contrib/forms/well_child/templates/well_child/general_new.html

   1 <html>
   2
   3 <head>
   4 {php}html_header_show();{/php}
   5
   6 {literal}
   7
   8  <style type="text/css" title="mystyles" media="all">
   9
  10 <!--
  11
  12 td {
  13
  14         font-size:12pt;
  15
  16         font-family:helvetica;
  17
  18 }
  19
  20 li{
  21
  22         font-size:11pt;
  23
  24         font-family:helvetica;
  25
  26         margin-left: 15px;
  27
  28 }
  29
  30 a {
  31
  32         font-size:11pt;
  33
  34         font-family:helvetica;
  35
  36 }
  37
  38 .title {
  39
  40         font-family: sans-serif;
  41
  42         font-size: 12pt;
  43
  44         font-weight: bold;
  45
  46         text-decoration: none;
  47
  48         color: #000000;
  49
  50 }
  51
  52
  53
  54 .form_text{
  55
  56         font-family: sans-serif;
  57
  58         font-size: 9pt;
  59
  60         text-decoration: none;
  61
  62         color: #000000;
  63
  64 }
  65
  66
  67
  68 -->
  69
  70 </style>
  71
  72 {/literal}
  73
  74 </head>
  75
  76 <body bgcolor="{$STYLE.BGCOLOR2}">
  77
  78
  79
  80 <p><span class="title">Well Child Visit</span></p>
  81
  82 <form name="well_child" method="post" action="{$FORM_ACTION}/interface/forms/well_child/save.php"
  83
  84  onsubmit="return top.restoreSession()">
  85
  86 <table>
  87
  88 <tr>
  89
  90         <td>
  91
  92                 <span class=text>WT: </span><input size=3 type=entry name="wt" value="{$well_child->get_wt()}" ></input>
  93
  94                 <span class=text>HT: </span><input size=3 type=entry name="ht" value="{$well_child->get_ht()}" ></input>
  95
  96                 <span class=text>BP: </span><input size=3 type=entry name="bp" value="{$well_child->get_bp()}" ></input>
  97
  98                 <span class=text>TEMP: </span><input size=3 type=entry name="t" value="{$well_child->get_t()}" ></input>
  99
 100                 <span class=text>Years: </span><input size=3 type=entry name="years" value="{$well_child->get_years()}" ></input>
 101
 102                 <span class=text>Months: </span><input size=3 type=entry name="months" value="{$well_child->get_months()}" ></input>
 103
 104         </td>
 105
 106 </tr>
 107
 108 <tr>
 109
 110         <td>
 111
 112                 <span class=text>WT%: </span><input size=3 type=entry name="wt_percentile" value="{$well_child->get_wt_percentile()}" ></input>
 113
 114                 <span class=text>HT%: </span><input size=3 type=entry name="ht_percentile" value="{$well_child->get_ht_percentile()}" ></input>
 115
 116         </td>
 117
 118 </tr>
 119
 120 <tr>
 121
 122         <td><br><br></td>
 123
 124 </tr>
 125
 126 </table>
 127
 128 <table>
 129
 130
 131
 132 {foreach name=loops item=headings key=title from=$checks}
 133
 134 <tr>
 135
 136         {if $title eq "Genitalia"}
 137
 138                 <td valign="top" align="right">{$title}</td>
 139
 140         {else}
 141
 142                 <td align="right">{$title}</td>
 143
 144         {/if}
 145
 146         <td valign="top" align="left">
 147
 148           {foreach item=row key=row_title from=$headings}
 149
 150                         <table><tr>
 151
 152                                 {if !is_numeric($row_title)}
 153
 154                                         <td class="form_text">&nbsp;&nbsp;&nbsp;<b>{$row_title}</b></td>
 155
 156                                         <td class="form_text"><nobr>{html_checkboxes name="checks" options=$row selected=$well_child->checks separator="&nbsp;&nbsp;&nbsp;"}</nobr>
 157
 158                                         {if $row_title eq "Male"}
 159
 160                                         Tanner Stage:
 161
 162                                                 {html_options name="male_tanner" selected=$well_child->get_male_tanner() options=$well_child->tanner_stage_array}
 163
 164                                         {elseif $row_title eq "Female"}
 165
 166                                         Tanner Stage:
 167
 168                                                 {html_options name="female_tanner" selected=$well_child->get_female_tanner() options=$well_child->tanner_stage_array}
 169
 170                                         {/if}
 171
 172                                         </td>
 173
 174                                 {else}
 175
 176                                         <td colspan="6" class="form_text">
 177
 178
 179
 180                                         <nobr>{html_checkboxes name="checks" options=$row selected=$well_child->checks separator="&nbsp;&nbsp;&nbsp;"}</nobr>
 181
 182
 183
 184                                         {if $title eq "Breast:(FEMALE)"}
 185
 186                                         Tanner Stage:
 187
 188                                                 {html_options name="breast_tanner" selected=$well_child->get_breast_tanner() options=$well_child->tanner_stage_array}
 189
