contrib/forms/routine_screening_record/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");formHeader("Form: Routine screening record");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <? html_header_show();?>
  23
  24 <title>Form: Routine screening record</title>
  25
  26 <? include("../../acog_printable_h.css"); ?>
  27
  28 </head>
  29
  30
  31
  32 <?
  33
  34    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  35
  36    if ($fres){
  37
  38      $patient = sqlFetchArray($fres);
  39
  40    }
  41
  42    $fres=sqlStatement("select * from form_routine_screening_record where id=$id");
  43
  44    if ($fres){
  45
  46      $fdata = sqlFetchArray($fres);
  47
  48    }
  49
  50 ?>
  51
  52 <body <?echo $top_bg_line;?>>
  53
  54 <div class="srvChapter">Routine screening record </div>
  55
  56 <div style="border: solid 2px black; background-color:#FFFFFF;">
  57
  58   <table  border="0" cellpadding="2" cellspacing="0">
  59
  60     <tr align="left" valign="bottom">
  61
  62       <td colspan="4" class="fibody2" id="bordR">Patient name: <?  echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'}; ?></td>
  63
  64       <td colspan="4" class="fibody2" id="bordR">Birth date: <?   echo $patient{'DOB'};  ?></td>
  65
  66       <td colspan="3" class="fibody2">ID No: <?    echo $patient{'id'};   ?></td>
  67
  68     </tr>
  69
  70     <tr align="center" valign="middle">
  71
  72       <td class="ficaption2" id="bordR">age</td>
  73
  74       <td width="9%" class="ficaption2" id="bordR">Cervical cytology </td>
  75
  76       <td width="9%" class="ficaption2" id="bordR">Lipid profile assessment<sup>*</sup></td>
  77
  78       <td width="9%" class="ficaption2" id="bordR">Mammo-<br>
  79
  80         graphy<sup>*</sup></td>
  81
  82       <td width="9%" class="ficaption2" id="bordR">Colorectal cancer screening <sup>*</sup></td>
  83
  84       <td width="9%" class="ficaption2" id="bordR">Bone density screening<sup>*</sup> </td>
  85
  86       <td width="9%" class="ficaption2" id="bordR">Chlamydia screening<sup>*</sup> </td>
  87
  88       <td width="9%" class="ficaption2" id="bordR">Gonor-<br>
  89
  90         rhea screening <sup>*</sup> </td>
  91
  92       <td width="9%" class="ficaption2" id="bordR">Urinalysis</td>
  93
  94       <td width="9%" class="ficaption2" id="bordR">Fasting glucose test<sup>*</sup> </td>
  95
  96       <td width="9%" class="ficaption2">Thyroid stimulating hormone screening </td>
  97
  98     </tr>
  99
 100     <tr align="center" valign="middle">
 101
 102       <td class="fibody2" id="bordR">13-18</td>
 103
 104       <td class="fibody2" id="bordR">ANNUALLY BEGINNING
 105
 106         APPROXIMATELY 3 YEARS
 107
 108         AFTER INITIATION OF
 109
 110         SEXUAL INTERCOURSE</td>
 111
 112       <td class="fibody2" id="bordR">&nbsp; </td>
 113
 114       <td class="fibody2" id="bordR">&nbsp; </td>
 115
 116       <td class="fibody2" id="bordR">&nbsp; </td>
 117
 118       <td class="fibody2" id="bordR">&nbsp; </td>
 119
 120       <td class="fibody2" id="bordR">        SEXUALLY ACTIVE WOMEN
 121
 122         UNDER AGE 25</td>
 123
 124       <td class="fibody2" id="bordR">SEXUALLY ACTIVE
 125
 126         ADOLES-<br>
 127
 128         CENTS</td>
 129
 130       <td class="fibody2" id="bordR">&nbsp;</td>
 131
 132       <td class="fibody2" id="bordR">&nbsp;</td>
 133
 134       <td class="fibody2">&nbsp;</td>
 135
 136     </tr>
 137
 138     <tr align="center" valign="middle">
 139
 140       <td class="fibody2" id="bordR">19-39</td>
 141
 142       <td class="fibody2" id="bordR">ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS</td>
 143
 144       <td class="fibody2" id="bordR">&nbsp; </td>
 145
