contrib/forms/mh_therapy_progress/view.php

   1 <!-- Forms generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <? html_header_show();?>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <?php
  11 include_once("$srcdir/api.inc");
  12
  13 $obj = formFetch("form_mh_therapy_progress", $_GET["id"]);
  14
  15 ?>
  16 <form method=post action="<?echo $rootdir?>/forms/mh_therapy_progress/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  17 <span class="title"><center><b>Therapy Progress Note</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"
  21  onclick="top.restoreSession()">[Don't Save Changes]</a></center>
  22 <br></br>
  23
  24 <? /* From New */ ?>
  25
  26 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  27 $result = SqlFetchArray($res); ?>
  28 <b><u>A. Client and meeting Information</u></b><br><br>
  29 <b>Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  30 <img src="../../../images/space.gif" width="125" height="1">
  31 <b>Date:</b>&nbsp; <?php print date('m/d/y'); ?>
  32 <img src="../../../images/space.gif" width="72" height="1">
  33 <b>Time In:</b>&nbsp;<input type="text" name="time_in" value="<? echo stripslashes($obj{"time_in"});?>">
  34 <img src="../../../images/space.gif" width="14" height="1">
  35 <b>Time Out:</b>&nbsp;<input type="text" name="time_out" value="<? echo stripslashes($obj{"time_out"});?>"><br><br>
  36
  37 <b>Meeting was:</b>&nbsp;<input type=checkbox name='meeting_scheduled' <? if ($obj{"meeting_scheduled"} == "on") {echo "checked";};?>><b>Scheduled</b>
  38 <img src="../../../images/space.gif" width="6" height="1">
  39 <input type=checkbox name='meeting_emergency' <? if ($obj{"meeting_emergency"} == "on") {echo "checked";};?>><b>Emergency</b>
  40 <img src="../../../images/space.gif" width="12" height="1">
  41 <b>Others Present</b><img src="../../../images/space.gif" width="6" height="1">
  42 <textarea cols=55 rows=1 wrap=virtual name="others_present" ><? echo stripslashes($obj{"others_present"});?></textarea><br><br>
  43
  44 <b>Meeting lasted:</b>&nbsp;<input type="text" name="meeting_lasted" value="<? echo stripslashes($obj{"meeting_lasted"});?>">&nbsp;<b>minutes</b>
  45 <img src="../../../images/space.gif" width="18" height="1">
  46 <b>Number of Units</b>&nbsp;<input type="text" name="number_of_units" value="<? echo stripslashes($obj{"number_of_units"});?>">
  47 <img src="../../../images/space.gif" width="18" height="1">
  48 <b>ICD-9 Diagnosis</b>&nbsp;<input type="text" name="icd9" value="<? echo stripslashes($obj{"icd9"});?>"><br><br>
  49
  50 <b>Client:</b>&nbsp;<input type=checkbox name='client_ontime' <? if ($obj{"client_ontime"} == "on") {echo "checked";};?>><b>Was on time</b>
  51 <img src="../../../images/space.gif" width="6" height="1">
  52 <input type=checkbox name='client_late' <? if ($obj{"client_late"} == "on") {echo "checked";};?>><b>Was late by</b>
  53 <img src="../../../images/space.gif" width="6" height="1">
  54 <input type="text" name="was_late_by" value="<? echo stripslashes($obj{"was_late_by"});?>">
  55 <img src="../../../images/space.gif" width="6" height="1">
  56 <b>min.</b>
  57 <img src="../../../images/space.gif" width="6" height="1">
  58 <input type=checkbox name='did_not_show' <? if ($obj{"did_not_show"} == "on") {echo "checked";};?>>&nbsp;<b>Did not show</b>
  59 <img src="../../../images/space.gif" width="6" height="1">
  60 <input type=checkbox name='cancelled' <? if ($obj{"cancelled"} == "on") {echo "checked";};?>>&nbsp;<b>Cancelled</b>
  61 <img src="../../../images/space.gif" width="18" height="1">
  62 <b>Next Meeting</b>
  63 <img src="../../../images/space.gif" width="6" height="1">
  64 <input type="text" name="next_meeting" value="<? echo stripslashes($obj{"next_meeting"});?>"><br><br>
  65
  66 <b>Location:</b>&nbsp;