 190                                         {/if}
 191
 192
 193
 194                                         </td>
 195
 196                                 {/if}
 197
 198
 199
 200                         </tr></table>
 201
 202           {/foreach}
 203
 204
 205
 206         </td>
 207
 208 </tr>
 209
 210 {/foreach}
 211
 212 </table>
 213
 214
 215
 216 <table>
 217
 218 <tr>
 219
 220         <td><br><br></td>
 221
 222 </tr>
 223
 224 <tr>
 225
 226         <td>History:</td>
 227
 228 </tr>
 229
 230 <tr>
 231
 232         <td colspan="2"><textarea name="history" wrap="virtual" cols="75" rows="3">{$well_child->get_history()}</textarea></td>
 233
 234 </tr>
 235
 236 <tr>
 237
 238         <td><span class=text>Drug Allergy: </span></td>
 239
 240 </tr>
 241
 242 <tr>
 243
 244         <td><input size=80 type=entry name="drug_allergy" value="{$well_child->get_drug_allergy()}" ></input></td>
 245
 246 </tr>
 247
 248 <tr>
 249
 250         <td><span class=text>School Development: </span></td>
 251
 252 </tr>
 253
 254 <tr>
 255
 256         <td><input size=80 type=entry name="school_development" value="{$well_child->get_school_development()}" ></input></td>
 257
 258 </tr>
 259
 260 </table>
 261
 262 <br><br>
 263
 264 <table>
 265
 266 <tr>
 267
 268         <td>Additional or Abnormal Findings</td>
 269
 270 </tr>
 271
 272 <tr>
 273
 274         <td> <textarea name="additional_findings" wrap="virtual" cols="75" rows="8">{$well_child->get_additional_findings()}</textarea></td>
 275
 276 </tr>
 277
 278 <tr>
 279
 280         <td>Assesment/Diagnosis</td>
 281
 282 </tr>
 283
 284 <tr>
 285
 286         <td><textarea name="assesment" wrap="virtual" cols="75" rows="8">{$well_child->get_assesment()}</textarea></td>
 287
 288 </tr>
 289
 290 </table>
 291
 292 <table>
 293
 294 <tr>
 295
 296         <td>
 297
 298         {foreach name=loops item=headings key=title from=$checks2}
 299
 300         <tr>
 301
 302                 <td>
 303
 304                         {$title}
 305
 306                 </td>
 307
 308                 <td><table>
 309
 310                   {foreach item=row key=row_title from=$headings}
 311
 312
 313
 314                                 <tr>
 315
 316                                         {if !is_numeric($row_title)}
 317
 318                                                 <td>{$row_title}</td>
 319
 320                                                 <td class="form_text"><nobr>{html_checkboxes name="checks2" options=$row selected=$well_child->checks2 separator="&nbsp;&nbsp;&nbsp;"}</nobr></td>
 321
 322                                         {else}
 323
 324                                                 <td class="form_text">
 325
 326                                                 <nobr>{html_checkboxes name="checks2" options=$row selected=$well_child->checks2 separator="&nbsp;&nbsp;&nbsp;"}</nobr>
 327
 328                                                 </td>
 329
 330                                         {/if}
 331
 332
 333
 334                                 </tr>
 335
 336                   {/foreach}
 337
 338                   </table>
 339
 340                 </td>
 341
 342         </tr>
 343
 344         {/foreach}
 345
 346         <td>
 347
 348 </tr>
 349
 350 </table>
 351
 352 <table>
 353
 354 <tr>
 355
 356         <td>
 357
 358                 <span class=text>PPD:</span><input size=3 type=entry name="ppd" value="{$well_child->get_ppd()}" ></input>
 359
 360                 <span class=text>UA DIP:</span><input size=3 type=entry name="ua_dip" value="{$well_child->get_ua_dip()}" ></input>
 361
 362                 <span class=text>HCT:</span><input size=3 type=entry name="hct" value="{$well_child->get_hct()}" ></input>
 363
 364                 <span class=text>LEAD:</span><input size=3 type=entry name="lead" value="{$well_child->get_lead()}" ></input>
 365
 366         </td>
 367
 368 </tr>
 369
 370 <tr>
 371
 372         <td>RX</td>
 373
 374 </tr>
 375
 376 <tr>
 377
 378         <td colspan="6"><textarea name="rx" wrap="virtual" cols="75" rows="3">{$well_child->get_rx()}</textarea></td>
 379
 380 </tr>
 381
 382
 383
 384 <tr>
 385
 386         <td>RTC</td>
 387
 388 </tr>
 389
 390 <tr>
 391
 392         <td colspan="6"><textarea name="rtc" wrap="virtual" cols="75" rows="2">{$well_child->get_rtc()}</textarea></td>
 393
 394 </tr>
 395
 396 <tr>
 397
 398         <td><br><br></td>
 399
 400 </tr>
 401
 402 <tr>
 403
 404         <td>
 405
 406                 <table>
 407
 408                   <tr>
 409
 410                     <td>Vision</td>
 411
 412                     <td>Corrected</td>
 413
 414                     <td>Uncorrected</td>
 415
 416                   </tr>
 417
 418                   <tr>
 419
 420                     <td>OU</td>
 421
 422                     <td class="form_text">20/<input size=6 type=entry name="ou_corrected" value="{$well_child->get_ou_corrected()}" ></input></td>
 423
