1 <!-- Form generated from formsWiz
-->
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: obstetrical");
8 <?
html_header_show();?
>
9 <link rel
=stylesheet href
="<?echo $css_header;?>" type
="text/css">
11 <body
<?
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
12 <form method
=post action
="<?echo $rootdir;?>/forms/obstetrical/save.php?mode=new" name
="my_form">
13 <span
class="title">Obstetrical Form
</span
><br
><br
>
16 <tr
><td
><span
class=text
>Name
: </span
></td
><td
><input type
=entry name
="name" value
="" ></td
>
17 <td
><span
class=text
>Birthdate
: </span
></td
><td
><input type
=entry name
='birthdate' size
=10 value
='YYYY-MM-DD' ></td
>
18 <td
><span
class=text
>Birth Status
: </span
></td
><td
><input type
=entry name
="birth_status" value
="" ></td
>
19 <td
><span
class=text
>Gender
: </span
></td
><td
><input type
=entry name
="gender" value
="" ></td
>
20 <td
><input type
=checkbox name
='circumcised' ></td
><td
><span
class=text
>Circumcised
</span
></td
></tr
>
25 <tr
><td
><span
class=text
>Pediatrician
: </span
></td
><td
><input type
=entry name
="pediatrician" value
="" ></td
>
26 <td
><span
class=text
>Birth Weight
: </span
></td
><td
><input type
=entry name
="birth_weight" value
="" ></td
></tr
>
27 <tr
><td
><span
class=text
>Length (Inches
): </span
></td
><td
><input type
=entry name
="length_inches" value
="" ></td
>
28 <td
><span
class=text
>Head
Circumference (Inches
): </span
></td
><td
><input type
=entry name
="head_circumference_inches" value
="" ></td
></tr
>
30 <tr
><td
><span
class=text
>Feeding
: </span
></td
><td
><input type
=entry name
="feeding" value
="" ></td
>
31 <td
><span
class=text
>Delivery Method
: </span
></td
><td
><input type
=entry name
="delivery_method" value
="" ></td
></tr
>
32 <tr
><td
><span
class=text
>Labor Hours
: </span
></td
><td
><input type
=entry name
="labor_hours" value
="" ></td
>
33 <td
><span
class=text
>Pregnancy (Weeks
): </span
></td
><td
><input type
=entry name
="pregnancy_weeks" value
="" ></td
></tr
>
34 <tr
><td
><span
class=text
>Anesthesia
: </span
></td
><td colspan
=3><input type
=entry name
="anesthesia" value
="" ></td
></tr
>
40 <span
class=text
>Reactions to Medications
and Immunizations
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="reactions_to_medications_and_immunizations" ></textarea
></td
>
41 <td
><span
class=text
>Birth Complications
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="birth_complications" ></textarea
></td
></tr
>
43 <span
class=text
>Developmental Problems
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="developmental_problems" ></textarea
></td
>
44 <td
><span
class=text
>Chronic Illness
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="chronic_illness" ></textarea
></td
></tr
>
46 <span
class=text
>Chronic Medication
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="chronic_medication" ></textarea
></td
>
47 <td
><span
class=text
>Hospitalization
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="hospitalization" ></textarea
></td
></tr
>
49 <span
class=text
>Surgery
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="surgery" ></textarea
></td
>
50 <td
><span
class=text
>Injury
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="injury" ></textarea
></td
></tr
>
52 <span
class=text
>Day Care
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="day_care" ></textarea
></td
>
53 <td
><span
class=text
>Additional Notes
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="additional_notes" ></textarea
></td
></tr
>
56 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
58 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
59 onclick
="top.restoreSession()">[Don
't Save]</a>