contrib/forms/hearingtest/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  cornfeed <jdough823@gmail.com>
  10  * @author  fndtn357 <fndtn357@gmail.com>
  11  * @author  Robert Down <robertdown@live.com>
  12  * @author  sunsetsystems <sunsetsystems>
  13  * @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan>
  14  * @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com>
  15  * @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com>
  16  * @copyright Copyright (c) 2017-2023 Robert Down <robertdown@live.com>
  17  * @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems>
  18  * @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  19  */
  20
  21 ?>
  22 <!-- Forms generated from formsWiz -->
  23 <?php
  24 require_once("../../globals.php");
  25
  26 use OpenEMR\Core\Header;
  27
  28 ?>
  29 <html><head>
  30     <?php Header::setupHeader(); ?>
  31 </head>
  32 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  33 <?php
  34 require_once("$srcdir/api.inc.php");
  35 $obj = formFetch("form_hearingtest", $_GET["id"]);
  36 ?>
  37 <form method=post action="<?php echo $rootdir?>/forms/hearingtest/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form">
  38 <span class="title">Hearing Test</span><br /><br />
  39 <input type=checkbox name="with_hearing_aid" <?php if ($obj["with_hearing_aid"] == "on") {
  40     echo "checked";
  41                                              };?>><span class=text>With hearing Aid?</span><br />
  42 <table>
  43 <tr>
  44 <td>
  45 <span class=text>Right Ear 250: </span><input type="text" name="right_ear_250" value="<?php echo attr($obj["right_ear_250"]); ?>" ><br />
  46 <span class=text>Right Ear 500: </span><input type="text" name="right_ear_500" value="<?php echo attr($obj["right_ear_500"]); ?>" ><br />
  47 <span class=text>Right Ear 1000: </span><input type="text" name="right_ear_1000" value="<?php echo attr($obj["right_ear_1000"]); ?>" ><br />
  48 <span class=text>Right Ear 2000: </span><input type="text" name="right_ear_2000" value="<?php echo attr($obj["right_ear_2000"]); ?>" ><br />
  49 <span class=text>Right Ear 3000: </span><input type="text" name="right_ear_3000" value="<?php echo attr($obj["right_ear_3000"]); ?>" ><br />
  50 <span class=text>Right Ear 4000: </span><input type="text" name="right_ear_4000" value="<?php echo attr($obj["right_ear_4000"]); ?>" ><br />
  51 <span class=text>Right Ear 5000: </span><input type="text" name="right_ear_5000" value="<?php echo attr($obj["right_ear_5000"]); ?>" ><br />
  52 <span class=text>Right Ear 6000: </span><input type="text" name="right_ear_6000" value="<?php echo attr($obj["right_ear_6000"]); ?>" ><br />
  53 </td>
  54 <td>
  55 <span class=text>Left Ear 250: </span><input type="text" name="left_ear_250" value="<?php echo attr($obj["left_ear_250"]); ?>" ><br />
  56 <span class=text>Left Ear 500: </span><input type="text" name="left_ear_500" value="<?php echo attr($obj["left_ear_500"]); ?>" ><br />
  57 <span class=text>Left Ear 1000: </span><input type="text" name="left_ear_1000" value="<?php echo attr($obj["left_ear_1000"]); ?>" ><br />
  58 <span class=text>Left Ear 2000: </span><input type="text" name="left_ear_2000" value="<?php echo attr($obj["left_ear_2000"]); ?>" ><br />
  59 <span class=text>Left Ear 3000: </span><input type="text" name="left_ear_3000" value="<?php echo attr($obj["left_ear_3000"]); ?>" ><br />
  60 <span class=text>Left Ear 4000: </span><input type="text" name="left_ear_4000" value="<?php echo attr($obj["left_ear_4000"]); ?>" ><br />
  61 <span class=text>Left Ear 5000: </span><input type="text" name="left_ear_5000" value="<?php echo attr($obj["left_ear_5000"]); ?>" ><br />
  62 <span class=text>Left Ear 6000: </span><input type="text" name="left_ear_6000" value="<?php echo attr($obj["left_ear_6000"]); ?>" ><br />
  63 </td>
  64 </tr>
  65 </table>
  66 <br />
  67 <table>
  68 <tr>
  69 <td valign=top>
  70 <span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?php echo text($obj["additional_notes"]); ?></textarea><br />
  71 </td>
  72 </tr>
  73 </table>
  74
  75 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  76 <br />
  77 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
  78 </form>
  79 <?php
  80 formFooter();
  81 ?>