contrib/forms/progressnotes/new.php

   1 <?php
   2
   3 #######################################################
   4
   5 # Progress Notes Form created by Kam Sharifi          #
   6
   7 # kam@sharmen.com                                     #
   8
   9 #######################################################
  10
  11 include_once("../../globals.php");
  12
  13 include_once("$srcdir/api.inc");
  14
  15 formHeader("Form: progressnotes");
  16
  17 ?>
  18
  19 <html><head>
  20 <? html_header_show();?>
  21
  22 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  23
  24 </head>
  25
  26 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  27
  28 <form method=post action="<?echo $rootdir;?>/forms/progressnotes/save.php?mode=new" name="my_form">
  29
  30 <span class="title">Progress Notes</span><br><br>
  31
  32
  33
  34 <table width=100%>
  35
  36 <b>
  37
  38 <span class=text>P: </span><input size=3 type=entry name="prog_p" value="" >
  39
  40 <span class=text>R: </span><input size=3 type=entry name="prog_r" value="" >
  41
  42 <span class=text>BP: </span><input size=3 type=entry name="prog_bp" value="" >
  43
  44 <span class=text>HT: </span><input size=3 type=entry name="prog_ht" value="" >
  45
  46 <span class=text>WT: </span><input size=3 type=entry name="prog_wt" value="" >
  47
  48 <span class=text>TEMP: </span><input size=3 type=entry name="prog_temp" value="" >
  49
  50 <span class=text>LMP: </span><input size=3 type=entry name="prog_lmp" value="" >
  51
  52 <br><span class=text>Last Pap Smear: </span><input size=3 type=entry name="prog_last_pap_smear" value="" >
  53
  54 <span class=text>Last Td. Booster: </span><input size=3 type=entry name="prog_last_td_booster" value="" >
  55
  56 <span class=text>Allergies: </span><input size=3 type=entry name="prog_allergies" value="" >
  57
  58 <span class=text>Last Mammogram: </span><input size=3 type=entry name="prog_last_mammogram" value="" >
  59
  60 </b>
  61
  62 </table>
  63
  64 <br>
  65
  66
  67
  68 <span class=text><b>Present Complaint*:</b> </span><br><textarea cols=40 rows=8 wrap=virtual name="prog_present_complaint" ></textarea>
  69
  70
  71
  72 <br><br>
  73
  74 <b>Past Medical History</b>
  75
  76
  77
  78     <TABLE ID="Table1" BORDER=1 CELLSPACING=2 CELLPADDING=1 WIDTH="100%" >
  79
  80         <TR>
  81
  82             <TD WIDTH=53>
  83
  84                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
  85
  86             </TD>
  87
  88             <TD WIDTH=40>
  89
  90                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>ABN</B></FONT><B></B></P>
  91
  92             </TD>
  93
  94             <TD WIDTH=34>
  95
  96                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NE</B></FONT><B></B></P>
  97
  98             </TD>
  99
 100             <TD WIDTH=324>
 101
 102                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>PHYSICAL EXAMINATION -Comments</B></FONT><B></B></P>
 103
 104             </TD>
 105
 106         </TR>
 107
 108         <TR>
 109
 110             <TD HEIGHT=14>
 111
 112                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 113
 114             </TD>
 115
 116             <TD WIDTH=40>
 117
 118                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 119
 120                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 121
 122                         <TR>
 123
 124                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox2" TYPE=CHECKBOX NAME="prog_skin_abn" VALUE=""></TD>
 125
 126                         </TR>
 127
 128                     </TABLE>
 129
 130                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 131
 132             <TD WIDTH=34>
 133
 134                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 135
 136                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 137
 138                         <TR>
 139
 140                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox8" TYPE=CHECKBOX NAME="prog_skin_ne" VALUE=""></TD>
 141
 142                         </TR>
 143
 144                     </TABLE>
 145
 146                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 147
 148             <TD WIDTH=324>
 149
 150                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>SKIN: no significant lesions</B></FONT><B></B></P>
 151
 152             </TD>
 153
 154         </TR>
 155
 156         <TR>
 157
 158             <TD HEIGHT=14>
 159
 160                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 161
 162             </TD>
 163
 164             <TD WIDTH=40>
 165
 166                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 167
 168                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 169
 170                         <TR>
 171
 172                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox7" TYPE=CHECKBOX NAME="prog_head_abn" VALUE=""></TD>
 173
 174                         </TR>
 175
 176                     </TABLE>
 177
 178                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 179
 180             <TD WIDTH=34>
 181
 182                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 183
 184                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 185
 186                         <TR>
 187
 188                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox9" TYPE=CHECKBOX NAME="prog_head_ne" VALUE=""></TD>
 189
 190                         </TR>
 191
 192                     </TABLE>
 193
 194                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 195
 196             <TD WIDTH=324>
 197
 198                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>HEAD: normocephalic. no headache</B></FONT><B></B></P>
 199
 200             </TD>
 201
 202         </TR>
 203
 204         <TR>
 205
 206             <TD HEIGHT=11>
 207
 208                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 209
 210             </TD>
 211
 212             <TD WIDTH=40>
 213
 214                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 215
 216                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 217
 218                         <TR>
 219
 220                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox10" TYPE=CHECKBOX NAME="prog_eyes_abn" VALUE=""></TD>
