contrib/forms/high_risk_screening_record/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_high_risk_screening_record';
   7 $ftitle = 'High risk screening record';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  17   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  18   $id = $newid;
  19   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  20   exit;
  21   }
  22   }
  23 ?>
  24 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  25 "http://www.w3.org/TR/html4/loose.dtd">
  26
  27 <html>
  28 <head>
  29 <title>Form: High risk screening record</title>
  30 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  31 <link rel=stylesheet href="../../acog.css" type="text/css">
  32 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  33 <script language="JavaScript" type="text/JavaScript">
  34 window.onload = initialize;
  35 </script>
  36 </head>
  37
  38 <?
  39    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  40    if ($fres){
  41      $patient = sqlFetchArray($fres);
  42    }
  43 ?>
  44 <body <?echo $top_bg_line;?>>
  45
  46 <form action="<?echo $rootdir;?>/forms/high_risk_screening_record/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  47 <? include("../../acog_menu.inc"); ?>
  48 <div class="srvChapter">High risk screening  record <a href="#" onMouseOver="toolTip('See Table of High-Risk Factors.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  49 <div style="border: solid 2px black; background-color:#FFFFFF;">
  50   <table  border="0" cellpadding="2" cellspacing="0">
  51     <tr align="left" valign="bottom">
  52       <td colspan="6" class="fibody2" id="bordR">patient name:
  53         <input name="pname" type="text" class="fullin" id="pname" style="width: 70%" value="<?
  54           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  55           ?>"></td>
  56       <td colspan="5" class="fibody2" id="bordR">Birth date:
  57         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  58           echo $patient{'DOB'};
  59           ?>"></td>
  60       <td colspan="4" class="fibody2">ID No:
  61         <input name="hr_pid" type="text" class="fullin" id="hr_pid" style="width:80%" value="<?
  62           echo $patient{'id'};
  63           ?>"></td>
  64       </tr>
  65     <tr align="center" valign="middle">
  66       <td class="ficaption2" id="bordR">&nbsp;</td>
  67       <td width="6%" class="ficaption2" id="bordR">HEMO-<br>
  68         GLOBIN<br>
  69         TEST</td>
  70       <td width="6%" class="ficaption2" id="bordR">BONE DENSITY<br>
  71         SCREENING</td>
  72       <td width="6%" class="ficaption2" id="bordR">BACTERI-<br>
  73         URIA&nbsp;TEST</td>
  74       <td width="6%" class="ficaption2" id="bordR">STD<br>
  75         TESTING</td>
  76       <td width="6%" class="ficaption2" id="bordR">HIV test <a href="#" onMouseOver="toolTip('Check state requirements before recording results.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  77       <td width="6%" class="ficaption2" id="bordR">Genetic testing </td>
  78       <td width="6%" class="ficaption2" id="bordR">Rubella titer </td>
  79       <td width="6%" class="ficaption2" id="bordR">TB skin test </td>
  80       <td width="6%" class="ficaption2" id="bordR">Lipid profile assessment </td>
  81       <td width="6%" class="ficaption2" id="bordR">mammo-<br>
  82         graphy</td>
  83       <td width="6%" class="ficaption2" id="bordR">FASTING<br>
  84         GLUCOSE TEST</td>
  85       <td width="6%" class="ficaption2" id="bordR">TSH<br>
  86         TEST</td>
  87       <td width="6%" class="ficaption2" id="bordR">COLORECTAL<br>
  88         CANCER<br>
  89         SCREENING</td>
  90       <td width="6%" class="ficaption2">HEPATITIS C<br>
  91         VIRUS TEST</td>
  92     </tr>
  93 <?
