contrib/forms/hp_tje_primary/templates/hp_tje/general_new.html

   1 <html>
   2 <head>
   3 {literal}
   4  <style type="text/css" title="mystyles" media="all">
   5 <!--
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  15 a {
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  19 .title {
  20         font-family: sans-serif;
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  27 .form_text{
  28         font-family: sans-serif;
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  30         text-decoration: none;
  31         color: #000000;
  32 }
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  35 </style>
  36 {/literal}
  37 </head>
  38 <body bgcolor="{$STYLE.BGCOLOR2}">
  39 <p><span class="title">Head Pain and Temporomandibular Jaw Examination</span></p>
  40 <form name="hptje" method="post" action="{$FORM_ACTION}/interface/forms/hp_tje_primary/save.php"
  41  onsubmit="return top.restoreSession()">
  42 <table>
  43 <tr>
  44         <td>REFERRED BY &nbsp&nbsp;<input type="text" name="referred_by" size="39"value="{$hptje_primary->get_referred_by()}"></td>
  45 </tr>
  46
  47 <tr>
  48         <td>CHIEF COMPLAINTS</td>
  49 </tr>
  50 <tr>
  51         <td><p><textarea name="complaints" cols="75" rows="3" wrap="virtual" >{$hptje_primary->get_complaints()}</textarea></p><br /></td>
  52 </tr>
  53 <tr>
  54         <td><p>DATE OF ONSET&nbsp;&nbsp;{html_select_date start_year="1910"  time=$hptje_primary->get_date_of_onset() time=$hptje_primary->date_of_onset prefix="date_of_onset_"}</p><br></td>
  55 </tr>
  56 <tr>
  57         <td>PRECIPITATING/AGGRAVATING EVENT:    <select name="event"><option name="" value="">{html_options selected=$hptje_primary->get_event() options=$hptje_primary->event_array}</select></td>
  58 </tr>
  59 <tr>
  60 <td><p>Other Explain:&nbsp;<input type="text" name="event_description" value="{$hptje_primary->get_event_description()}" maxlength="255" size="39"></p><br /></td>
  61 </tr>
  62 <tr>
  63 <td><p><input type="checkbox" name="prior_symptoms" value="1" {if $hptje_primary->get_prior_symptoms() eq 1}checked{/if}">&nbsp;Denies presence of symptoms prior to accident &nbsp;&nbsp;&nbsp;<input type="checkbox" name="aggravated_symptoms" value="1" {if $hptje_primary->get_aggravated_symptoms() eq 1}checked{/if}>&nbsp;Affirms aggravation of symptoms after accident</p><br /></td>
  64 </tr>
  65 </table>
  66 <table>
  67
  68 {foreach name=loops item=headings key=title from=$checks}
  69 <tr>
  70         <td>
  71                 {if $smarty.foreach.loops.first ne 1}<br>{/if}
  72                 {$title}
  73         </td>
  74 </tr>
  75 <tr>
  76         <td>
  77           {foreach item=row key=row_title from=$headings}
  78                         <tr>
  79                                 {if !is_numeric($row_title)}
  80                                         <td>{$row_title}</td>
  81                                         <td class="form_text">{html_checkboxes name="checks" options=$row selected=$hptje_primary->checks separator="&nbsp;</td><td class=\"form_text\">"}</td>
  82                                 {else}
  83                                         <td width="20"></td>
  84                                         <td colspan="6"><table><tr><td class="form_text">
  85
  86                                         {html_checkboxes name="checks" options=$row selected=$hptje_primary->checks separator="&nbsp;&nbsp;&nbsp;</td><td class=\"form_text\">"}
  87                                         {if $title eq "Teeth"}
  88                                                 &nbsp;&nbsp;Sore#&nbsp;<input type="text" name="teeth_sore_number" size="1" value="{$hptje_primary->get_teeth_sore_number()}">
  89                                                 &nbsp;&nbsp;Mobile#&nbsp;<input type="text" name="teeth_mobile_number" size="1" value="{$hptje_primary->get_teeth_mobile_number()}">
  90                                                 &nbsp;&nbsp;Fractured#&nbsp;<input type="text" name="teeth_fractured_number" size="1" value="{$hptje_primary->get_teeth_fractured_number()}">
  91                                                 &nbsp;&nbsp;Avulsed#&nbsp;<input type="text" name="teeth_avulsed_number" size="1" value="{$hptje_primary->get_teeth_avulsed_number()}">
  92                                         {elseif $title eq "Precipitating Factors" and $row_title eq 2}