 221
 222                         </TR>
 223
 224                     </TABLE>
 225
 226                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 227
 228             <TD WIDTH=34>
 229
 230                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 231
 232                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 233
 234                         <TR>
 235
 236                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox11" TYPE=CHECKBOX NAME="prog_eyes_ne" VALUE=""></TD>
 237
 238                         </TR>
 239
 240                     </TABLE>
 241
 242                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 243
 244             <TD WIDTH=324>
 245
 246                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EYES: perla. eom satisfactory</B></FONT><B></B></P>
 247
 248             </TD>
 249
 250         </TR>
 251
 252         <TR>
 253
 254             <TD>
 255
 256                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 257
 258             </TD>
 259
 260             <TD WIDTH=40>
 261
 262                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 263
 264                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 265
 266                         <TR>
 267
 268                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox12" TYPE=CHECKBOX NAME="prog_ears_abn" VALUE=""></TD>
 269
 270                         </TR>
 271
 272                     </TABLE>
 273
 274                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 275
 276             <TD WIDTH=34>
 277
 278                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 279
 280                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 281
 282                         <TR>
 283
 284                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox13" TYPE=CHECKBOX NAME="prog_ears_ne" VALUE=""></TD>
 285
 286                         </TR>
 287
 288                     </TABLE>
 289
 290                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 291
 292             <TD WIDTH=324>
 293
 294                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EARS: drums intact</B></FONT><B></B></P>
 295
 296             </TD>
 297
 298         </TR>
 299
 300         <TR>
 301
 302             <TD HEIGHT=19>
 303
 304                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 305
 306             </TD>
 307
 308             <TD WIDTH=40>
 309
 310                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 311
 312                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 313
 314                         <TR>
 315
 316                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox14" TYPE=CHECKBOX NAME="prog_nose_abn" VALUE=""></TD>
 317
 318                         </TR>
 319
 320                     </TABLE>
 321
 322                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 323
 324             <TD WIDTH=34>
 325
 326                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 327
 328                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 329
 330                         <TR>
 331
 332                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox16" TYPE=CHECKBOX NAME="prog_nose_ne" VALUE=""></TD>
 333
 334                         </TR>
 335
 336                     </TABLE>
 337
 338                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 339
 340             <TD WIDTH=324>
 341
 342                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NOSE: no abnormality</B></FONT><B></B></P>
 343
 344             </TD>
 345
 346         </TR>
 347
 348         <TR>
 349
 350             <TD>
 351
 352                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 353
 354             </TD>
 355
 356             <TD WIDTH=40>
 357
 358                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 359
 360                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 361
 362                         <TR>
 363
 364                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox17" TYPE=CHECKBOX NAME="prog_throat_abn" VALUE=""></TD>
 365
 366                         </TR>
 367
 368                     </TABLE>
 369
 370                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 371
 372             <TD WIDTH=34>
 373
 374                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 375
 376                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 377
 378                         <TR>
 379
 380                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox15" TYPE=CHECKBOX NAME="prog_throat_ne" VALUE=""></TD>
 381
 382                         </TR>
 383
 384                     </TABLE>
 385
 386                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 387
 388             <TD WIDTH=324>
 389
 390                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>THROAT: dear, no infection</B></FONT><B></B></P>
 391
 392             </TD>
 393
 394         </TR>
 395
 396         <TR>
 397
 398             <TD HEIGHT=18>
 399
 400                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 401
 402             </TD>
 403
 404             <TD WIDTH=40>
 405
 406                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 407
 408                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 409
 410                         <TR>
 411
 412                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox19" TYPE=CHECKBOX NAME="prog_teeth_abn" VALUE=""></TD>
 413
 414                         </TR>
 415
 416                     </TABLE>
 417
 418                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 419
 420             <TD WIDTH=34>
 421
 422                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 423
 424                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 425
 426                         <TR>
 427
 428                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox20" TYPE=CHECKBOX NAME="prog_teeth_ne" VALUE=""></TD>
 429
 430                         </TR>
 431
 432                     </TABLE>
 433
 434                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 435