  67 <input type=checkbox name='location_office' <? if ($obj{"location_office"} == "on") {echo "checked";};?>>&nbsp;<b>Office</b>
  68 <img src="../../../images/space.gif" width="6" height="1">
  69 <input type=checkbox name='location_detention' <? if ($obj{"location_detention"} == "on") {echo "checked";};?>>&nbsp;<b>Detention</b>
  70 <img src="../../../images/space.gif" width="6" height="1">
  71 <input type=checkbox name='location_home' <? if ($obj{"location_home"} == "on") {echo "checked";};?>>&nbsp;<b>Home</b>
  72 <img src="../../../images/space.gif" width="6" height="1">
  73 <input type=checkbox name='location_school' <? if ($obj{"location_school"} == "on") {echo "checked";};?>>&nbsp;<b>School</b>
  74 <img src="../../../images/space.gif" width="6" height="1">
  75 <input type=checkbox name='location_hosp' <? if ($obj{"location_hosp"} == "on") {echo "checked";};?>>&nbsp;<b>Hosp.</b>
  76 <img src="../../../images/space.gif" width="6" height="1">
  77 <input type=checkbox name='location_other' <? if ($obj{"location_other"} == "on") {echo "checked";};?>>&nbsp;<b>Other</b>
  78 <img src="../../../images/space.gif" width="6" height="1">
  79 <input type="text" name="location_other_block" value="<? echo stripslashes($obj{"location_other_block"});?>">
  80 <img src="../../../images/space.gif" width="6" height="1">
  81 <b>Facility Code:</b>
  82 <img src="../../../images/space.gif" width="6" height="1">
  83 <input type="text" name="location_facility_code"value="<? echo stripslashes($obj{"location_facility_code"});?>"><br><br>
  84
  85 <b>Treatment:</b>
  86 <img src="../../../images/space.gif" width="6" height="1">
  87 <input type=checkbox name='treatment_individual_therapy' <? if ($obj{"treatment_individual_therapy"} == "on") {echo "checked";};?>>&nbsp;<b>Individual therapy</b>
  88 <img src="../../../images/space.gif" width="6" height="1">
  89 <input type=checkbox name='treatment_family' <? if ($obj{"treatment_family"} == "on") {echo "checked";};?>>&nbsp;<b>Family</b>
  90 <img src="../../../images/space.gif" width="6" height="1">
  91 <input type=checkbox name='treatment_group' <? if ($obj{"treatment_group"} == "on") {echo "checked";};?>>&nbsp;<b>Group</b>
  92 <img src="../../../images/space.gif" width="6" height="1">
  93 <input type=checkbox name='treatment_couple' <? if ($obj{"treatment_couple"} == "on") {echo "checked";};?>>&nbsp;<b>Couple</b>
  94 <img src="../../../images/space.gif" width="6" height="1">
  95 <input type=checkbox name='treatment_assessment' <? if ($obj{"treatment_assessment"} == "on") {echo "checked";};?>>&nbsp;<b>Assessment</b>
  96 <img src="../../../images/space.gif" width="6" height="1">
  97 <b>Service Code:</b>
  98 <img src="../../../images/space.gif" width="6" height="1">
  99 <input type="text" name="treatment_service_code" value="<? echo stripslashes($obj{"treatment_service_code"});?>"><br><br>
 100
 101 <b>Pay Source:</b>
 102 <img src="../../../images/space.gif" width="6" height="1">
 103 <input type=checkbox name='paysource_medicaid' <? if ($obj{"paysource_medicaid"} == "on") {echo "checked";};?>>&nbsp;<b>Medicaid</b>
 104 <img src="../../../images/space.gif" width="6" height="1">
 105 <input type=checkbox name='paysource_dfs' <? if ($obj{"paysource_dfs"} == "on") {echo "checked";};?>>&nbsp;<b>DFS</b>
 106 <img src="../../../images/space.gif" width="6" height="1">
 107 <input type=checkbox name='paysource_private' <? if ($obj{"paysource_private"} == "on") {echo "checked";};?>>&nbsp;<b>Private</b>
 108 <img src="../../../images/space.gif" width="6" height="1">
 109 <input type=checkbox name='paysource_other' <? if ($obj{"paysource_other"} == "on") {echo "checked";};?>>&nbsp;<b>Other</b>
 110 <img src="../../../images/space.gif" width="6" height="1">
 111 <input type="text" name="paysource_other_block" value="<? echo stripslashes($obj{"paysource_other_block"});?>">
