contrib/forms/individual_treatment_plan/view.php

   1 <?php
   2 include_once("../../globals.php");
   3 ?>
   4 <html><head>
   5 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   6 </head>
   7 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
   8 <?php
   9 include_once("$srcdir/api.inc");
  10
  11
  12 $obj = formFetch("form_individual_treatment_plan", $_GET["id"]);
  13
  14
  15 ?>
  16 <form method=post action="<?echo $rootdir?>/forms/individual_treatment_plan/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  17 <span class="title"><center><b>Individual Treatment Plan</b></center></span><br><br>
  18 <center>
  19 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  20 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a></center>
  21 <br></br>
  22
  23 <? /* From New */ ?>
  24
  25 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  26 $result = SqlFetchArray($res); ?>
  27
  28 <b>Date of Referral:</b>&nbsp;<input type="text" name="date_of_referal" value="<? echo stripslashes($obj{"date_of_referal"});?>">
  29 <img src="../../../images/space.gif" width="260" height="1">
  30 <b>Date of Plan:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  31
  32 <img src="../../../images/space.gif" width="28" height="1">
  33 <b>Client Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  34 <img src="../../../images/space.gif" width="292" height="1">
  35 <b>DCN:</b>
  36 <img src="../../../images/space.gif" width="1" height="1">
  37 <input type="text" name="dcn" value="<? echo stripslashes($obj{"dcn"});?>"> <br><br>
  38
  39 <b>ICD/9/CM Code:</b>&nbsp;<input type="text" name="icd9" value="<? echo stripslashes($obj{"icd9"});?>">
  40 <img src="../../../images/space.gif" width="200" height="1">
  41 <b>Prognosis:</b>&nbsp;<input type="text" name="prognosis" value="<? echo stripslashes($obj{"prognosis"});?>"><br><br>
  42
  43 <b>Diagnosis Description:</b><br>
  44 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ><? echo stripslashes($obj{"diagnosis_description"});?></textarea><br><br>
  45
  46 <b>Presenting Problem Description and Psychosocial Information:</b><br>
  47 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ><? echo stripslashes($obj{"presenting_problem"});?></textarea><br><br>
  48
  49 <b>Frequency:</b>&nbsp;<input type="text" name="frequency" size="12" maxlength="10" value="<? echo stripslashes($obj{"frequency"});?>">
  50 <img src="../../../images/space.gif" width="40" height="1">
  51 <b>Duration:</b>&nbsp;<input type="text" name="duration" size="12" maxlength="10" value="<? echo stripslashes($obj{"duration"});?>">
  52 <img src="../../../images/space.gif" width="40" height="1">
  53 <b>Scope:</b>&nbsp;<input type="text" name="scope" size="12" maxlength="10" value="<? echo stripslashes($obj{"scope"});?>"><br><br>
  54
  55 <b>Short Term Goals:</b>
  56 <img src="../../../images/space.gif" width="162" height="1">
  57 <b>Time Frame:</b><br>
  58 <input type="text" name="short_term_goals_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_1"});?>">
  59 <img src="../../../images/space.gif" width="6" height="1">
  60 <input type="text" name="time_frame_1" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_1"});?>"><br>
  61
  62 <input type="text" name="short_term_goals_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_2"});?>">
  63 <img src="../../../images/space.gif" width="6" height="1">
  64 <input type="text" name="time_frame_2" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_2"});?>"><br>
  65
  66 <input type="text" name="short_term_goals_3" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_3"});?>">
  67 <img src="../../../images/space.gif" width="6" height="1">
  68 <input type="text" name="time_frame_3" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_3"});?>"><br><br>
  69
  70 <b>Long Term Goals:</b><br>
  71 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ><? echo stripslashes($obj{"long_term_goals"});?></textarea><br><br>
  72
  73 <b>Discharge Criteria:</b><br>
  74 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ><? echo stripslashes($obj{"discharge_criteria"});?></textarea><br><br>
  75
  76 <b>Recommendations:</b><br>
  77 <input type="checkbox" name="individual_family_therapy" <? if ($obj{"individual_family_therapy"} == "on") {echo "checked";};?>>&nbsp;<b>Individual and / or Family Therapy</b></input>
  78 <img src="../../../images/space.gif" width="6" height="1">
  79 <input type="checkbox" name="substance_abuse" <? if ($obj{"substance_abuse"} == "on") {echo "checked";};?>>&nbsp;<b>Substance Abuse</b></input><br>
  80
  81 <input type="checkbox" name="group_therapy" <? if ($obj{"group_therapy"} == "on") {echo "checked";};?>>&nbsp;<b>Group Therapy - psychoeducational group</b></input>
  82 <img src="../../../images/space.gif" width="6" height="1">
  83 <input type="checkbox" name="parenting" <? if ($obj{"parenting"} == "on") {echo "checked";};?>>&nbsp;<b>Parenting</b></input><br><br>
  84
  85 <b>Action Steps by supports - family:</b><br>
  86 <textarea cols=85 rows=3 wrap=virtual name="action_steps_by_supports" ><? echo stripslashes($obj{"action_steps_by_supports"});?></textarea><br><br>
  87
  88 <b>Other supports - agencies</b>
  89 <b>Name:</b>
  90 <img src="../../../images/space.gif" width="38" height="1">
  91 <b>Contact Information</b><br>
  92 <input type="text" name="other_supports_name_1" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_name_1"});?>">
  93 <img src="../../../images/space.gif" width="6" height="1">
  94 <input type="text" name="other_supports_contact_1" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_contact_1"});?>"><br>
  95
  96 <input type="text" name="other_supports_name_2" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_name_2"});?>">
  97 <img src="../../../images/space.gif" width="6" height="1">
  98 <input type="text" name="other_supports_contact_2" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_contact_2"});?>"><br><br>
  99
 100 <b>Medications</b>
 101 <img src="../../../images/space.gif" width="204" height="1">
 102 <b>Referrals</b><br>
 103
 104 <input type="text" name="medications_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"medications_1"});?>">
 105 <img src="../../../images/space.gif" width="6" height="1">
 106 <input type="text" name="referrals_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"referrals_1"});?>"><br>
 107
 108 <input type="text" name="medications_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"medications_2"});?>">
 109 <img src="../../../images/space.gif" width="6" height="1">
 110 <input type="text" name="referrals_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"referrals_2"});?>"><br><br>
 111
 112 <? /* From New */ ?>
 113 <br>
 114 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 115 <br>
 116 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 117 </form>
 118 <?php
 119 formFooter();
 120 ?>