3 require_once("../../globals.php");
5 use OpenEMR\Core\Header
;
9 <?php Header
::setupHeader(); ?
>
11 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
13 require_once("$srcdir/api.inc.php");
16 $obj = formFetch("form_individual_treatment_plan", $_GET["id"]);
20 <form method
=post action
="<?php echo $rootdir?>/forms/individual_treatment_plan/save.php?mode=update&id=<?php echo attr_url($_GET["id
"]); ?>" name
="my_form">
21 <span
class="title"><center
><b
>Individual Treatment Plan
</b
></center
></span
><br
/><br
/>
23 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
24 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick
="top.restoreSession()">[Don
't Save Changes]</a></center>
27 <?php /* From New */ ?>
29 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = ?", [$pid]);
30 $result = SqlFetchArray($res); ?>
32 <b>Date of Referral:</b> <input type="text" name="date_of_referal" value="<?php echo attr($obj["date_of_referal"]);?>">
33 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="260" height="1">
34 <b>Date of Plan:</b> <?php print text(date('m
/d
/y
')); ?><br /><br />
36 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="28" height="1">
37 <b>Client Name:</b> <?php echo text($result['fname
']) . ' 
' . text($result['mname
']) . ' 
;' . text($result['lname
']); ?>
38 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="292" height="1">
40 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="1" height="1">
41 <input type="text" name="dcn" value="<?php echo attr($obj["dcn"]);?>"> <br /><br />
43 <b>ICD/9/CM Code:</b> <input type="text" name="icd9" value="<?php echo attr($obj["icd9"]);?>">
44 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="200" height="1">
45 <b>Prognosis:</b> <input type="text" name="prognosis" value="<?php echo attr($obj["prognosis"]);?>"><br /><br />
47 <b>Diagnosis Description:</b><br />
48 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ><?php echo attr($obj["diagnosis_description"]);?></textarea><br /><br />
50 <b>Presenting Problem Description and Psychosocial Information:</b><br />
51 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ><?php echo attr($obj["presenting_problem"]);?></textarea><br /><br />
53 <b>Frequency:</b> <input type="text" name="frequency" size="12" maxlength="10" value="<?php echo attr($obj["frequency"]);?>">
54 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="40" height="1">
55 <b>Duration:</b> <input type="text" name="duration" size="12" maxlength="10" value="<?php echo attr($obj["duration"]);?>">
56 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="40" height="1">
57 <b>Scope:</b> <input type="text" name="scope" size="12" maxlength="10" value="<?php echo attr($obj["scope"]);?>"><br /><br />
59 <b>Short Term Goals:</b>
60 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="162" height="1">
61 <b>Time Frame:</b><br />
62 <input type="text" name="short_term_goals_1" size="42" maxlength="40" value="<?php echo attr($obj["short_term_goals_1"]);?>">
63 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
64 <input type="text" name="time_frame_1" size="16" maxlength="15" value="<?php echo attr($obj["time_frame_1"]);?>"><br />
66 <input type="text" name="short_term_goals_2" size="42" maxlength="40" value="<?php echo attr($obj["short_term_goals_2"]);?>">
67 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
68 <input type="text" name="time_frame_2" size="16" maxlength="15" value="<?php echo attr($obj["time_frame_2"]);?>"><br />
70 <input type="text" name="short_term_goals_3" size="42" maxlength="40" value="<?php echo attr($obj["short_term_goals_3"]);?>">
71 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
72 <input type="text" name="time_frame_3" size="16" maxlength="15" value="<?php echo attr($obj["time_frame_3"]);?>"><br /><br />
74 <b>Long Term Goals:</b><br />
75 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ><?php echo text($obj["long_term_goals"]);?></textarea><br /><br />
77 <b>Discharge Criteria:</b><br />
78 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ><?php echo text($obj["discharge_criteria"]);?></textarea><br /><br />
80 <b>Recommendations:</b><br />
81 <input type="checkbox" name="individual_family_therapy" <?php if ($obj["individual_family_therapy"] == "on") {
83 };?>> <b>Individual and / or Family Therapy</b></input>
84 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
85 <input type="checkbox" name="substance_abuse" <?php if ($obj["substance_abuse"] == "on") {
87 };?>> <b>Substance Abuse</b></input><br />
89 <input type="checkbox" name="group_therapy" <?php if ($obj["group_therapy"] == "on") {
91 };?>> <b>Group Therapy - psychoeducational group</b></input>
92 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
93 <input type="checkbox" name="parenting" <?php if ($obj["parenting"] == "on") {
95 };?>> <b>Parenting</b></input><br /><br />
97 <b>Action Steps by supports - family:</b><br />
98 <textarea cols=85 rows=3 wrap=virtual name="action_steps_by_supports" ><?php echo text($obj["action_steps_by_supports"]);?></textarea><br /><br />
100 <b>Other supports - agencies</b>
102 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="38" height="1">
103 <b>Contact Information</b><br />
104 <input type="text" name="other_supports_name_1" size="37" maxlength="35" value="<?php echo attr($obj["other_supports_name_1"]);?>">
105 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
106 <input type="text" name="other_supports_contact_1" size="37" maxlength="35" value="<?php echo attr($obj["other_supports_contact_1"]);?>"><br />
108 <input type="text" name="other_supports_name_2" size="37" maxlength="35" value="<?php echo attr($obj["other_supports_name_2"]);?>">
109 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
110 <input type="text" name="other_supports_contact_2" size="37" maxlength="35" value="<?php echo attr($obj["other_supports_contact_2"]);?>"><br /><br />
113 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="204" height="1">
114 <b>Referrals</b><br />
116 <input type="text" name="medications_1" size="42" maxlength="40" value="<?php echo attr($obj["medications_1"]);?>">
117 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
118 <input type="text" name="referrals_1" size="42" maxlength="40" value="<?php echo attr($obj["referrals_1"]);?>"><br />
120 <input type="text" name="medications_2" size="42" maxlength="40" value="<?php echo attr($obj["medications_2"]);?>">
121 <img src="<?php echo $GLOBALS['images_static_relative
'];?>/space.gif" width="6" height="1">
122 <input type="text" name="referrals_2" size="42" maxlength="40" value="<?php echo attr($obj["referrals_2"]);?>"><br /><br />
124 <?php /* From New */ ?>
126 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
128 <a href="<?php echo $GLOBALS['form_exit_url
']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes
]</a
>