 112 <img src="../../../images/space.gif" width="18" height="1">
 113 <b>County:</b>
 114 <img src="../../../images/space.gif" width="6" height="1">
 115 <input type="text" name="paysource_county" value="<? echo stripslashes($obj{"paysource_county"});?>"><br><br>
 116
 117 <br>
 118 <b><u>B. Topic of Discussion (Content)</u></b><br>
 119 <textarea cols=120 rows=7 wrap=virtual name="topics_of_discussion" ><? echo stripslashes($obj{"topics_of_discussion"});?></textarea><br><br>
 120
 121 <b><u>C. Progress Toward Goals (Process)</u></b><br>
 122 <textarea cols=120 rows=7 wrap=virtual name="progress_towards_goals" ><? echo stripslashes($obj{"progress_towards_goals"});?></textarea><br><br>
 123
 124 <b><u>D. Client Description and Assessment</u></b><br><br>
 125
 126 <b>Medications:</b>
 127 <img src="../../../images/space.gif" width="6" height="1">
 128 <textarea cols=107 rows=1 wrap=virtual name="medications" ><? echo stripslashes($obj{"medications"});?></textarea><br><br>
 129
 130 <b>Report of Functioning since last session:</b>
 131 <img src="../../../images/space.gif" width="6" height="1">
 132 <textarea cols=84 rows=1 wrap=virtual name="functioning_since_session" ><? echo stripslashes($obj{"functioning_since_session"});?></textarea><br><br>
 133
 134 <b>Mood:</b>
 135 <img src="../../../images/space.gif" width="6" height="1">
 136 <input type=checkbox name='mood_normal' <? if ($obj{"mood_normal"} == "on") {echo "checked";};?>>&nbsp;<b>Normal/euthymic</b>
 137 <img src="../../../images/space.gif" width="6" height="1">
 138 <input type=checkbox name='mood_anxious' <? if ($obj{"mood_anxious"} == "on") {echo "checked";};?>>&nbsp;<b>Anxious</b>
 139 <img src="../../../images/space.gif" width="6" height="1">
 140 <input type=checkbox name='mood_depressed' <? if ($obj{"mood_depressed"} == "on") {echo "checked";};?>>&nbsp;<b>Depressed</b>
 141 <img src="../../../images/space.gif" width="6" height="1">
 142 <input type=checkbox name='mood_angry' <? if ($obj{"mood_angry"} == "on") {echo "checked";};?>>&nbsp;<b>Angry</b>
 143 <img src="../../../images/space.gif" width="6" height="1">
 144 <input type=checkbox name='mood_euphoric' <? if ($obj{"mood_euphoric"} == "on") {echo "checked";};?>>&nbsp;<b>Euphoric</b><br><br>
 145
 146 <b>Affect:</b>
 147 <img src="../../../images/space.gif" width="6" height="1">
 148 <input type=checkbox name='affect_normal' <? if ($obj{"affect_normal"} == "on") {echo "checked";};?>>&nbsp;<b>Normal/appropriate</b>
 149 <img src="../../../images/space.gif" width="6" height="1">
 150 <input type=checkbox name='affect_intense' <? if ($obj{"affect_intense"} == "on") {echo "checked";};?>>&nbsp;<b>Intense</b>
 151 <img src="../../../images/space.gif" width="6" height="1">
 152 <input type=checkbox name='affect_blunted' <? if ($obj{"affect_blunted"} == "on") {echo "checked";};?>>&nbsp;<b>Blunted</b>
 153 <img src="../../../images/space.gif" width="6" height="1">
 154 <input type=checkbox name='affect_inappropriate' <? if ($obj{"affect_inappropriate"} == "on") {echo "checked";};?>>&nbsp;<b>Inappropriate</b>
 155 <img src="../../../images/space.gif" width="6" height="1">
 156 <input type=checkbox name='affect_labile' <? if ($obj{"affect_labile"} == "on") {echo "checked";};?>>&nbsp;<b>Labile</b><br><br>
 157
 158 <b>Mental status:</b>
 159 <img src="../../../images/space.gif" width="6" height="1">
 160 <input type=checkbox name='mentalstatus_normal' <? if ($obj{"mentalstatus_normal"} == "on") {echo "checked";};?>>&nbsp;<b>Normal</b>
 161 <img src="../../../images/space.gif" width="6" height="1">
 162 <input type=checkbox name='mentalstatus_lessened_awareness' <? if ($obj{"mentalstatus_lessened_awareness"} == "on") {echo "checked";};?>>&nbsp;<b>Lessened awareness</b>
 163 <img src="../../../images/space.gif" width="6" height="1">
