contrib/forms/obstetrical/view.php

   1 <!-- Forms generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   7 </head>
   8 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
   9 <?php
  10 include_once("$srcdir/api.inc");
  11 $obj = formFetch("form_obstetrical", $_GET["id"]);
  12 ?>
  13 <form method=post action="<?echo $rootdir?>/forms/obstetrical/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  14 <span class="title">Obstetrical Form</span><Br><br>
  15 <table>
  16 <tr>
  17 <td><span class=text>Name: </span></td><td><input type=entry name="name" value="<?echo $obj{"name"};?>" ></td>
  18 <td><span class=text>Birthdate: </span></td><td><input type=entry size=10 name=birthdate value="<?if ($obj{"birthdate"} != "0000-00-00 00:00:00") {echo date("Y-m-d",strtotime($obj{"birthdate"}));} else {echo "YYYY-MM-DD";}?>"></td>
  19 <td><span class=text>Birth Status: </span></td><td><input type=entry name="birth_status" value="<?echo $obj{"birth_status"};?>" ></td>
  20 <td><span class=text>Gender: </span></td><td><input type=entry name="gender" value="<?echo $obj{"gender"};?>" ></td>
  21 <td><input type=checkbox name="circumcised"  <?if ($obj{"circumcised"} == "on") {echo "checked";};?>></td><td><span class=text>Circumcised</span></td>
  22 </tr>
  23 </table>
  24
  25 <table>
  26 <tr>
  27 <td><span class=text>Pediatrician: </span></td><td><input type=entry name="pediatrician" value="<?echo $obj{"pediatrician"};?>" ></td>
  28 <td><span class=text>Birth Weight: </span></td><td><input type=entry name="birth_weight" value="<?echo $obj{"birth_weight"};?>" ></td>
  29 </tr><tr>
  30 <td><span class=text>Length (Inches): </span></td><td><input type=entry name="length_inches" value="<?echo $obj{"length_inches"};?>" ></td>
  31 <td><span class=text>Head Circumference (Inches): </span></td><td><input type=entry name="head_circumference_inches" value="<?echo $obj{"head_circumference_inches"};?>" ></td>
  32 </tr><tr>
  33 <td><span class=text>Feeding: </span></td><td><input type=entry name="feeding" value="<?echo $obj{"feeding"};?>" ></td>
  34 <td><span class=text>Delivery Method: </span></td><td><input type=entry name="delivery_method" value="<?echo $obj{"delivery_method"};?>" ></td>
  35 </tr><tr>
  36 <td><span class=text>Labor Hours: </span></td><td><input type=entry name="labor_hours" value="<?echo $obj{"labor_hours"};?>" ></td>
  37 <td><span class=text>Pregnancy (Weeks): </span></td><td><input type=entry name="pregnancy_weeks" value="<?echo $obj{"pregnancy_weeks"};?>" ></td>
  38 </tr><tr>
  39 <td><span class=text>Anesthesia: </span></td><td colspan=3><input type=entry name="anesthesia" value="<?echo $obj{"anesthesia"};?>" ></td>
  40 </tr>
  41 </table>
  42
  43
  44
  45 <table>
  46 <tr>
  47 <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>
  48 <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 </tr><tr>
  50 <td><span class=text>Developmental Problems: </span><br><textarea cols=40 rows=4 wrap=virtual name="developmental_problems" ><?echo $obj{"developmental_problems"};?></textarea></td>
  51 <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 </tr><tr>
  53 <td><span class=text>Chronic Medication: </span><br><textarea cols=40 rows=4 wrap=virtual name="chronic_medication" ><?echo $obj{"chronic_medication"};?></textarea></td>
  54 <td><span class=text>Hospitalization: </span><br><textarea cols=40 rows=4 wrap=virtual name="hospitalization" ><?echo $obj{"hospitalization"};?></textarea></td>
  55 </tr><tr>
  56 <td><span class=text>Surgery: </span><br><textarea cols=40 rows=4 wrap=virtual name="surgery" ><?echo $obj{"surgery"};?></textarea></td>
  57 <td><span class=text>Injury: </span><br><textarea cols=40 rows=4 wrap=virtual name="injury" ><?echo $obj{"injury"};?></textarea></td>
  58 </tr><tr>
  59 <td><span class=text>Day Care: </span><br><textarea cols=40 rows=4 wrap=virtual name="day_care" ><?echo $obj{"day_care"};?></textarea></td>
  60 <td><span class=text>Additional Notes: </span><br><textarea cols=40 rows=4 wrap=virtual name="additional_notes" ><?echo $obj{"additional_notes"};?></textarea></td>
  61 </tr>
  62 </table>
  63 <br>
  64 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  65 <br>
  66 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link" target=Main>[Don't Save Changes]</a>
  67 </form>
  68 <?php
  69 formFooter();
  70 ?>