contrib/forms/immunization_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_immunization_record';
   7 $ftitle = 'Immunization 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: ACOG Immunization 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 <!--
  35 window.onload = initialize;
  36 //-->
  37 </script>
  38 </head>
  39
  40 <?
  41    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  42    if ($fres){
  43      $patient = sqlFetchArray($fres);
  44    }
  45 ?>
  46 <body <?echo $top_bg_line;?>>
  47
  48
  49 <form action="<?echo $rootdir;?>/forms/immunization_record/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  50 <? include("../../acog_menu.inc"); ?>
  51 <div class="srvChapter">Immunization record<sup><a href="#" onClick="toolTip('The Immunization Record lists immunization services recommended by ACOG for either routine use or in high-risk patients, as defined in the enclosed table of high-risk factors. space for listing problems and immunization services allows the same form to be used for years.<br><br>For immunizations based on risk refer to the Table of High-Risk Factors')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0"></a></sup></div>
  52 <div style="border: solid 2px black; background-color:#FFFFFF;">
  53   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
  54     <tr align="left" valign="bottom">
  55       <td colspan="4" class="fibody2" id="bordR">patient name:
  56         <input name="pname" type="text" class="fullin" id="pname" style="width: 74%" value="<?
  57           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  58           ?>"></td>
  59       <td colspan="2" class="fibody2" id="bordR">Birth date:
  60         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  61           echo $patient{'DOB'};
  62           ?>"></td>
  63       <td colspan="2" class="fibody2">ID No:
  64         <input name="pl_pid" type="text" class="fullin" id="pl_pid" style="width:80%" value="<?
  65           echo $patient{'id'};
  66           ?>"></td>
  67       </tr>
  68     <tr align="center" valign="middle">
  69       <td width="9%" class="ficaption2" id="bordR">age</td>
  70       <td width="13%" class="ficaption2" id="bordR">Tetanus-<br>
  71         Diphteria<br>
  72         booster </td>
  73       <td width="13%" class="ficaption2" id="bordR">Influenza<br>
  74         vaccine </td>
  75       <td width="13%" class="ficaption2" id="bordR">Pneumococcal vaccine </td>
  76       <td width="13%" class="ficaption2" id="bordR">MMR Vaccine </td>
  77       <td width="13%" class="ficaption2" id="bordR">Hepatitis B vaccine </td>
  78       <td width="13%" class="ficaption2" id="bordR">Hepatitis A vaccine </td>
  79       <td width="13%" class="ficaption2">Varicella vaccine </td>
  80     </tr>
  81     <tr align="center" valign="middle">
  82       <td class="fibody2" id="bordR">13-18</td>
  83       <td class="fibody2" id="bordR">Once between ages 11-16 </td>
  84       <td class="fibody2" id="bordR">Based on risk </td>
  85       <td class="fibody2" id="bordR">Based on risk</td>
  86       <td class="fibody2" id="bordR">Based on risk</td>
  87       <td class="fibody2" id="bordR">One series for those not previously immunized </td>
  88       <td class="fibody2" id="bordR">Based on risk</td>
  89       <td class="fibody2">Based on risk</td>
  90     </tr>
  91     <tr align="center" valign="middle">
  92       <td class="fibody2" id="bordR">19-39</td>
  93       <td class="fibody2" id="bordR">Every 10 years </td>
  94       <td class="fibody2" id="bordR">Based on risk</td>
  95       <td class="fibody2" id="bordR">Based on risk</td>
  96       <td class="fibody2" id="bordR">Based on risk</td>
  97       <td class="fibody2" id="bordR">Based on risk</td>
  98       <td class="fibody2" id="bordR">Based on risk</td>
  99       <td class="fibody2">Based on risk</td>
 100     </tr>
 101     <tr align="center" valign="middle">
 102       <td class="fibody2" id="bordR">40-64</td>
 103       <td class="fibody2" id="bordR">Every 10 years</td>
 104       <td class="fibody2" id="bordR">Annually beginning at age 50 years </td>
 105       <td class="fibody2" id="bordR">Based on risk</td>
 106       <td class="fibody2" id="bordR">Based on risk</td>
 107       <td class="fibody2" id="bordR">Based on risk</td>
 108       <td class="fibody2" id="bordR">Based on risk</td>
 109       <td class="fibody2">Based on risk</td>
 110     </tr>
 111     <tr align="center" valign="middle">
 112       <td class="fibody2" id="bordR">65 and older </td>
 113       <td class="fibody2" id="bordR">Every 10 years</td>
 114       <td class="fibody2" id="bordR">Annually</td>
 115       <td class="fibody2" id="bordR">Once</td>
 116       <td class="fibody2" id="bordR">&nbsp;</td>
 117       <td class="fibody2" id="bordR">Based on risk</td>
 118       <td class="fibody2" id="bordR">Based on risk</td>
 119       <td class="fibody2">Based on risk</td>
 120     </tr>
 121   </table>
 122 </div>
 123 <p>&nbsp;</p>
 124 <div style="border: solid 2px black; background-color:#FFFFFF;">
 125   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 126 <?
 127 $vacci=0;
 128 while ($vacci<20){
 129 print <<<EOL
 130     <tr align="left" valign="bottom">
 131       <td width="9%" class="fibody2" id="bordR">Date</td>
 132       <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2"></td>
 133       <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2"></td>
 134       <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2"></td>
 135       <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2"></td>
 136       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2"></td>
 137       <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2"></td>
 138       <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2"></td>
 139     </tr>
 140 EOL;
 141 $vacci++;
 142 }
 143 ?>
 144   </table>
 145 </div>
 146 <p><sup>*</sup>For immunizations based on risk refer to the Table of High-Risk Factors.</p>
 147 <p>&nbsp;</p>
 148 <table width="100%" border="0">
 149   <tr>
 150     <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 151     <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 152      onclick="top.restoreSession()">[Don't Save]</a> </td>
 153   </tr>
 154 </table>
 155 </form>
 156 <?php
 157 formFooter();
 158 ?>
 159 </body>
 160 </html>