contrib/forms/high_risk_screening_record/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <? html_header_show();?>
  23
  24 <title>Form: High risk screening record</title>
  25
  26 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  27
  28 <link rel=stylesheet href="../../acog.css" type="text/css">
  29
  30 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  31
  32 <script language="JavaScript" type="text/JavaScript">
  33
  34 window.onload = initialize;
  35
  36 </script>
  37
  38 </head>
  39
  40
  41
  42 <?
  43
  44    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  45
  46    if ($fres){
  47
  48      $patient = sqlFetchArray($fres);
  49
  50    }
  51
  52    $fres=sqlStatement("select * from form_high_risk_screening_record where id=$id");
  53
  54    if ($fres){
  55
  56      $fdata = sqlFetchArray($fres);
  57
  58    }
  59
  60 ?>
  61
  62 <body <?echo $top_bg_line;?>>
  63
  64
  65
  66 <form action="<?echo $rootdir;?>/forms/high_risk_screening_record/save.php?mode=update&id=<? echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
  67
  68 <? include("../../acog_menu.inc"); ?>
  69
  70 <div class="srvChapter">High risk screening  record <a href="#" onMouseOver="toolTip('See Table of High-Risk Factors.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  71
  72 <div style="border: solid 2px black; background-color:#FFFFFF;">
  73
  74   <table  border="0" cellpadding="2" cellspacing="0">
  75
  76     <tr align="left" valign="bottom">
  77
  78       <td colspan="6" class="fibody2" id="bordR">patient name:
  79
  80         <input name="pname" type="text" class="fullin" id="pname" style="width: 70%" value="<?
  81
  82           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  83
  84           ?>"></td>
  85
  86       <td colspan="5" class="fibody2" id="bordR">Birth date:
  87
  88         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  89
  90           echo $patient{'DOB'};
  91
  92           ?>"></td>
  93
  94       <td colspan="4" class="fibody2">ID No:
  95
  96         <input name="hr_pid" type="text" class="fullin" id="hr_pid" style="width:80%" value="<?
  97
  98           echo $patient{'id'};
  99
 100           ?>"></td>
 101
 102       </tr>
 103
 104     <tr align="center" valign="middle">
 105
 106       <td class="ficaption2" id="bordR">&nbsp;</td>
 107
 108       <td width="6%" class="ficaption2" id="bordR">HEMO-<br>
 109
 110         GLOBIN<br>
 111
 112         TEST</td>
 113
 114       <td width="6%" class="ficaption2" id="bordR">BONE DENSITY<br>
 115
 116         SCREENING</td>
 117
 118       <td width="6%" class="ficaption2" id="bordR">BACTERI-<br>
 119
 120         URIA&nbsp;TEST</td>
 121
 122       <td width="6%" class="ficaption2" id="bordR">STD<br>
 123
 124         TESTING</td>
 125
 126       <td width="6%" class="ficaption2" id="bordR">HIV test <a href="#" onMouseOver="toolTip('Check state requirements before recording results.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
 127
 128       <td width="6%" class="ficaption2" id="bordR">Genetic testing </td>
 129
 130       <td width="6%" class="ficaption2" id="bordR">Rubella titer </td>
 131
 132       <td width="6%" class="ficaption2" id="bordR">TB skin test </td>
 133
 134       <td width="6%" class="ficaption2" id="bordR">Lipid profile assessment </td>
 135
 136       <td width="6%" class="ficaption2" id="bordR">Mammo-<br>
 137
 138         graphy</td>
 139
 140       <td width="6%" class="ficaption2" id="bordR">Fasting<br>
 141
 142         GLUCOSE TEST</td>
 143
 144       <td width="6%" class="ficaption2" id="bordR">TSH<br>
 145
 146         TEST</td>
 147
 148       <td width="6%" class="ficaption2" id="bordR">COLORECTAL<br>
 149
 150         CANCER<br>
 151
 152         SCREENING</td>
 153
 154       <td width="6%" class="ficaption2">HEPATITIS C<br>
 155
 156         VIRUS TEST</td>
 157
 158     </tr>
 159
 160 <?