 436             <TD WIDTH=324>
 437
 438                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>TEETH: good repair, no dentures</B></FONT><B></B></P>
 439
 440             </TD>
 441
 442         </TR>
 443
 444         <TR>
 445
 446             <TD>
 447
 448                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 449
 450             </TD>
 451
 452             <TD WIDTH=40>
 453
 454                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 455
 456                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 457
 458                         <TR>
 459
 460                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox18" TYPE=CHECKBOX NAME="prog_neck_abn" VALUE=""></TD>
 461
 462                         </TR>
 463
 464                     </TABLE>
 465
 466                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 467
 468             <TD WIDTH=34>
 469
 470                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 471
 472                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 473
 474                         <TR>
 475
 476                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox21" TYPE=CHECKBOX NAME="prog_neck_ne" VALUE=""></TD>
 477
 478                         </TR>
 479
 480                     </TABLE>
 481
 482                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 483
 484             <TD WIDTH=324>
 485
 486                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NECK: supple, no adenopathy</B></FONT><B></B></P>
 487
 488             </TD>
 489
 490         </TR>
 491
 492         <TR>
 493
 494             <TD>
 495
 496                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 497
 498             </TD>
 499
 500             <TD WIDTH=40>
 501
 502                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 503
 504                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 505
 506                         <TR>
 507
 508                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox22" TYPE=CHECKBOX NAME="prog_chest_abn" VALUE=""></TD>
 509
 510                         </TR>
 511
 512                     </TABLE>
 513
 514                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 515
 516             <TD WIDTH=34>
 517
 518                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 519
 520                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 521
 522                         <TR>
 523
 524                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox23" TYPE=CHECKBOX NAME="prog_chest_ne" VALUE=""></TD>
 525
 526                         </TR>
 527
 528                     </TABLE>
 529
 530                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 531
 532             <TD WIDTH=324>
 533
 534                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>CHEST: symmetrical, no pain</B></FONT><B></B></P>
 535
 536             </TD>
 537
 538         </TR>
 539
 540         <TR>
 541
 542             <TD>
 543
 544                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 545
 546             </TD>
 547
 548             <TD WIDTH=40>
 549
 550                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 551
 552                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 553
 554                         <TR>
 555
 556                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox24" TYPE=CHECKBOX NAME="prog_breast_abn" VALUE=""></TD>
 557
 558                         </TR>
 559
 560                     </TABLE>
 561
 562                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 563
 564             <TD WIDTH=34>
 565
 566                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 567
 568                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 569
 570                         <TR>
 571
 572                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox25" TYPE=CHECKBOX NAME="prog_breast_ne" VALUE=""></TD>
 573
 574                         </TR>
 575
 576                     </TABLE>
 577
 578                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 579
 580             <TD WIDTH=324>
 581
 582                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>BREAST: no masses</B></FONT><B></B></P>
 583
 584             </TD>
 585
 586         </TR>
 587
 588         <TR>
 589
 590             <TD>
 591
 592                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 593
 594             </TD>
 595
 596             <TD WIDTH=40>
 597
 598                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 599
 600                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 601
 602                         <TR>
 603
 604                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox26" TYPE=CHECKBOX NAME="prog_lungs_abn" VALUE=""></TD>
 605
 606                         </TR>
 607
 608                     </TABLE>
 609
 610                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 611
 612             <TD WIDTH=34>
 613
 614                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 615
 616                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 617
 618                         <TR>
 619
 620                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox27" TYPE=CHECKBOX NAME="prog_lungs_ne" VALUE=""></TD>
 621
 622                         </TR>
 623
 624                     </TABLE>
 625
 626                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 627
 628             <TD WIDTH=324>
 629
 630                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>LUNGS: dear to P&amp;a. no mono, no rales</B></FONT><B></B></P>
 631
 632             </TD>
 633
 634         </TR>
 635
 636         <TR>
 637
 638             <TD>
 639
 640                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 641
 642             </TD>
 643
 644             <TD WIDTH=40>
 645
 646                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 647
 648                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 649
 650                         <TR>
 651
 652                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox28" TYPE=CHECKBOX NAME="prog_heart_abn" VALUE=""></TD>
