1 <!-- Forms generated from formsWiz
-->
3 include_once("../../globals.php");
6 <?
html_header_show();?
>
7 <link rel
=stylesheet href
="<?echo $css_header;?>" type
="text/css">
9 <body
<?
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
11 include_once("$srcdir/api.inc");
12 $obj = formFetch("form_obstetrical", $_GET["id"]);
14 <form method
=post action
="<?echo $rootdir?>/forms/obstetrical/save.php?mode=update&id=<?echo $_GET["id
"];?>" name
="my_form">
15 <span
class="title">Obstetrical Form
</span
><Br
><br
>
18 <td
><span
class=text
>Name
: </span
></td
><td
><input type
=entry name
="name" value
="<?echo $obj{"name
"};?>" ></td
>
19 <td
><span
class=text
>Birthdate
: </span
></td
><td
><input type
=entry size
=10 name
=birthdate value
="<?if ($obj{"birthdate
"} != "0000-00-00 00:00:00") {echo date("Y
-m
-d
",strtotime($obj{"birthdate
"}));} else {echo "YYYY
-MM
-DD
";}?>"></td
>
20 <td
><span
class=text
>Birth Status
: </span
></td
><td
><input type
=entry name
="birth_status" value
="<?echo $obj{"birth_status
"};?>" ></td
>
21 <td
><span
class=text
>Gender
: </span
></td
><td
><input type
=entry name
="gender" value
="<?echo $obj{"gender
"};?>" ></td
>
22 <td
><input type
=checkbox name
="circumcised" <?
if ($obj{"circumcised"} == "on") {echo "checked";};?
>></td
><td
><span
class=text
>Circumcised
</span
></td
>
28 <td
><span
class=text
>Pediatrician
: </span
></td
><td
><input type
=entry name
="pediatrician" value
="<?echo $obj{"pediatrician
"};?>" ></td
>
29 <td
><span
class=text
>Birth Weight
: </span
></td
><td
><input type
=entry name
="birth_weight" value
="<?echo $obj{"birth_weight
"};?>" ></td
>
31 <td
><span
class=text
>Length (Inches
): </span
></td
><td
><input type
=entry name
="length_inches" value
="<?echo $obj{"length_inches
"};?>" ></td
>
32 <td
><span
class=text
>Head
Circumference (Inches
): </span
></td
><td
><input type
=entry name
="head_circumference_inches" value
="<?echo $obj{"head_circumference_inches
"};?>" ></td
>
34 <td
><span
class=text
>Feeding
: </span
></td
><td
><input type
=entry name
="feeding" value
="<?echo $obj{"feeding
"};?>" ></td
>
35 <td
><span
class=text
>Delivery Method
: </span
></td
><td
><input type
=entry name
="delivery_method" value
="<?echo $obj{"delivery_method
"};?>" ></td
>
37 <td
><span
class=text
>Labor Hours
: </span
></td
><td
><input type
=entry name
="labor_hours" value
="<?echo $obj{"labor_hours
"};?>" ></td
>
38 <td
><span
class=text
>Pregnancy (Weeks
): </span
></td
><td
><input type
=entry name
="pregnancy_weeks" value
="<?echo $obj{"pregnancy_weeks
"};?>" ></td
>
40 <td
><span
class=text
>Anesthesia
: </span
></td
><td colspan
=3><input type
=entry name
="anesthesia" value
="<?echo $obj{"anesthesia
"};?>" ></td
>
46 <td
><span
class=text
>Reactions to Medications
and Immunizations
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="reactions_to_medications_and_immunizations" ><?
echo $obj{"reactions_to_medications_and_immunizations"};?
></textarea
></td
>
47 <td
><span
class=text
>Birth Complications
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="birth_complications" ><?
echo $obj{"birth_complications"};?
></textarea
></td
>
49 <td
><span
class=text
>Developmental Problems
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="developmental_problems" ><?
echo $obj{"developmental_problems"};?
></textarea
></td
>
50 <td
><span
class=text
>Chronic Illness
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="chronic_illness" ><?
echo $obj{"chronic_illness"};?
></textarea
></td
>
52 <td
><span
class=text
>Chronic Medication
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="chronic_medication" ><?
echo $obj{"chronic_medication"};?
></textarea
></td
>
53 <td
><span
class=text
>Hospitalization
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="hospitalization" ><?
echo $obj{"hospitalization"};?
></textarea
></td
>
55 <td
><span
class=text
>Surgery
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="surgery" ><?
echo $obj{"surgery"};?
></textarea
></td
>
56 <td
><span
class=text
>Injury
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="injury" ><?
echo $obj{"injury"};?
></textarea
></td
>
58 <td
><span
class=text
>Day Care
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="day_care" ><?
echo $obj{"day_care"};?
></textarea
></td
>
59 <td
><span
class=text
>Additional Notes
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="additional_notes" ><?
echo $obj{"additional_notes"};?
></textarea
></td
>
63 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
65 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
66 onclick
="top.restoreSession()">[Don
't Save Changes]</a>