 146       <td class="fibody2" id="bordR">&nbsp; </td>
 147
 148       <td class="fibody2" id="bordR">&nbsp; </td>
 149
 150       <td class="fibody2" id="bordR">&nbsp; </td>
 151
 152       <td class="fibody2" id="bordR"> SEXUALLY ACTIVE WOMEN<br>
 153
 154 UNDER AGE 25</td>
 155
 156       <td class="fibody2" id="bordR">&nbsp; </td>
 157
 158       <td class="fibody2" id="bordR">&nbsp;</td>
 159
 160       <td class="fibody2" id="bordR">&nbsp;</td>
 161
 162       <td class="fibody2">&nbsp;</td>
 163
 164     </tr>
 165
 166     <tr align="center" valign="middle">
 167
 168       <td class="fibody2" id="bordR">40-64</td>
 169
 170       <td class="fibody2" id="bordR">EVERY 2�3 YEARS AFTER 3
 171
 172         CONSECuTIVE NEGATIVE TEST
 173
 174         RESULTS IF NO HISTORY OF
 175
 176         CIN 2 OR 3,
 177
 178         IMMUNOSUP-<br>
 179
 180         PRESSION,
 181
 182         HIV INFECTION, OR DES
 183
 184         EXPOSURE IN UTERO</td>
 185
 186       <td class="fibody2" id="bordR">EVERY 5 YEARS
 187
 188         BEGINNING
 189
 190         AT AGE 45</td>
 191
 192       <td class="fibody2" id="bordR">EVERY 1�2 YEARS UNTIL
 193
 194         AGE 50; YEARLY
 195
 196         BEGINNING AT AGE 50</td>
 197
 198       <td class="fibody2" id="bordR">        BEGINNING AT AGE 50
 199
 200         YEARLY FOBT OR FLEXIBLE
 201
 202         SIGMOIDOSCOPY EVERY
 203
 204         5 YEARS OR YEARLY FOBT
 205
 206         PLUS FLEXIBLE
 207
 208         SIGMOIDOSCOPY EVERY 5
 209
 210         YEARS OR DCBE EVERY 5
 211
 212         YEARS OR COLONOSCOPY
 213
 214         EVERY 10 YEARS</td>
 215
 216       <td class="fibody2" id="bordR">&nbsp; </td>
 217
 218       <td class="fibody2" id="bordR">&nbsp; </td>
 219
 220       <td class="fibody2" id="bordR">&nbsp; </td>
 221
 222       <td class="fibody2" id="bordR">&nbsp;</td>
 223
 224       <td class="fibody2" id="bordR">EVERY 3 YEARS
 225
 226         AFTER AGE 45</td>
 227
 228       <td class="fibody2">EVERY 5 YEARS
 229
 230         BEGINNING AT AGE 50</td>
 231
 232     </tr>
 233
 234     <tr align="center" valign="middle">
 235
 236       <td class="fibody2" id="bordR">65 and older </td>
 237
 238       <td class="fibody2" id="bordR">EVERY 2�3 YEARS AFTER 3<br>
 239
 240         CONSECUTIVE NEGATIVE TEST
 241
 242         RESULTS IF NO HISTORY OF
 243
 244         CIN 2 OR 3,
 245
 246         IMMUNOSUP-<br>
 247
 248         PRESSION,
 249
 250         HIV INFECTION, OR DES
 251
 252         EXPOSURE IN UTERO</td>
 253
 254       <td class="fibody2" id="bordR">EVERY 5 YEARS</td>
 255
 256       <td class="fibody2" id="bordR">YEARLY OR AS
 257
 258         APPROPRIATE</td>
 259
 260       <td class="fibody2" id="bordR">        YEARLY FOBT OR FLEXIBLE
 261
 262         SIGMOIDOSCOPY EVERY
 263
 264         5 YEARS OR YEARLY FOBT
 265
 266         PLUS FLEXIBLE
 267
 268         SIGMOIDOSCOPY EVERY
 269
 270         YEARS OR DCBE EVERY
 271
 272         YEARS OR COLONOSCOPY
 273
 274         EVERY 10 YEARS</td>
 275
 276       <td class="fibody2" id="bordR">        IN THE ABSENCE OF
 277
 278         NEW RISK FACTORS,
 279
 280         SUBSEQUENT SCREENING
 281
 282         NOT MORE FREQUENTLY
 283
 284         THAN EVERY 2 YEARS</td>
 285
 286       <td class="fibody2" id="bordR">&nbsp; </td>
 287
 288       <td class="fibody2" id="bordR">&nbsp; </td>
 289
 290       <td class="fibody2" id="bordR">YEARLY OR AS
 291
 292         APPROPRIATE</td>
 293
 294       <td class="fibody2" id="bordR">EVERY 3 YEARS</td>
 295
 296       <td class="fibody2">EVERY 5 YEARS</td>
 297
 298     </tr>
 299
 300     <tr align="left" valign="bottom">
 301
 302       <td colspan="11" class="fibody2" style="border-bottom: 2px solid black;">&nbsp;</td>
 303
 304     </tr>
 305
 306 <?
