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");
10 $dt = sqlFetchArray($old);
11 $fid = $dt{'form_id'};
12 if ($fid && ($fid != 0) && ($fid != '')){
13 $fdir = $dt{'formdir'};
15 $dt = formFetch($frmn, $fid);
16 $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
17 addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
19 formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
24 <!DOCTYPE HTML
PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
25 "http://www.w3.org/TR/html4/loose.dtd">
29 <?
html_header_show();?
>
30 <title
>Form
: ACOG Immunization record
</title
>
31 <link rel
=stylesheet href
="<?echo $css_header;?>" type
="text/css">
32 <link rel
=stylesheet href
="../../acog.css" type
="text/css">
33 <script language
="JavaScript" src
="../../acog.js" type
="text/JavaScript"></script
>
34 <script language
="JavaScript" type
="text/JavaScript">
36 window
.onload
= initialize
;
42 $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
44 $patient = sqlFetchArray($fres);
47 <body
<?
echo $top_bg_line;?
>>
50 <form action
="<?echo $rootdir;?>/forms/immunization_record/save.php?mode=new" method
="post" enctype
="multipart/form-data" name
="my_form">
51 <?
include("../../acog_menu.inc"); ?
>
52 <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
>
53 <div style
="border: solid 2px black; background-color:#FFFFFF;">
54 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
55 <tr align
="left" valign
="bottom">
56 <td colspan
="4" class="fibody2" id
="bordR">patient name
:
57 <input name
="pname" type
="text" class="fullin" id
="pname" style
="width: 74%" value
="<?
58 echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
60 <td colspan
="2" class="fibody2" id
="bordR">Birth date
:
61 <input name
="pbdate" type
="text" class="fullin" id
="pbdate" style
="width: 65%" value
="<?
64 <td colspan
="2" class="fibody2">ID No
:
65 <input name
="pl_pid" type
="text" class="fullin" id
="pl_pid" style
="width:80%" value
="<?
69 <tr align
="center" valign
="middle">
70 <td width
="9%" class="ficaption2" id
="bordR">age
</td
>
71 <td width
="13%" class="ficaption2" id
="bordR">Tetanus
-<br
>
74 <td width
="13%" class="ficaption2" id
="bordR">Influenza
<br
>
76 <td width
="13%" class="ficaption2" id
="bordR">Pneumococcal vaccine
</td
>
77 <td width
="13%" class="ficaption2" id
="bordR">MMR Vaccine
</td
>
78 <td width
="13%" class="ficaption2" id
="bordR">Hepatitis B vaccine
</td
>
79 <td width
="13%" class="ficaption2" id
="bordR">Hepatitis A vaccine
</td
>
80 <td width
="13%" class="ficaption2">Varicella vaccine
</td
>
82 <tr align
="center" valign
="middle">
83 <td
class="fibody2" id
="bordR">13-18</td
>
84 <td
class="fibody2" id
="bordR">Once between ages
11-16 </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">Based on risk
</td
>
88 <td
class="fibody2" id
="bordR">One series
for those not previously immunized
</td
>
89 <td
class="fibody2" id
="bordR">Based on risk
</td
>
90 <td
class="fibody2">Based on risk
</td
>
92 <tr align
="center" valign
="middle">
93 <td
class="fibody2" id
="bordR">19-39</td
>
94 <td
class="fibody2" id
="bordR">Every
10 years
</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" id
="bordR">Based on risk
</td
>
100 <td
class="fibody2">Based on risk
</td
>
102 <tr align
="center" valign
="middle">
103 <td
class="fibody2" id
="bordR">40-64</td
>
104 <td
class="fibody2" id
="bordR">Every
10 years
</td
>
105 <td
class="fibody2" id
="bordR">Annually beginning at age
50 years
</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" id
="bordR">Based on risk
</td
>
110 <td
class="fibody2">Based on risk
</td
>
112 <tr align
="center" valign
="middle">
113 <td
class="fibody2" id
="bordR">65 and older
</td
>
114 <td
class="fibody2" id
="bordR">Every
10 years
</td
>
115 <td
class="fibody2" id
="bordR">Annually
</td
>
116 <td
class="fibody2" id
="bordR">Once
</td
>
117 <td
class="fibody2" id
="bordR"> 
;</td
>
118 <td
class="fibody2" id
="bordR">Based on risk
</td
>
119 <td
class="fibody2" id
="bordR">Based on risk
</td
>
120 <td
class="fibody2">Based on risk
</td
>
125 <div style
="border: solid 2px black; background-color:#FFFFFF;">
126 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
131 <tr align="left" valign="bottom">
132 <td width="9%" class="fibody2" id="bordR">Date</td>
133 <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2"></td>
134 <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2"></td>
135 <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2"></td>
136 <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2"></td>
137 <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2"></td>
138 <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2"></td>
139 <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2"></td>
147 <p
><sup
>*</sup
>For immunizations based on risk refer to the Table of High
-Risk Factors
.</p
>
149 <table width
="100%" border
="0">
151 <td align
="left"> <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data
]</a
> </td
>
152 <td align
="right"> <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
153 onclick
="top.restoreSession()">[Don
't Save]</a> </td>