 164 <input type=checkbox name='mentalstatus_memory_deficiencies' <? if ($obj{"mentalstatus_memory_deficiencies"} == "on") {echo "checked";};?>>&nbsp;<b>Memory Deficiencies</b>
 165 <img src="../../../images/space.gif" width="6" height="1">
 166 <input type=checkbox name='mentalstatus_disorientated' <? if ($obj{"mentalstatus_disorientated"} == "on") {echo "checked";};?>>&nbsp;<b>Disoriented</b>
 167 <img src="../../../images/space.gif" width="6" height="1">
 168 <br><input type=checkbox name='mentalstatus_disorganized' <? if ($obj{"mentalstatus_disorganized"} == "on") {echo "checked";};?>>&nbsp;<b>Disorganized</b>
 169 <img src="../../../images/space.gif" width="6" height="1">
 170 <input type=checkbox name='mentalstatus_vigilant' <? if ($obj{"mentalstatus_vigilant"} == "on") {echo "checked";};?>>&nbsp;<b>Vigilant</b>
 171 <img src="../../../images/space.gif" width="6" height="1">
 172 <input type=checkbox name='mentalstatus_delusional' <? if ($obj{"mentalstatus_delusional"} == "on") {echo "checked";};?>>&nbsp;<b>Delusional</b>
 173 <img src="../../../images/space.gif" width="6" height="1">
 174 <input type=checkbox name='mentalstatus_hallucinating' <? if ($obj{"mentalstatus_hallucinating"} == "on") {echo "checked";};?>>&nbsp;<b>Hallucinating</b>
 175 <img src="../../../images/space.gif" width="6" height="1">
 176 <input type=checkbox name='mentalstatus_other' <? if ($obj{"mentalstatus_other"} == "on") {echo "checked";};?>>&nbsp;<b>Other:</b>
 177 <img src="../../../images/space.gif" width="6" height="1">
 178 <input type="text" name="mentalstatus_other_block" value="<? echo stripslashes($obj{"mentalstatus_other_block"});?>" ><br><br>
 179
 180 <b>Suicide/violence risk:</b>
 181 <img src="../../../images/space.gif" width="6" height="1">
 182 <input type=checkbox name='suicide_violance_risk_none'<? if ($obj{"suicide_violance_risk_none"} == "on") {echo "checked";};?>>&nbsp;<b>None</b>
 183 <img src="../../../images/space.gif" width="6" height="1">
 184 <input type=checkbox name='suicide_violance_risk_ideation_only' <? if ($obj{"suicide_violance_risk_ideation_only"} == "on") {echo "checked";};?>>&nbsp;<b>Ideation only</b>
 185 <img src="../../../images/space.gif" width="6" height="1">
 186 <input type=checkbox name='suicide_violance_risk_threat' <? if ($obj{"suicide_violance_risk_threat"} == "on") {echo "checked";};?>>&nbsp;<b>Threat</b>
 187 <img src="../../../images/space.gif" width="6" height="1">
 188 <input type=checkbox name='suicide_violance_risk_gesture' <? if ($obj{"suicide_violance_risk_gesture"} == "on") {echo "checked";};?>>&nbsp;<b>Gesture</b>
 189 <img src="../../../images/space.gif" width="6" height="1">
 190 <input type=checkbox name='suicide_violance_risk_rehearsal' <? if ($obj{"suicide_violance_risk_rehearsal"} == "on") {echo "checked";};?>>&nbsp;<b>Rehearsal</b>
 191 <img src="../../../images/space.gif" width="6" height="1">
 192 <input type=checkbox name='suicide_violance_risk_attempt' <? if ($obj{"suicide_violance_risk_attempt"} == "on") {echo "checked";};?>>&nbsp;<b>Attempt</b><br><br>
 193
 194 <b>Sleep quality:</b>
 195 <img src="../../../images/space.gif" width="6" height="1">
 196 <input type=checkbox name='sleep_quality_normal' <? if ($obj{"sleep_quality_normal"} == "on") {echo "checked";};?>>&nbsp;<b>Normal</b>
 197 <img src="../../../images/space.gif" width="6" height="1">
 198 <input type=checkbox name='sleep_quality_restless' <? if ($obj{"sleep_quality_restless"} == "on") {echo "checked";};?>>&nbsp;<b>Restless</b>
 199 <img src="../../../images/space.gif" width="6" height="1">
 200 <input type=checkbox name='sleep_quality_insomnia' <? if ($obj{"sleep_quality_insomnia"} == "on") {echo "checked";};?>>&nbsp;<b>Insomnia</b>
 201 <img src="../../../images/space.gif" width="6" height="1">