 307
 308 $factors = array("cervical", "lipid", "mammo", "colorectal",
 309
 310 "bone", "chlamyd", "gonor", "urinal", "glucose", "thyroid");
 311
 312 $rsi = 1;
 313
 314 while ($rsi < 9){
 315
 316 $chunks = explode("|~", $fdata["record_$rsi"]);
 317
 318 list($cervical_date, $cervical_res) = explode('|', $chunks[0]);
 319
 320 list($lipid_date, $lipid_res) = explode('|', $chunks[1]);
 321
 322 list($mammo_date,$mammo_res) = explode('|', $chunks[2]);
 323
 324 list($colorectal_date,$colorectal_res) = explode('|', $chunks[3]);
 325
 326 list($bone_date,$bone_res) = explode('|', $chunks[4]);
 327
 328 list($chlamyd_date,$chlamyd_res) = explode('|', $chunks[5]);
 329
 330 list($gonor_date,$gonor_res) = explode('|', $chunks[6]);
 331
 332 list($urinal_date,$urinal_res) = explode('|', $chunks[7]);
 333
 334 list($glucose_date,$glucose_res) = explode('|', $chunks[8]);
 335
 336 list($thyroid_date,$thyroid_res) = explode('|', $chunks[9]);
 337
 338
 339
 340
 341
 342 print <<<EOL
 343
 344     <tr align="left" valign="bottom">
 345
 346       <td class="fibody2" id="bordR">Date</td>
 347
 348       <td class="fibody3" id="bordR">${cervical_date} &nbsp;</td>
 349
 350       <td class="fibody3" id="bordR">${lipid_date} &nbsp;</td>
 351
 352       <td class="fibody3" id="bordR">${mammo_date} &nbsp;</td>
 353
 354       <td class="fibody3" id="bordR">${colorectal_date} &nbsp;</td>
 355
 356       <td class="fibody3" id="bordR">${bone_date} &nbsp;</td>
 357
 358       <td class="fibody3" id="bordR">${chlamyd_date} &nbsp;</td>
 359
 360       <td class="fibody3" id="bordR">${gonor_date} &nbsp;</td>
 361
 362       <td class="fibody3" id="bordR">${urinal_date} &nbsp;</td>
 363
 364       <td class="fibody3" id="bordR">${glucose_date} &nbsp;</td>
 365
 366       <td class="fibody3">${thyroid_date} &nbsp;</td>
 367
 368     </tr>
 369
 370     <tr align="left" valign="bottom">
 371
 372       <td class="fibody2" id="bordR">result</td>
 373
 374       <td class="fibody5" id="bordR">${cervical_res} &nbsp;</td>
 375
 376       <td class="fibody5" id="bordR">${lipid_res} &nbsp;</td>
 377
 378       <td class="fibody5" id="bordR">${mammo_res} &nbsp;</td>
 379
 380       <td class="fibody5" id="bordR">${colorectal_res} &nbsp;</td>
 381
 382       <td class="fibody5" id="bordR">${bone_res} &nbsp;</td>
 383
 384       <td class="fibody5" id="bordR">${chlamyd_res} &nbsp;</td>
 385
 386       <td class="fibody5" id="bordR">${gonor_res} &nbsp;</td>
 387
 388       <td class="fibody5" id="bordR">${urinal_res} &nbsp;</td>
 389
 390       <td class="fibody5" id="bordR">${glucose_res} &nbsp;</td>
 391
 392       <td class="fibody5">${thyroid_res} &nbsp;</td>
 393
 394     </tr>
 395
 396 EOL;
 397
 398 $rsi++;
 399
 400 }
 401
 402 ?>
 403
 404   </table>
 405
 406 </div>
 407
 408 <p><sup>*</sup>This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)</p>
 409
 410 </body>
 411
 412 </html>