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_pain", $_GET["id"]);
14 <form method
=post action
="<?echo $rootdir?>/forms/pain/save.php?mode=update&id=<?echo $_GET["id
"];?>" name
="my_form">
15 <span
class="title">Pain Evaluation
</span
><Br
><br
>
20 <input type
=checkbox name
="dull" <?
if ($obj{"dull"} == "on") {echo "checked";};?
>><span
class=text
>Dull
</span
>
21 <input type
=checkbox name
="colicky" <?
if ($obj{"colicky"} == "on") {echo "checked";};?
>><span
class=text
>Colicky
</span
>
22 <input type
=checkbox name
="sharp" <?
if ($obj{"sharp"} == "on") {echo "checked";};?
>><span
class=text
>Sharp
</span
>
23 <span
class=text
>Duration of Pain
: </span
><input type
=entry name
="duration_of_pain" value
="<?echo stripslashes($obj{"duration_of_pain
"});?>" ><br
>
26 <span
class=text
>History of Pain
: </span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="history_of_pain" ><?
echo stripslashes($obj{"history_of_pain"});?
></textarea
><br
>
31 <td
><span
class=text
>Accompanying Symptoms Vomitting
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_vomitting" value
="<?echo stripslashes($obj{"accompanying_symptoms_vomitting
"});?>" ></td
>
33 <td
><span
class=text
>Accompanying Symptoms Nausea
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_nausea" value
="<?echo stripslashes($obj{"accompanying_symptoms_nausea
"});?>" ></td
>
35 <td
><span
class=text
>Accompanying Symptoms Headache
: </span
></td
><td
><input type
=entry name
="accompanying_symptoms_headache" value
="<?echo stripslashes($obj{"accompanying_symptoms_headache
"});?>" ></td
>
38 <span
class=text
>Accompanying Symptoms Other
: </span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="accompanying_symptoms_other" ><?
echo stripslashes($obj{"accompanying_symptoms_other"});?
></textarea
><br
>
43 <span
class=text
>Pain Referred to Other Sites?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="pain_referred_to_other_sites" ><?
echo stripslashes($obj{"pain_referred_to_other_sites"});?
></textarea
>
45 <span
class=text
>What Relieves Pain?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="what_relieves_pain" ><?
echo stripslashes($obj{"what_relieves_pain"});?
></textarea
>
47 <span
class=text
>What Makes Pain
Worse (Movement
/Positions
/Activities
)?
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="what_makes_pain_worse" ><?
echo stripslashes($obj{"what_makes_pain_worse"});?
></textarea
>
49 <span
class=text
>Additional Notes
: </span
><br
><textarea cols
=40 rows
=4 wrap
=virtual name
="additional_notes" ><?
echo stripslashes($obj{"additional_notes"});?
></textarea
>
55 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
57 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
58 onclick
="top.restoreSession()">[Don
't Save Changes]</a>