 653
 654                         </TR>
 655
 656                     </TABLE>
 657
 658                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 659
 660             <TD WIDTH=34>
 661
 662                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 663
 664                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 665
 666                         <TR>
 667
 668                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox29" TYPE=CHECKBOX NAME="prog_heart_ne" VALUE=""></TD>
 669
 670                         </TR>
 671
 672                     </TABLE>
 673
 674                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 675
 676             <TD WIDTH=324>
 677
 678                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>HEART: rsr. no cardiomegaly</B></FONT><B></B></P>
 679
 680             </TD>
 681
 682         </TR>
 683
 684         <TR>
 685
 686             <TD>
 687
 688                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 689
 690             </TD>
 691
 692             <TD WIDTH=40>
 693
 694                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 695
 696                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 697
 698                         <TR>
 699
 700                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox30" TYPE=CHECKBOX NAME="prog_abdomen_abn" VALUE=""></TD>
 701
 702                         </TR>
 703
 704                     </TABLE>
 705
 706                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 707
 708             <TD WIDTH=34>
 709
 710                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 711
 712                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 713
 714                         <TR>
 715
 716                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox31" TYPE=CHECKBOX NAME="prog_abdomen_ne" VALUE=""></TD>
 717
 718                         </TR>
 719
 720                     </TABLE>
 721
 722                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 723
 724             <TD WIDTH=324>
 725
 726                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>ABDOMEN: non-tender, soft, no masses</B></FONT><B></B></P>
 727
 728             </TD>
 729
 730         </TR>
 731
 732         <TR>
 733
 734             <TD>
 735
 736                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 737
 738             </TD>
 739
 740             <TD WIDTH=40>
 741
 742                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 743
 744                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 745
 746                         <TR>
 747
 748                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox32" TYPE=CHECKBOX NAME="prog_spine_abn" VALUE=""></TD>
 749
 750                         </TR>
 751
 752                     </TABLE>
 753
 754                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 755
 756             <TD WIDTH=34>
 757
 758                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 759
 760                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 761
 762                         <TR>
 763
 764                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox33" TYPE=CHECKBOX NAME="prog_spine_ne" VALUE=""></TD>
 765
 766                         </TR>
 767
 768                     </TABLE>
 769
 770                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 771
 772             <TD WIDTH=324>
 773
 774                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>SPINE: no abnormalities</B></FONT><B></B></P>
 775
 776             </TD>
 777
 778         </TR>
 779
 780         <TR>
 781
 782             <TD>
 783
 784                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 785
 786             </TD>
 787
 788             <TD WIDTH=40>
 789
 790                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 791
 792                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 793
 794                         <TR>
 795
 796                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox34" TYPE=CHECKBOX NAME="prog_extremeities_abn" VALUE=""></TD>
 797
 798                         </TR>
 799
 800                     </TABLE>
 801
 802                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 803
 804             <TD WIDTH=34>
 805
 806                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 807
 808                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 809
 810                         <TR>
 811
 812                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox35" TYPE=CHECKBOX NAME="prog_extremeities_ne" VALUE=""></TD>
 813
 814                         </TR>
 815
 816                     </TABLE>
 817
 818                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 819
 820             <TD WIDTH=324>
 821
 822                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EXTREMEITIES: no abnormalities</B></FONT><B></B></P>
 823
 824             </TD>
 825
 826         </TR>
 827
 828         <TR>
 829
 830             <TD>
 831
 832                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 833
 834             </TD>
 835
 836             <TD WIDTH=40>
 837
 838                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 839
 840                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 841
 842                         <TR>
 843
 844                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox36" TYPE=CHECKBOX NAME="prog_lowback_abn" VALUE=""></TD>
 845
 846                         </TR>
 847
 848                     </TABLE>
 849
 850                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 851
 852             <TD WIDTH=34>
 853
 854                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 855
 856                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 857
 858                         <TR>
 859
 860                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox37" TYPE=CHECKBOX NAME="prog_lowback_ne" VALUE=""></TD>
 861
 862                         </TR>
 863
 864                     </TABLE>
 865
