contrib/forms/vision/new.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  sunsetsystems <sunsetsystems>
  11  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  12  * @copyright Copyright (c) 2008 cfapress <cfapress>
  13  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  14  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  15  */
  16
  17 ?>
  18 <?php
  19 require_once("../../globals.php");
  20 require_once("$srcdir/api.inc.php");
  21
  22 use OpenEMR\Core\Header;
  23
  24 formHeader("Form: vision");
  25 ?>
  26 <html><head>
  27     <?php Header::setupHeader(); ?>
  28 </head>
  29 <body class="body_top">
  30 <form method=post action="<?php echo $rootdir;?>/forms/vision/save.php?mode=new" name="my_form">
  31 <span class="title">Vision</span><br /><br />
  32 <span class=bold>Keratometry</span><br />
  33
  34 <table>
  35 <tr>
  36 <td><span class=text>OD K1: </span></td><td><input size=3 type="text" name="od_k1" value="" ></td>
  37 <td><span class=text>OD K1 Axis: </span></td><td><input size=3 type="text" name="od_k1_axis" value="" ></td>
  38 <td><span class=text>OD K2: </span></td><td><input size=3 type="text" name="od_k2" value="" ></td>
  39 <td><span class=text>OD K2 Axis: </span></td><td><input size=3 type="text" name="od_k2_axis" value="" ></td>
  40 </tr>
  41 <tr>
  42 <td colspan=8>
  43
  44 <span class=text>OD Testing Status: </span><input type="text" name="od_testing_status" value="" >
  45 </td>
  46 </tr>
  47 </table>
  48
  49 <table>
  50 <tr>
  51 <td><span class=text>OS K1: </span></td><td><input size=3 type="text" name="os_k1" value="" ></td>
  52 <td><span class=text>OS K1 Axis: </span></td><td><input size=3 type="text" name="os_k1_axis" value="" ></td>
  53 <td><span class=text>OS K2: </span></td><td><input size=3 type="text" name="os_k2" value="" ></td>
  54 <td><span class=text>OS K2 Axis: </span></td><td><input size=3 type="text" name="os_k2_axis" value="" ></td>
  55 </tr>
  56 <tr>
  57 <td colspan=8>
  58
  59 <span class=text>OS Testing Status: </span><input type="text" name="os_testing_status" value="" >
  60 </td>
  61 </tr>
  62 </table>
  63
  64 <span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea>
  65 <br />
  66 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  67 <br />
  68 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save]</a>
  69 </form>
  70 <?php
  71 formFooter();
  72 ?>