 202 <input type=checkbox name='sleep_quality_nightmares' <? if ($obj{"sleep_quality_nightmares"} == "on") {echo "checked";};?>>&nbsp;<b>Nightmares</b>
 203 <img src="../../../images/space.gif" width="6" height="1">
 204 <input type=checkbox name='sleep_quality_oversleeps' <? if ($obj{"sleep_quality_oversleeps"} == "on") {echo "checked";};?>>&nbsp;<b>Oversleeps</b><br><br>
 205
 206 <b>Participation level:</b>
 207 <img src="../../../images/space.gif" width="6" height="1">
 208 <input type=checkbox name='participation_level_active' <? if ($obj{"participation_level_active"} == "on") {echo "checked";};?>>&nbsp;<b>Active/eager</b>
 209 <img src="../../../images/space.gif" width="6" height="1">
 210 <input type=checkbox name='participation_level_variable'<? if ($obj{"participation_level_variable"} == "on") {echo "checked";};?>>&nbsp;<b>Variable</b>
 211 <img src="../../../images/space.gif" width="6" height="1">
 212 <input type=checkbox name='participation_level_only_responsive' <? if ($obj{"participation_level_responsive"} == "on") {echo "checked";};?>>&nbsp;<b>Only responsive</b>
 213 <img src="../../../images/space.gif" width="6" height="1">
 214 <input type=checkbox name='participation_level_minimal' <? if ($obj{"participation_level_minimal"} == "on") {echo "checked";};?>>&nbsp;<b>Minimal</b>
 215 <img src="../../../images/space.gif" width="6" height="1">
 216 <input type=checkbox name='participation_level_none' <? if ($obj{"participation_level_none"} == "on") {echo "checked";};?>>&nbsp;<b>None</b>
 217 <img src="../../../images/space.gif" width="6" height="1">
 218 <input type=checkbox name='participation_level_resistant' <? if ($obj{"participation_level_resistant"} == "on") {echo "checked";};?>>&nbsp;<b>Resistant</b>
 219 <br><br>
 220
 221 <b>Treatment_compliance:</b>
 222 <img src="../../../images/space.gif" width="6" height="1">
 223 <input type=checkbox name='treatment_compliance_full' <? if ($obj{"treatment_compliance_full"} == "on") {echo "checked";};?>>&nbsp;<b>Full</b>
 224 <img src="../../../images/space.gif" width="6" height="1">
 225 <input type=checkbox name='treatment_compliance_partial' <? if ($obj{"treatment_compliance_partial"} == "on") {echo "checked";};?>>&nbsp;<b>Partial</b>
 226 <img src="../../../images/space.gif" width="6" height="1">
 227 <input type=checkbox name='treatment_compliance_low' <? if ($obj{"treatment_compliance_low"} == "on") {echo "checked";};?>>&nbsp;<b>Low</b><br><br>
 228
 229 <b>Response to treatment:</b>
 230 <img src="../../../images/space.gif" width="6" height="1">
 231 <input type=checkbox name='response_to_treatment_as_expected' <? if ($obj{"response_to_treatment_as_expected"} == "on") {echo "checked";};?>>&nbsp;<b>As expected</b>
 232 <img src="../../../images/space.gif" width="6" height="1">
 233 <input type=checkbox name='response_to_treatment_better' <? if ($obj{"response_to_treatment_better"} == "on") {echo "checked";};?>>&nbsp;<b>Better than expected</b>
 234 <img src="../../../images/space.gif" width="6" height="1">
 235 <input type=checkbox name='response_to_treatment_much' <? if ($obj{"response_to_treatment_much"} == "on") {echo "checked";};?>>&nbsp;<b>Much</b>
 236 <img src="../../../images/space.gif" width="6" height="1">
 237 <input type=checkbox name='response_to_treatment_poorer' <? if ($obj{"response_to_treatment_poorer"} == "on") {echo "checked";};?>>&nbsp;<b>Poorer</b>
 238 <img src="../../../images/space.gif" width="6" height="1">
 239 <input type=checkbox name='response_to_treatment_very_poor' <? if ($obj{"response_to_treatment_very_poor"} == "on") {echo "checked";};?>>&nbsp;<b>Very poor</b><br><br>
 240
 241 <b>GAF (Global Assessment of Functioning) from 100 to 0 is currently:</b>
 242 <img src="../../../images/space.gif" width="6" height="1">
 243 <input type="text" name="gaf" value="<? echo stripslashes($obj{"gaf"});?>"><br><br>
 244
