contrib/forms/individual_treatment_plan/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: individual_treatment_plan");
   5 ?>
   6 <html><head>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <form method=post action="<?echo $rootdir;?>/forms/individual_treatment_plan/save.php?mode=new" name="my_form">
  11 <br>
  12 <span class="title"><center>Individual Treatment Plan</center></span><br><br>
  13 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  14 <img src="../../../images/space.gif" width="5" height="1">
  15 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit" onclick="top.restoreSession()">[Don't Save]</a></center>
  16 <br>
  17
  18 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  19 $result = SqlFetchArray($res); ?>
  20
  21 <b>Date of Referral:</b>&nbsp;<input type="text" name="date_of_referal">
  22 <img src="../../../images/space.gif" width="260" height="1">
  23 <b>Date of Plan:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  24
  25 <img src="../../../images/space.gif" width="28" height="1">
  26 <b>Client Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  27 <img src="../../../images/space.gif" width="292" height="1">
  28 <b>DCN:</b>
  29 <img src="../../../images/space.gif" width="1" height="1">
  30 <input type="text" name="dcn"> <br><br>
  31
  32 <b>ICD/9/CM Code:</b>&nbsp;<input type="text" name="icd9">
  33 <img src="../../../images/space.gif" width="200" height="1">
  34 <b>Prognosis:</b>&nbsp;<input type="text" name="prognosis"><br><br>
  35
  36 <b>Diagnosis Description:</b><br>
  37 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ></textarea><br><br>
  38
  39 <b>Presenting Problem Description and Psychosocial Information:</b><br>
  40 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ></textarea><br><br>
  41
  42 <b>Frequency:</b>&nbsp;<input type="text" name="frequency" size="12" maxlength="10">
  43 <img src="../../../images/space.gif" width="40" height="1">
  44 <b>Duration:</b>&nbsp;<input type="text" name="duration" size="12" maxlength="10">
  45 <img src="../../../images/space.gif" width="40" height="1">
  46 <b>Scope:</b>&nbsp;<input type="text" name="scope" size="12" maxlength="10"><br><br>
  47
  48 <b>Short Term Goals:</b>
  49 <img src="../../../images/space.gif" width="162" height="1">
  50 <b>Time Frame:</b><br>
  51 <input type="text" name="short_term_goals_1" size="42" maxlength="40">
  52 <img src="../../../images/space.gif" width="6" height="1">
  53 <input type="text" name="time_frame_1" size="16" maxlength="15"><br>
  54
  55 <input type="text" name="short_term_goals_2" size="42" maxlength="40">
  56 <img src="../../../images/space.gif" width="6" height="1">
  57 <input type="text" name="time_frame_2" size="16" maxlength="15"><br>
  58
  59 <input type="text" name="short_term_goals_3" size="42" maxlength="40">
  60 <img src="../../../images/space.gif" width="6" height="1">
  61 <input type="text" name="time_frame_3" size="16" maxlength="15"><br><br>
  62
  63 <b>Long Term Goals:</b><br>
  64 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ></textarea><br><br>
  65
  66 <b>Discharge Criteria:</b><br>
  67 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ></textarea><br><br>
  68
  69 <b>Recommendations:</b><br>
  70 <input type="checkbox" name="individual_family_therapy">&nbsp;<b>Individual and / or Family Therapy</b></input>
  71 <img src="../../../images/space.gif" width="6" height="1">
  72 <input type="checkbox" name="substance_abuse">&nbsp;<b>Substance Abuse</b></input><br>
  73
  74 <input type="checkbox" name="group_therapy">&nbsp;<b>Group Therapy - psychoeducational group</b></input>
  75 <img src="../../../images/space.gif" width="6" height="1">
  76 <input type="checkbox" name="parenting">&nbsp;<b>Parenting</b></input><br><br>
  77
  78 <b>Action Steps by supports - family:</b><br>
  79 <textarea cols=85 rows=3 wrap=virtual name="action_steps_by_supports" ></textarea><br><br>
  80
  81 <b>Other supports - agencies</b>
  82 <b>Name:</b>
  83 <img src="../../../images/space.gif" width="38" height="1">
  84 <b>Contact Information</b><br>
  85 <input type="text" name="other_supports_name_1" size="37" maxlength="35">
  86 <img src="../../../images/space.gif" width="6" height="1">
  87 <input type="text" name="other_supports_contact_1" size="37" maxlength="35"><br>
  88
  89 <input type="text" name="other_supports_name_2" size="37" maxlength="35">
  90 <img src="../../../images/space.gif" width="6" height="1">
  91 <input type="text" name="other_supports_contact_2" size="37" maxlength="35"><br><br>
  92
  93 <b>Medications</b>
  94 <img src="../../../images/space.gif" width="204" height="1">
  95 <b>Referrals</b><br>
  96
  97 <input type="text" name="medications_1" size="42" maxlength="40">
  98 <img src="../../../images/space.gif" width="6" height="1">
  99 <input type="text" name="referrals_1" size="42" maxlength="40"><br>
 100
 101 <input type="text" name="medications_2" size="42" maxlength="40">
 102 <img src="../../../images/space.gif" width="6" height="1">
 103 <input type="text" name="referrals_2" size="42" maxlength="40"><br><br>
 104
 105
 106 <br><br>
 107 <center><a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 108 <img src="../../../images/space.gif" width="5" height="1">
 109 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit" onclick="top.restoreSession()">[Don't Save]</a></center>
 110 <br>
 111 </form>
 112 <?php
 113 formFooter();
 114 ?>