contrib/forms/individual_treatment_plan/view.php

   1 <?php
   2
   3 require_once("../../globals.php");
   4
   5 use OpenEMR\Core\Header;
   6
   7 ?>
   8 <html><head>
   9     <?php Header::setupHeader(); ?>
  10 </head>
  11 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  12 <?php
  13 require_once("$srcdir/api.inc.php");
  14
  15
  16 $obj = formFetch("form_individual_treatment_plan", $_GET["id"]);
  17
  18
  19 ?>
  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 />
  22 <center>
  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>
  25 <br /><br />
  26
  27 <?php /* From New */ ?>
  28
  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); ?>
  31
  32 <b>Date of Referral:</b>&nbsp;<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>&nbsp; <?php print text(date('m/d/y')); ?><br /><br />
  35
  36 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="28" height="1">
  37 <b>Client Name:</b>&nbsp; <?php echo text($result['fname']) . '&nbsp' . text($result['mname']) . '&nbsp;' . text($result['lname']); ?>
  38 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="292" height="1">
  39 <b>DCN:</b>
  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 />
  42
  43 <b>ICD/9/CM Code:</b>&nbsp;<input type="text" name="icd9" value="<?php echo attr($obj["icd9"]);?>">
  44 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="200" height="1">
  45 <b>Prognosis:</b>&nbsp;<input type="text" name="prognosis" value="<?php echo attr($obj["prognosis"]);?>"><br /><br />
  46
  47 <b>Diagnosis Description:</b><br />
  48 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ><?php echo attr($obj["diagnosis_description"]);?></textarea><br /><br />
  49
  50 <b>Presenting Problem Description and Psychosocial Information:</b><br />
  51 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ><?php echo attr($obj["presenting_problem"]);?></textarea><br /><br />
  52
  53 <b>Frequency:</b>&nbsp;<input type="text" name="frequency" size="12" maxlength="10" value="<?php echo attr($obj["frequency"]);?>">
  54 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="40" height="1">
  55 <b>Duration:</b>&nbsp;<input type="text" name="duration" size="12" maxlength="10" value="<?php echo attr($obj["duration"]);?>">
  56 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="40" height="1">
  57 <b>Scope:</b>&nbsp;<input type="text" name="scope" size="12" maxlength="10" value="<?php echo attr($obj["scope"]);?>"><br /><br />
  58
  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 />
  65
  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 />
  69
  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 />
  73
  74 <b>Long Term Goals:</b><br />
  75 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ><?php echo text($obj["long_term_goals"]);?></textarea><br /><br />
  76
  77 <b>Discharge Criteria:</b><br />
  78 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ><?php echo text($obj["discharge_criteria"]);?></textarea><br /><br />
  79
  80 <b>Recommendations:</b><br />
  81 <input type="checkbox" name="individual_family_therapy" <?php if ($obj["individual_family_therapy"] == "on") {
  82     echo "checked";
  83                                                         };?>>&nbsp;<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") {
  86     echo "checked";
  87                                               };?>>&nbsp;<b>Substance Abuse</b></input><br />
  88
  89 <input type="checkbox" name="group_therapy" <?php if ($obj["group_therapy"] == "on") {
  90     echo "checked";
  91                                             };?>>&nbsp;<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") {
  94     echo "checked";
  95                                         };?>>&nbsp;<b>Parenting</b></input><br /><br />
  96
  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 />
  99
 100 <b>Other supports - agencies</b>
 101 <b>Name:</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 />
 107
 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 />
 111
 112 <b>Medications</b>
 113 <img src="<?php echo $GLOBALS['images_static_relative'];?>/space.gif" width="204" height="1">
 114 <b>Referrals</b><br />
 115
 116 <input type="text" name="medications_1" size="42" maxlength="40" value="<?php echo attr($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 />
 119
 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 />
 123
 124 <?php /* From New */ ?>
 125 <br />
 126 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 127 <br />
 128 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 129 </form>
 130 <?php
 131 formFooter();
 132 ?>