 866                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 867
 868             <TD WIDTH=324>
 869
 870                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>LOW BACK: rom normal</B></FONT><B></B></P>
 871
 872             </TD>
 873
 874         </TR>
 875
 876         <TR>
 877
 878             <TD>
 879
 880                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 881
 882             </TD>
 883
 884             <TD WIDTH=40>
 885
 886                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 887
 888                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 889
 890                         <TR>
 891
 892                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox38" TYPE=CHECKBOX NAME="prog_neuro_abn" VALUE=""></TD>
 893
 894                         </TR>
 895
 896                     </TABLE>
 897
 898                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 899
 900             <TD WIDTH=34>
 901
 902                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 903
 904                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 905
 906                         <TR>
 907
 908                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox39" TYPE=CHECKBOX NAME="prog_neuro_ne" VALUE=""></TD>
 909
 910                         </TR>
 911
 912                     </TABLE>
 913
 914                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 915
 916             <TD WIDTH=324>
 917
 918                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NEURO: d(r&gt;&gt;2&gt;&gt;. no abnormal findings</B></FONT><B></B></P>
 919
 920             </TD>
 921
 922         </TR>
 923
 924         <TR>
 925
 926             <TD>
 927
 928                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 929
 930             </TD>
 931
 932             <TD WIDTH=40>
 933
 934                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 935
 936                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 937
 938                         <TR>
 939
 940                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox40" TYPE=CHECKBOX NAME="prog_rectal_abn" VALUE=""></TD>
 941
 942                         </TR>
 943
 944                     </TABLE>
 945
 946                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 947
 948             <TD WIDTH=34>
 949
 950                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 951
 952                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 953
 954                         <TR>
 955
 956                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox41" TYPE=CHECKBOX NAME="prog_rectal_ne" VALUE=""></TD>
 957
 958                         </TR>
 959
 960                     </TABLE>
 961
 962                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 963
 964             <TD WIDTH=324>
 965
 966                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>RECTAL: no abnormalities</B></FONT><B></B></P>
 967
 968             </TD>
 969
 970         </TR>
 971
 972         <TR>
 973
 974             <TD>
 975
 976                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 977
 978             </TD>
 979
 980             <TD WIDTH=40>
 981
 982                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 983
 984                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 985
 986                         <TR>
 987
 988                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox42" TYPE=CHECKBOX NAME="prog_pelvic_abn" VALUE=""></TD>
 989
 990                         </TR>
 991
 992                     </TABLE>
 993
 994                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 995
 996             <TD WIDTH=34>
 997
 998                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 999
1000                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
1001
1002                         <TR>
1003
1004                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox43" TYPE=CHECKBOX NAME="prog_pelvic_ne" VALUE=""></TD>
1005
1006                         </TR>
1007
1008                     </TABLE>
1009
1010                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
1011
1012             <TD WIDTH=324>
1013
1014                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>PELVIC:</B></FONT><B></B></P>
1015
1016             </TD>
1017
1018         </TR>
1019
1020     </TABLE>
1021
1022
1023
1024 <br>
1025
1026
1027
1028
1029
1030 <span class=text><b>HEALTH EDUCATION PROVIDED<br>ASSESSMENT:</b></span><br><textarea cols=40 rows=8 wrap=virtual name="prog_assessment" ></textarea>
1031
1032
1033
1034 <br><br>
1035
1036
1037
1038 <span class=text><b>Plan:</b></span><br><textarea cols=40 rows=8 wrap=virtual name="prog_plan" ></textarea>
1039
1040
1041
1042 <br><br>
1043
1044 <td><input size=3 type=entry name="prog_breast_se" value="" >&nbsp;<span class=text><b>Breast Self Examination </span></td><br></b>
1045
1046 <td><input size=3 type=entry name="prog_dental_h" value="" >&nbsp;<span class=text><b>Dental Health </span></td><br></b>
1047
1048 <td><input size=3 type=entry name="prog_diagnosis" value="" >&nbsp;<span class=text><b>Diagnosis/Prognosis </span></td><br></b>
1049
1050 <td><input size=3 type:entry name="prog_injur_p" value="" >&nbsp;<span class=text><b>Injury Prevention </span></td><br></b>
1051
1052 <td><input size=3 type=entry name="prog_new_treat" value="" >&nbsp;<span class=text><b>New Treatment/Medication </span></td><br></b>
1053
1054 <td><input size=3 type=entry name="prog_nutrition_e" value="" >&nbsp;<span class=text><b>Nutrition/Exercise </span></td><br></b>
1055
1056 <td><input size=3 type=entry name="prog_sexual_p" value="" >&nbsp;<span class=text><b>Sexual Practice </span></td><br></b>
1057
1058 <td><input size=3 type=entry name="prog_substance_a" value="" >&nbsp;<span class=text><b>Substance Abuse </span></td><br></b>
1059
1060
1061
1062
1063
1064 <br>
1065
1066 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
1067
1068 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
1069
1070 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
1071
1072  onclick="top.restoreSession()">[Don't Save]</a>
1073
1074 </form>
1075
1076 <?php
1077
1078 formFooter();
1079
1080 ?>
1081