  93                                                 &nbsp;<input type="text" name="precipitating_factors_other_text" size="15" value="{$hptje_primary->get_precipitating_factors_other_text()}">
  94                                         {/if}
  95                                         </td></tr></table></td>
  96                                 {/if}
  97
  98                         </tr>
  99           {/foreach}
 100
 101         </td>
 102 </tr>
 103 {/foreach}
 104 </table>
 105 <table>
 106 <tr>
 107         <td colspan="10">HISTORY OF PREVIOUS TREATMENT</td>
 108 </tr>
 109 <tr>
 110         <td>&nbsp;&nbsp;&nbsp;A.</td><td colspan="10">Specialty<br>
 111         (A)Anesthesiologist (C) Chiropractor (D) Dentist (E) ENT (F) Family Physician (H) Hospital ER<br>
 112         (N) Neurologist (O)Orthopedist (P) Physical Therapist (R)Rheumatologist<br><br></td>
 113 </tr>
 114 <tr>
 115         <td>&nbsp;&nbsp;&nbsp;B.</td><td colspan="10">Treatment Modalities<br>
 116         (1)Chiropractic (2)Equilibration (3) Examination (4) Medication (5) MRI (6) Orthodontic (7) Orhtopedic<br>
 117         (8) Pallative (soft diet, heat, etc.) (9) Physical Therapy (10)Prolotherapy (11)Reconstruction (12) Referal<br>
 118         (13) Soft Collar (14) Cervical Immobilization (15) Splint Therapy (16) TMJ Surgery (17) X-rays<br><br></td>
 119 </tr>
 120 <tr>
 121         <td>&nbsp;&nbsp;&nbsp;C.</td><td colspan="10">Effectiveness of Treatment: (N) None&nbsp;&nbsp;(F) Fair&nbsp;&nbsp;(G)Good&nbsp;&nbsp;(E)Excellent<br><br></td>
 122 </tr>
 123 <tr>
 124         <td>Doctor</td><td>Specialty</td><td>TX Rendered</td><td>Effectiveness</td><td>Date</td>
 125 </tr>
 126 {section name="history" loop=8 start="0"}
 127 <tr>
 128         <td><input type="text" name="history[{$smarty.section.history.index}][doctor]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].doctor}"></td>
 129         <td><input type="text" name="history[{$smarty.section.history.index}][specialty]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].specialty}"></td>
 130         <td><input type="text" name="history[{$smarty.section.history.index}][tx_rendered]" size="25" value="{$hptje_primary->history[$smarty.section.history.index].tx_rendered}"></td>
 131         <td><input type="text" name="history[{$smarty.section.history.index}][effectiveness]" size="15" value="{$hptje_primary->history[$smarty.section.history.index].effectiveness}"></td>
 132         <td><input type="text" name="history[{$smarty.section.history.index}][date]" size="10" value="{$hptje_primary->history[$smarty.section.history.index].date}"></td>
 133 </tr>
 134 {/section}
 135 </table>
 136 <table>
 137 <tr>
 138         <td colspan="3"><br><br>HISTORY OF PREVIOUS ACCIDENTS OR INJURIES</td>
 139 </tr>
 140 <tr>
 141         <td>Nature of Accident</td><td>Injuries</td><td>Date</td>
 142 </tr>
 143 {section name="previous_accidents" loop=8 start="0"}
 144 <tr>
 145
 146         <td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][nature_of_accident]" size="35" value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].nature_of_accident}"></td>
 147         <td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][injuries]" size="25"        value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].injuries}"></td>
 148         <td><input type="text" name="previous_accidents[{$smarty.section.previous_accidents.index}][date]" size="10"            value="{$hptje_primary->previous_accidents[$smarty.section.previous_accidents.index].date}"></td>
 149 </tr>
 150 {/section}
 151 </table>
 152 <table>
 153 <tr>
 154         <td>COMMENTS</td>
 155 </tr>
 156 <tr>
 157         <td><textarea name="comments" value="{$hptje_primary->get_comments()}" wrap="virtual" cols="75" rows="8">{$hptje_primary->get_comments()}</textarea></td>
 158 </tr>
 159 {if $VIEW != true}
 160 <tr>
 161         <td><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 162 <a href="{$DONT_SAVE_LINK}" class="link" onclick="top.restoreSession()">[Don't Save]</a></td>
 163 </tr>
 164 {/if}
 165 </table>
 166 <input type="hidden" name="id" value="{$hptje_primary->get_id()}" />
 167 <input type="hidden" name="activity" value="{$hptje_primary->get_activity()}">
 168 <input type="hidden" name="pid" value="{$hptje_primary->get_pid()}">
 169 <input type="hidden" name="process" value="true">
 170 </form>
 171 </body>
 172 </html>