4 <style type=
"text/css" title=
"mystyles" media=
"all">
12 font-family:helvetica;
17 font-family:helvetica;
20 font-family: sans-serif;
23 text-decoration: none;
28 font-family: sans-serif;
30 text-decoration: none;
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()">
44 <td>REFERRED BY  
<input type=
"text" name=
"referred_by" size=
"39"value=
"{$hptje_primary->get_referred_by()}"></td>
48 <td>CHIEF COMPLAINTS
</td>
51 <td><p><textarea name=
"complaints" cols=
"75" rows=
"3" wrap=
"virtual" >{$hptje_primary-
>get_complaints()}
</textarea></p><br /></td>
54 <td><p>DATE OF ONSET
{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>
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>
60 <td><p>Other Explain:
<input type=
"text" name=
"event_description" value=
"{$hptje_primary->get_event_description()}" maxlength=
"255" size=
"39"></p><br /></td>
63 <td><p><input type=
"checkbox" name=
"prior_symptoms" value=
"1" {if $hptje_primary-
>get_prior_symptoms() eq
1}checked{/if}
"> Denies presence of symptoms prior to accident <input type="checkbox
" name="aggravated_symptoms
" value="1" {if $hptje_primary->get_aggravated_symptoms() eq 1}checked{/if}> Affirms aggravation of symptoms after accident</p><br /></td>
68 {foreach name=loops item=headings key=title from=$checks}
71 {if $smarty.foreach.loops.first ne 1}<br>{/if}
77 {foreach item=row key=row_title from=$headings}
79 {if !is_numeric($row_title)}
81 <td class="form_text
">{html_checkboxes name="checks
" options=$row selected=$hptje_primary->checks separator=" </td><td class=\
"form_text\">"}</td>
84 <td colspan="6"><table><tr><td class="form_text
">
86 {html_checkboxes name="checks
" options=$row selected=$hptje_primary->checks separator=" </td><td class=\
"form_text\">"}
87 {if $title eq "Teeth
"}
88 Sore# <input type="text
" name="teeth_sore_number
" size="1" value="{$hptje_primary-
>get_teeth_sore_number()}
">
89 Mobile# <input type="text
" name="teeth_mobile_number
" size="1" value="{$hptje_primary-
>get_teeth_mobile_number()}
">
90 Fractured# <input type="text
" name="teeth_fractured_number
" size="1" value="{$hptje_primary-
>get_teeth_fractured_number()}
">
91 Avulsed# <input type="text
" name="teeth_avulsed_number
" size="1" value="{$hptje_primary-
>get_teeth_avulsed_number()}
">
92 {elseif $title eq "Precipitating Factors
" and $row_title eq 2}
93 <input type="text
" name="precipitating_factors_other_text
" size="15" value="{$hptje_primary-
>get_precipitating_factors_other_text()}
">
95 </td></tr></table></td>
107 <td colspan="10">HISTORY OF PREVIOUS TREATMENT</td>
110 <td> 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>
115 <td> 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>
121 <td> C.</td><td colspan="10">Effectiveness of Treatment: (N) None (F) Fair (G)Good (E)Excellent<br><br></td>
124 <td>Doctor</td><td>Specialty</td><td>TX Rendered</td><td>Effectiveness</td><td>Date</td>
126 {section name="history
" loop=8 start="0"}
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[$smarty.section.history.index].date}
"></td>
138 <td colspan="3"><br><br>HISTORY OF PREVIOUS ACCIDENTS OR INJURIES</td>
141 <td>Nature of Accident</td><td>Injuries</td><td>Date</td>
143 {section name="previous_accidents
" loop=8 start="0"}
146 <td><input type="text
" name="previous_accidents[{$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>
157 <td><textarea name="comments
" value="{$hptje_primary-
>get_comments()}
" wrap="virtual
" cols="75" rows="8">{$hptje_primary->get_comments()}</textarea></td>
161 <td><input type="submit
" name="Submit
" value="Save Form
">
162 <a href="{$DONT_SAVE_LINK}
" class="link
" onclick="top.restoreSession()
">[Don't Save]</a></td>
166 <input type="hidden
" name="id
" value="{$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
">