 245 <b>Other observations/evaluations:</b>
 246 <img src="../../../images/space.gif" width="12" height="1">
 247 <textarea cols=83 rows=1 wrap=virtual name="other_observations" ><? echo stripslashes($obj{"other_observations"});?></textarea><br><br>
 248
 249 <b>Changes to diagnosis:</b>
 250 <img src="../../../images/space.gif" width="6" height="1">
 251 <input type=checkbox name='diagnosis_changes_none' <? if ($obj{"diagnosis_changes_none"} == "on") {echo "checked";};?>>&nbsp;<b>None</b>
 252 <img src="../../../images/space.gif" width="6" height="1">
 253 <textarea cols=83 rows=1 wrap=virtual name="diagnosis_changes" ><? echo stripslashes($obj{"diagnosis_changes"});?></textarea><br><br>
 254
 255 <h5><b>If treatment was changed, Indicate rational, alternatives considered/rejected/selected in notes.</b></h5>
 256
 257 <b>G. Follow-Ups</b><br><br>
 258
 259 <input type=checkbox name='followups_next' <? if ($obj{"followups_next"} == "on") {echo "checked";};?>>
 260 <img src="../../../images/space.gif" width="6" height="1">
 261 <b>Next appointment is scheduled for:</b>
 262 <input type="text" name='followups_next_date'  value="<? echo stripslashes($obj{"followups_next_date"});?>">
 263 <img src="../../../images/space.gif" width="6" height="1">
 264 <input type=checkbox name='followups_next_week' <? if ($obj{"followups_next_week"} == "on") {echo "checked";};?>>&nbsp;<b>Week</b>
 265 <img src="../../../images/space.gif" width="6" height="1">
 266 <input type=checkbox name='followups_next_month' <? if ($obj{"followups_next_month"} == "on") {echo "checked";};?>>&nbsp;<b>Month</b>
 267 <img src="../../../images/space.gif" width="6" height="1">
 268 <input type=checkbox name='followups_next_2_months' <? if ($obj{"followups_next_2_months"} == "on") {echo "checked";};?>>&nbsp;<b>2 Months</b>
 269 <img src="../../../images/space.gif" width="6" height="1">
 270 <input type=checkbox name='followups_next_3_months' <? if ($obj{"followups_next_3_months"} == "on") {echo "checked";};?>>&nbsp;<b>3 Months</b>
 271 <img src="../../../images/space.gif" width="6" height="1">
 272 <input type=checkbox name='followups_next_as_needed' <? if ($obj{"followups_next_as_needed"} == "on") {echo "checked";};?>>&nbsp;<b>as needed</b><br><br>
 273
 274 <input type=checkbox name='followups_referral' <? if ($obj{"followups_referral"} == "on") {echo "checked";};?>>
 275 <img src="../../../images/space.gif" width="6" height="1">
 276 <b>Referral/consultation to:</b>
 277 <img src="../../../images/space.gif" width="6" height="1">
 278 <input type="text" name='followups_referral_to' value="<? echo stripslashes($obj{"followups_referral_to"});?>">
 279 <img src="../../../images/space.gif" width="6" height="1">
 280 <b>For:</b>
 281 <img src="../../../images/space.gif" width="6" height="1">
 282 <input type="text" name='followups_referral_for'  value="<? echo stripslashes($obj{"followups_referral_for"});?>"><br><br>
 283
 284 <input type=checkbox name='followups_call' <? if ($obj{"followups_call"} == "on") {echo "checked";};?>>
 285 <img src="../../../images/space.gif" width="6" height="1">
 286 <b>Call/write to:</b>
 287 <img src="../../../images/space.gif" width="6" height="1">
 288 <input type="text" name='followups_call_to'  value="<? echo stripslashes($obj{"followups_call_to"});?>">
 289 <img src="../../../images/space.gif" width="6" height="1">
 290 <b>For:</b>
 291 <img src="../../../images/space.gif" width="6" height="1">
 292 <input type="text" name='followups_call_for'  value="<? echo stripslashes($obj{"followups_call_for"});?>"><br>
 293
 294 <?php /* From New */ ?>
 295 <br>
 296 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 297 <br>
 298 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
 299  onclick="top.restoreSession()">[Don't Save Changes]</a>
 300 </form>
 301 <?php
 302 formFooter();
 303 ?>