_with_urination"  <?php if ($obj["burning_with_urination"] == "on") {
 255     echo "checked";
 256                                                     };?>><span class=text>Burning with Urination</span><br />
 257 <input type=checkbox name="discharge_from_urethra"  <?php if ($obj["discharge_from_urethra"] == "on") {
 258     echo "checked";
 259                                                     };?>><span class=text>Discharge From Urethra</span><br />
 260 </td>
 261 <td valign=top>
 262 <span class=bold>Gastrointestinal</span><br />
 263 <input type=checkbox name="stomach_pains"  <?php if ($obj["stomach_pains"] == "on") {
 264     echo "checked";
 265                                            };?>><span class=text>Stomach Pains</span><br />
 266 <input type=checkbox name="peptic_ulcer_disease"  <?php if ($obj["peptic_ulcer_disease"] == "on") {
 267     echo "checked";
 268                                                   };?>><span class=text>Peptic Ulcer Disease</span><br />
 269 <input type=checkbox name="gastritis"  <?php if ($obj["gastritis"] == "on") {
 270     echo "checked";
 271                                        };?>><span class=text>Gastritis</span><br />
 272 <input type=checkbox name="endoscopy"  <?php if ($obj["endoscopy"] == "on") {
 273     echo "checked";
 274                                        };?>><span class=text>Endoscopy</span><br />
 275 <input type=checkbox name="polyps"  <?php if ($obj["polyps"] == "on") {
 276     echo "checked";
 277                                     };?>><span class=text>Polyps</span><br />
 278 <input type=checkbox name="colonoscopy"  <?php if ($obj["colonoscopy"] == "on") {
 279     echo "checked";
 280                                          };?>><span class=text>colonoscopy</span><br />
 281 <input type=checkbox name="colon_cancer"  <?php if ($obj["colon_cancer"] == "on") {
 282     echo "checked";
 283                                           };?>><span class=text>Colon Cancer</span><br />
 284 <input type=checkbox name="colon_cancer_surgery"  <?php if ($obj["colon_cancer_surgery"] == "on") {
 285     echo "checked";
 286                                                   };?>><span class=text>Colon Cancer Surgery</span><br />
 287 <input type=checkbox name="ulcerative_colitis"  <?php if ($obj["ulcerative_colitis"] == "on") {
 288     echo "checked";
 289                                                 };?>><span class=text>Ulcerative Colitis</span><br />
 290 <input type=checkbox name="crohns_disease"  <?php if ($obj["crohns_disease"] == "on") {
 291     echo "checked";
 292                                             };?>><span class=text>Crohn's Disease</span><br />
 293 <input type=checkbox name="appendectomy"  <?php if ($obj["appendectomy"] == "on") {
 294     echo "checked";
 295                                           };?>><span class=text>Appendectomy</span><br />
 296 <input type=checkbox name="divirticulitis"  <?php if ($obj["divirticulitis"] == "on") {
 297     echo "checked";
 298                                             };?>><span class=text>Divirticulitis</span><br />
 299 <input type=checkbox name="divirticulitis_surgery"  <?php if ($obj["divirticulitis_surgery"] == "on") {
 300     echo "checked";
 301                                                     };?>><span class=text>Divirticulitis Surgery</span><br />
 302 <input type=checkbox name="gall_stones"  <?php if ($obj["gall_stones"] == "on") {
 303     echo "checked";
 304                                          };?>><span class=text>Gall Stones</span><br />
 305 <input type=checkbox name="cholecystectomy"  <?php if ($obj["cholecystectomy"] == "on") {
 306     echo "checked";
 307                                              };?>><span class=text>Cholecystectomy</span><br />
 308 <input type=checkbox name="hepatitis"  <?php if ($obj["hepatitis"] == "on") {
 309     echo "checked";
 310                                        };?>><span class=text>Hepatitis</span><br />
 311 <input type=checkbox name="cirrhosis_of_the_liver"  <?php if ($obj["cirrhosis_of_the_liver"] == "on") {
 312     echo "checked";
 313                                                     };?>><span class=text>Cirrhosis of the Liver</span><br />
 314 <input type=checkbox name="splenectomy"  <?php if ($obj["splenectomy"] == "on") {
 315     echo "checked";
 316                                          };?>><span class=text>Splenectomy</span><br />
 317 </td>
 318 <td valign=top>
 319 <span class=bold>Musculoskeletal</span><br />
 320 <input type=checkbox name="osetoarthritis"  <?php if ($obj["osetoarthritis"] == "on") {