 424                     <td class="form_text">20/<input size=6 type=entry name="ou_uncorrected" value="{$well_child->get_ou_uncorrected()}" ></input></td>
 425
 426                   </tr>
 427
 428                   <tr>
 429
 430                     <td>OD</td>
 431
 432                     <td class="form_text">20/<input size=6 type=entry name="od_corrected" value="{$well_child->get_od_corrected()}" ></input></td>
 433
 434                     <td class="form_text">20/<input size=6 type=entry name="od_uncorrected" value="{$well_child->get_od_uncorrected()}" ></input></td>
 435
 436                   </tr>
 437
 438                   <tr>
 439
 440                     <td>OS</td>
 441
 442                     <td class="form_text">20/<input size=6 type=entry name="os_corrected" value="{$well_child->get_os_corrected()}" ></input></td>
 443
 444                     <td class="form_text">20/<input size=6 type=entry name="os_uncorrected" value="{$well_child->get_os_uncorrected()}" ></input></td>
 445
 446                   </tr>
 447
 448                 </table>
 449
 450         </td>
 451
 452         <td>
 453
 454                 <table>
 455
 456                   <tr>
 457
 458                         <td>Audio</td>
 459
 460                         <td colspan="2">Frequency (HZ)</td>
 461
 462                   </tr>
 463
 464                   <tr>
 465
 466                     <td></td>
 467
 468                     <td>1000</td>
 469
 470                     <td>2000</td>
 471
 472                     <td>4000</td>
 473
 474                   </tr>
 475
 476                   <tr>
 477
 478                     <td>Right Ear</td>
 479
 480                     <td class="form_text"><input size=6 type=entry name="right_ear_1000" value="{$well_child->get_right_ear_1000()}" ></input></td>
 481
 482                     <td class="form_text"><input size=6 type=entry name="right_ear_2000" value="{$well_child->get_right_ear_2000()}" ></input></td>
 483
 484                     <td class="form_text"><input size=6 type=entry name="right_ear_4000" value="{$well_child->get_right_ear_4000()}" ></input></td>
 485
 486                   </tr>
 487
 488                   <tr>
 489
 490                     <td>Left Ear</td>
 491
 492                     <td class="form_text"><input size=6 type=entry name="left_ear_1000" value="{$well_child->get_left_ear_1000()}" ></input></td>
 493
 494                     <td class="form_text"><input size=6 type=entry name="left_ear_2000" value="{$well_child->get_left_ear_2000()}" ></input></td>
 495
 496                     <td class="form_text"><input size=6 type=entry name="left_ear_4000" value="{$well_child->get_left_ear_4000()}" ></input></td>
 497
 498                   </tr>
 499
 500                 </table>
 501
 502         </td>
 503
 504 </tr>
 505
 506 <table>
 507
 508 <tr>
 509
 510         <td>
 511
 512         {foreach name=loops item=headings key=title from=$checks3}
 513
 514         <tr>
 515
 516                 <td>
 517
 518                         {$title}
 519
 520                 </td>
 521
 522                 <td><table>
 523
 524                   {foreach item=row key=row_title from=$headings}
 525
 526
 527
 528                                 <tr>
 529
 530                                         {if !is_numeric($row_title)}
 531
 532                                                 <td>{$row_title}</td>
 533
 534                                                 <td class="form_text"><nobr>{html_checkboxes name="checks3" options=$row selected=$well_child->checks3 separator="&nbsp;&nbsp;&nbsp;"}</nobr></td>
 535
 536                                         {else}
 537
 538                                                 <td class="form_text">
 539
 540                                                 <nobr>{html_checkboxes name="checks3" options=$row selected=$well_child->checks3 separator="&nbsp;&nbsp;&nbsp;"}</nobr>
 541
 542                                                 </td>
 543
 544                                         {/if}
 545
 546
 547
 548                                 </tr>
 549
 550                   {/foreach}
 551
 552                   </table>
 553
 554                 </td>
 555
 556         </tr>
 557
 558         {/foreach}
 559
 560         <td>
 561
 562 </tr>
 563
 564 </table>
 565
 566
 567
 568 <tr>
 569
 570         <td><input type="submit" name="Submit" value="Save Form">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 571
 572 <a href="{$DONT_SAVE_LINK}" class="link" onclick="top.restoreSession()">[Don't Save]</a></td>
 573
 574 </tr>
 575
 576 </table>
 577
 578 <input type="hidden" name="id" value="{$well_child->get_id()}" />
 579
 580 <input type="hidden" name="activity" value="{$well_child->get_activity()}">
 581
 582 <input type="hidden" name="pid" value="{$well_child->get_pid()}">
 583
 584 <input type="hidden" name="process" value="true">
 585
 586 </form>
 587
 588 </body>
 589
 590 </html>
 591