 161
 162 $rsi = 1;
 163
 164 while ($rsi < 13){
 165
 166 list(
 167
 168 $hemoglobin, $bone_density, $bacteriuria, $std, $hiv, $genetic, $rubella, $tb_skin,
 169
 170 $lipid, $mammography, $fasting_glucose, $tsh, $cancer, $hepatitis_c
 171
 172 ) = explode("|~",$fdata["record_".$rsi]);
 173
 174 list( $hemoglobin_date, $hemoglobin_res) = explode(';', $hemoglobin);
 175
 176 list( $bone_density_date, $bone_density_res) = explode(';', $bone_density);
 177
 178 list( $bacteriuria_date, $bacteriuria_res) = explode(';', $bacteriuria);
 179
 180 list( $std_date, $std_res) = explode(';', $std);
 181
 182 list( $hiv_date, $hiv_res) = explode(';', $hiv);
 183
 184 list( $genetic_date, $genetic_res) = explode(';', $genetic);
 185
 186 list( $rubella_date, $rubella_res) = explode(';', $rubella);
 187
 188 list( $tb_skin_date, $tdb_skin_res) = explode(';', $tdb_skin);
 189
 190 list( $lipid_date, $lipid_res) = explode(';', $lipid);
 191
 192 list( $mammography_date, $mammography_res) = explode(';', $mammography);
 193
 194 list( $fasting_glucose_date, $fasting_glucose_res) = explode(';', $fasting_glucose);
 195
 196 list( $tsh_date, $tsh_res) = explode(';', $tsh);
 197
 198 list( $cancer_date, $cancer_res) = explode(';', $cancer);
 199
 200 list( $hepatitis_c_date, $hepatitis_c_res) = explode(';', $hepatitis_c);
 201
 202
 203
 204 print <<<EOL
 205
 206     <tr align="left" valign="bottom">
 207
 208       <td class="fibody3" id="bordR">Date:</td>
 209
 210       <td class="fibody3" id="bordR"><input name="hemoglobin_date_${rsi}" type="text" value="${hemoglobin_date}" class="fullin2"></td>
 211
 212       <td class="fibody3" id="bordR"><input name="bone_density_date_${rsi}" type="text" value="${bone_density_date}"  class="fullin2"></td>
 213
 214       <td class="fibody3" id="bordR"><input name="bacteriuria_date_${rsi}" type="text" value="${bacteriuria_date}"  class="fullin2"></td>
 215
 216       <td class="fibody3" id="bordR"><input name="std_date_${rsi}" type="text" value="${std_date}"  class="fullin2"></td>
 217
 218       <td class="fibody3" id="bordR"><input name="hiv_date_${rsi}" type="text" value="${hiv_date}"  class="fullin2"></td>
 219
 220       <td class="fibody3" id="bordR"><input name="genetic_date_${rsi}" type="text" value="${genetic_date}"  class="fullin2"></td>
 221
 222       <td class="fibody3" id="bordR"><input name="rubella_date_${rsi}" type="text" value="${rubella_date}"  class="fullin2"></td>
 223
 224       <td class="fibody3" id="bordR"><input name="tb_skin_date_${rsi}" type="text" value="${tb_skin_date}"  class="fullin2"></td>
 225
 226       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" value="${lipid_date}"  class="fullin2"></td>
 227
 228       <td class="fibody3" id="bordR"><input name="mammography_date_${rsi}" type="text" value="${mammography_date}"  class="fullin2"></td>
 229
 230       <td class="fibody3" id="bordR"><input name="fasting_glucose_date_${rsi}" type="text" value="${fasting_glucose_date}"  class="fullin2"></td>
 231
 232       <td class="fibody3" id="bordR"><input name="tsh_date_${rsi}" type="text" value="${tsh_date}"  class="fullin2"></td>
 233
 234       <td class="fibody3" id="bordR"><input name="cancer_date_${rsi}" type="text" value="${cancer_date}"  class="fullin2"></td>
 235
 236       <td class="fibody3"><input name="hepatitis_c_date_${rsi}" type="text" value="${hepatitis_c_date}"  class="fullin2"></td>
 237
 238     </tr>
 239
 240     <tr align="left" valign="bottom">
 241
 242       <td class="fibody2" id="bordR">Result:</td>
 243
 244       <td class="fibody2" id="bordR"><input name="hemoglobin_res_${rsi}" type="text" value="${hemoglobin_res}"  class="fullin2"></td>
 245
 246       <td class="fibody2" id="bordR"><input name="bone_density_res_${rsi}" type="text" value="${bone_density_res}"  class="fullin2"></td>
 247
 248       <td class="fibody2" id="bordR"><input name="bacteriuria_res_${rsi}" type="text" value="${bacteriuria_res}"  class="fullin2"></td>
 249
 250       <td class="fibody2" id="bordR"><input name="std_res_${rsi}" type="text" value="${std_res}"  class="fullin2"></td>
 251
 252       <td class="fibody2" id="bordR"><input name="hiv_res_${rsi}" type="text" value="${hiv_res}"  class="fullin2"></td>
 253
 254       <td class="fibody2" id="bordR"><input name="genetic_res_${rsi}" type="text" value="${genetic_res}"  class="fullin2"></td>
 255
 256       <td class="fibody2" id="bordR"><input name="rubella_res_${rsi}" type="text" value="${rubella_res}"  class="fullin2"></td>
 257
 258       <td class="fibody2" id="bordR"><input name="tb_skin_res_${rsi}" type="text" value="${tb_skin_res}"  class="fullin2"></td>
 259
 260       <td class="fibody2" id="bordR"><input name="lipid_res_${rsi}" type="text" value="${lipid_res}"  class="fullin2"></td>
 261
 262       <td class="fibody2" id="bordR"><input name="mammography_res_${rsi}" type="text" value="${mammography_res}"  class="fullin2"></td>
 263
 264       <td class="fibody2" id="bordR"><input name="fasting_glucose_res_${rsi}" type="text" value="${fasting_glucose_res}"  class="fullin2"></td>
 265
 266       <td class="fibody2" id="bordR"><input name="tsh_res_${rsi}" type="text" value="${tsh_res}"  class="fullin2"></td>
 267
 268       <td class="fibody2" id="bordR"><input name="cancer_res_${rsi}" type="text" value="${cancer_res}"  class="fullin2"></td>
 269
 270       <td class="fibody2"><input name="hepatitis_c_res_${rsi}" type="text" value="${hepatitis_c_res}"  class="fullin2"></td>
 271
 272     </tr>
 273
 274 EOL;
 275
 276 $rsi++;
 277
 278 }
 279
 280 ?>
 281
 282   </table>
 283
 284 </div>
 285
 286 <p>&nbsp;</p>
 287
 288   <table width="100%" border="0">
 289
 290     <tr>
 291
 292       <td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 293
 294       <td align="left" nowrap> <a href="<? echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<? echo $id; ?>&formname=<? echo $formname; ?>" target="_blank" class="link_submit"
 295
 296        onclick="top.restoreSession()">[Printable form]</a> </td>
 297
 298       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 299
 300        onclick="top.restoreSession()">[Don't Save]</a> </td>
 301
 302     </tr>
 303
 304   </table>
 305
 306 </form>
 307
 308 <?php
 309
 310 formFooter();
 311
 312 ?>
 313
 314 </body>
 315
 316 </html>