 321     echo "checked";
 322                                             };?>><span class=text>Osetoarthritis</span><br />
 323 <input type=checkbox name="rheumotoid_arthritis"  <?php if ($obj["rheumotoid_arthritis"] == "on") {
 324     echo "checked";
 325                                                   };?>><span class=text>Rheumotoid Arthritis</span><br />
 326 <input type=checkbox name="lupus"  <?php if ($obj["lupus"] == "on") {
 327     echo "checked";
 328                                    };?>><span class=text>Lupus</span><br />
 329 <input type=checkbox name="ankylosing_sondlilitis"  <?php if ($obj["ankylosing_sondlilitis"] == "on") {
 330     echo "checked";
 331                                                     };?>><span class=text>Ankylosing Sondlilitis</span><br />
 332 <input type=checkbox name="swollen_joints"  <?php if ($obj["swollen_joints"] == "on") {
 333     echo "checked";
 334                                             };?>><span class=text>Swollen Joints</span><br />
 335 <input type=checkbox name="stiff_joints"  <?php if ($obj["stiff_joints"] == "on") {
 336     echo "checked";
 337                                           };?>><span class=text>Stiff Joints</span><br />
 338 <input type=checkbox name="broken_bones"  <?php if ($obj["broken_bones"] == "on") {
 339     echo "checked";
 340                                           };?>><span class=text>Broken Bones</span><br />
 341 <input type=checkbox name="neck_problems"  <?php if ($obj["neck_problems"] == "on") {
 342     echo "checked";
 343                                            };?>><span class=text>Neck Problems</span><br />
 344 <input type=checkbox name="back_problems"  <?php if ($obj["back_problems"] == "on") {
 345     echo "checked";
 346                                            };?>><span class=text>Back Problems</span><br />
 347 <input type=checkbox name="back_surgery"  <?php if ($obj["back_surgery"] == "on") {
 348     echo "checked";
 349                                           };?>><span class=text>Back Surgery</span><br />
 350 <input type=checkbox name="scoliosis"  <?php if ($obj["scoliosis"] == "on") {
 351     echo "checked";
 352                                        };?>><span class=text>Scoliosis</span><br />
 353 <input type=checkbox name="herniated_disc"  <?php if ($obj["herniated_disc"] == "on") {
 354     echo "checked";
 355                                             };?>><span class=text>Herniated Disc</span><br />
 356 <input type=checkbox name="shoulder_problems"  <?php if ($obj["shoulder_problems"] == "on") {
 357     echo "checked";
 358                                                };?>><span class=text>Shoulder Problems</span><br />
 359 <input type=checkbox name="elbow_problems"  <?php if ($obj["elbow_problems"] == "on") {
 360     echo "checked";
 361                                             };?>><span class=text>Elbow Problems</span><br />
 362 <input type=checkbox name="wrist_problems"  <?php if ($obj["wrist_problems"] == "on") {
 363     echo "checked";
 364                                             };?>><span class=text>Wrist Problems</span><br />
 365 <input type=checkbox name="hand_problems"  <?php if ($obj["hand_problems"] == "on") {
 366     echo "checked";
 367                                            };?>><span class=text>Hand Problems</span><br />
 368 <input type=checkbox name="hip_problems"  <?php if ($obj["hip_problems"] == "on") {
 369     echo "checked";
 370                                           };?>><span class=text>Hip Problems</span><br />
 371 <input type=checkbox name="knee_problems"  <?php if ($obj["knee_problems"] == "on") {
 372     echo "checked";
 373                                            };?>><span class=text>Knee Problems</span><br />
 374 <input type=checkbox name="ankle_problems"  <?php if ($obj["ankle_problems"] == "on") {
 375     echo "checked";
 376                                             };?>><span class=text>Ankle Problems</span><br />
 377 <input type=checkbox name="foot_problems"  <?php if ($obj["foot_problems"] == "on") {
 378     echo "checked";
 379                                            };?>><span class=text>Foot Problems</span><br />
 380 </td>
 381 </tr>
 382 </table>
 383
 384 <span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?php echo text($obj["additional_notes"]); ?></textarea><br />
 385 <br />
 386 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 387 <br />
 388 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 389 </form>
 390 <?php
 391 formFooter();
 392 ?>