  94 $rsi = 1;
  95 while ($rsi <  13){
  96 print <<<EOL
  97     <tr align="left" valign="bottom">
  98       <td class="fibody3" id="bordR">Date:</td>
  99       <td class="fibody3" id="bordR"><input name="hemoglobin_date_${rsi}" type="text" class="fullin2"></td>
 100       <td class="fibody3" id="bordR"><input name="bone_density_date_${rsi}" type="text" class="fullin2"></td>
 101       <td class="fibody3" id="bordR"><input name="bacteriuria_date_${rsi}" type="text" class="fullin2"></td>
 102       <td class="fibody3" id="bordR"><input name="std_date_${rsi}" type="text" class="fullin2"></td>
 103       <td class="fibody3" id="bordR"><input name="hiv_date_${rsi}" type="text" class="fullin2"></td>
 104       <td class="fibody3" id="bordR"><input name="genetic_date_${rsi}" type="text" class="fullin2"></td>
 105       <td class="fibody3" id="bordR"><input name="rubella_date_${rsi}" type="text" class="fullin2"></td>
 106       <td class="fibody3" id="bordR"><input name="tb_skin_date_${rsi}" type="text" class="fullin2"></td>
 107       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" class="fullin2"></td>
 108       <td class="fibody3" id="bordR"><input name="mammography_date_${rsi}" type="text" class="fullin2"></td>
 109       <td class="fibody3" id="bordR"><input name="fasting_glucose_date_${rsi}" type="text" class="fullin2"></td>
 110       <td class="fibody3" id="bordR"><input name="tsh_date_${rsi}" type="text" class="fullin2"></td>
 111       <td class="fibody3" id="bordR"><input name="cancer_date_${rsi}" type="text" class="fullin2"></td>
 112       <td class="fibody3"><input name="hepatitis_c_date_${rsi}" type="text" class="fullin2"></td>
 113     </tr>
 114     <tr align="left" valign="bottom">
 115       <td class="fibody2" id="bordR">Result:</td>
 116       <td class="fibody2" id="bordR"><input name="hemoglobin_res_${rsi}" type="text" class="fullin2"></td>
 117       <td class="fibody2" id="bordR"><input name="bone_density_res_${rsi}" type="text" class="fullin2"></td>
 118       <td class="fibody2" id="bordR"><input name="bacteriuria_res_${rsi}" type="text" class="fullin2"></td>
 119       <td class="fibody2" id="bordR"><input name="std_res_${rsi}" type="text" class="fullin2"></td>
 120       <td class="fibody2" id="bordR"><input name="hiv_res_${rsi}" type="text" class="fullin2"></td>
 121       <td class="fibody2" id="bordR"><input name="genetic_res_${rsi}" type="text" class="fullin2"></td>
 122       <td class="fibody2" id="bordR"><input name="rubella_res_${rsi}" type="text" class="fullin2"></td>
 123       <td class="fibody2" id="bordR"><input name="tb_skin_res_${rsi}" type="text" class="fullin2"></td>
 124       <td class="fibody2" id="bordR"><input name="lipid_res_${rsi}" type="text" class="fullin2"></td>
 125       <td class="fibody2" id="bordR"><input name="mammography_res_${rsi}" type="text" class="fullin2"></td>
 126       <td class="fibody2" id="bordR"><input name="fasting_glucose_res_${rsi}" type="text" class="fullin2"></td>
 127       <td class="fibody2" id="bordR"><input name="tsh_res_${rsi}" type="text" class="fullin2"></td>
 128       <td class="fibody2" id="bordR"><input name="cancer_res_${rsi}" type="text" class="fullin2"></td>
 129       <td class="fibody2"><input name="hepatitis_c_res_${rsi}" type="text" class="fullin2"></td>
 130     </tr>
 131 EOL;
 132 $rsi++;
 133 }
 134 ?>
 135   </table>
 136 </div>
 137 <p>&nbsp;</p>
 138 <table width="100%" border="0">
 139   <tr>
 140     <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 141     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 142      onclick="top.restoreSession()">[Don't Save]</a> </td>
 143   </tr>
 144 </table>
 145 </form>
 146 <?php
 147 formFooter();
 148 ?>
 149 </body>
 150 </html>