contrib/forms/ped_pain/form.php

   1 <?
   2 /*
   3 pediatric pain form
   4 This form works as new and editing,
   5 */
   6 ?>
   7 <TABLE span class=text>
   8 <th><H2><U>Pediatric Pain Form</U></H2></th>
   9 <TR>
  10         <TD >Location:</TD>
  11         <TD>
  12                 <SELECT NAME="location">
  13                 <option <? if ($obj["location"]=='ear') print 'selected' ;?> >ear
  14                 <option <? if ($obj["location"]=='troat') print 'selected'; ?>>troat
  15                 <option <? if ($obj["location"]=='stomach') print 'selected'; ?>>stomach
  16                 <option <? if ($obj["location"]=='head') print 'selected'; ?>>head
  17                 </SELECT>
  18         </TD>
  19         <TD >Duration:</TD>
  20         <TD>
  21                 <SELECT NAME="duration">
  22                 <option <? if ($obj["duration"]=='one hour') print 'selected'; ?>>one hour
  23                 <option <? if ($obj["duration"]=='twelve hours') print 'selected'; ?>>twelve hours
  24                 <option <? if ($obj["duration"]=='one day') print 'selected'; ?>>one day
  25                 <option <? if ($obj["duration"]=='two days') print 'selected'; ?>>two days
  26                 <option <? if ($obj["duration"]=='three days') print 'selected'; ?>>three days
  27                 <option <? if ($obj["duration"]=='more than 3 days') print 'selected'; ?>>more than 3 days
  28                 </SELECT>
  29         </TD>
  30         <TD >Severity:</TD>
  31         <TD>
  32                 <SELECT NAME="severity">
  33                 <option <? if ($obj["severity"]=='consolable') print 'selected'; ?>>consolable
  34                 <option <? if ($obj["severity"]=='consolable with difficulty') print 'selected'; ?>>consolable with difficulty
  35                 <option <? if ($obj["severity"]=='inconsolable') print 'selected'; ?>>inconsolable
  36                 </SELECT>
  37         </TD>
  38 </TR>
  39 <TR>
  40         <TD >Fever:</TD>
  41         <TD>
  42                 <SELECT NAME="fever">
  43                 <option <? if ($obj["fever"]=='no') print 'selected'; ?>>no
  44                 <option <? if ($obj["fever"]=='yes') print 'selected'; ?>>yes
  45                 <option <? if ($obj["fever"]=='98') print 'selected'; ?>>98
  46                 <option <? if ($obj["fever"]=='98,5') print 'selected'; ?>>98,5
  47                 <option <? if ($obj["fever"]=='99') print 'selected'; ?>>99
  48                 <option <? if ($obj["fever"]=='99,5') print 'selected'; ?>>99,5
  49                 <option <? if ($obj["fever"]=='100') print 'selected'; ?>>100
  50                 <option <? if ($obj["fever"]=='100,5') print 'selected'; ?>>100,5
  51                 <option <? if ($obj["fever"]=='101') print 'selected'; ?>>101
  52                 <option <? if ($obj["fever"]=='101,5') print 'selected'; ?>>101,5
  53                 <option <? if ($obj["fever"]=='102') print 'selected'; ?>>102
  54                 <option <? if ($obj["fever"]=='102,5') print 'selected'; ?>>102,5
  55                 <option <? if ($obj["fever"]=='103') print 'selected'; ?>>103
  56                 <option <? if ($obj["fever"]=='103,5') print 'selected'; ?>>103,5
  57                 <option <? if ($obj["fever"]=='104') print 'selected'; ?>>104
  58                 <option <? if ($obj["fever"]=='104,5') print 'selected'; ?>>104,5
  59                 <option <? if ($obj["fever"]=='105 ') print 'selected'; ?>>105
  60                 </SELECT>
  61         </TD>
  62         <TD >Lethargy:</TD>
  63         <TD>
  64                 <SELECT NAME="lethargy">
  65                 <option <? if ($obj["lethargy"]=='no') print 'selected'; ?>>no
  66                 <option <? if ($obj["lethargy"]=='yes') print 'selected'; ?>>yes
  67                 </SELECT>
  68         </TD>
  69         <TD >Vomiting:</TD>
  70         <TD>
  71                 <SELECT NAME="vomiting">
  72                 <option <? if ($obj["vomiting"]=='no') print 'selected'; ?>>no
  73                 <option <? if ($obj["vomiting"]=='yes') print 'selected'; ?>>yes
  74                 </SELECT>
  75         </TD>
  76 </TR>
  77 <TR>
  78         <TD colspan=2 >Able to take oral hydration:</TD>
  79         <TD>
  80                 <SELECT NAME="oral_hydration_capable">
  81                 <option <? if ($obj["oral_hydration_capable"]=='yes') print 'selected'; ?>>yes
  82                 <option <? if ($obj["oral_hydration_capable"]=='no') print 'selected'; ?>>no
  83                 </SELECT>
  84         </TD>
  85         <TD colspan=2 >Urine output at least every 6 hrs.</TD>
  86         <TD>
  87                 <SELECT NAME="urine_output_last_6_hours">
  88                 <option <? if ($obj["urine_output_last_6_hours"]=='yes') print 'selected'; ?>>yes
  89                 <option <? if ($obj["urine_output_last_6_hours"]=='no') print 'selected'; ?>>no
  90                 </SELECT>
  91                 With Pain?:
  92                 <SELECT NAME="pain_with_urination">
  93                 <option <? if ($obj["pain_with_urination"]=='no') print 'selected'; ?>>no
  94                 <option <? if ($obj["pain_with_urination"]=='yes') print 'selected'; ?>>yes
  95                 </SELECT>
  96
  97         </TD>
  98 </TR>
  99 <TR>
 100         <TD colspan=2 >Cough or difficulty breathing:</TD>
 101         <TD>
 102                 <SELECT NAME="cough_or_breathing_difficulty">
 103                 <option <? if ($obj["cough_or_breathing_difficulty"]=='no') print 'selected'; ?>>no
 104                 <option <? if ($obj["cough_or_breathing_difficulty"]=='yes') print 'selected'; ?>>yes
 105                 </SELECT>
 106         </TD>
 107         <TD colspan=2 >Able to sleep confortably</TD>
 108         <TD>
 109                 <SELECT NAME="able_to_sleep">
 110                 <option <? if ($obj["able_to_sleep"]=='yes') print 'selected'; ?>>yes
 111                 <option <? if ($obj["able_to_sleep"]=='no') print 'selected'; ?>>no
 112                 </SELECT>
 113         </TD>
 114 </TR>
 115 <TR>
 116         <TD>Nasal Discharge:</TD>
 117         <TD>
 118                 <SELECT NAME="nasal_discharge">
 119                 <option <? if ($obj["nasal_discharge"]=='no') print 'selected'; ?>>no
 120                 <option <? if ($obj["nasal_discharge"]=='yes') print 'selected'; ?>>yes
 121                 </SELECT>
 122         </TD>
 123         <TD>Prior Hospitalization</TD>
 124         <TD>
 125                 <SELECT NAME="previous_hospitalization">
 126                 <option <? if ($obj["previous_hospitalization"]=='no') print 'selected'; ?>>no
 127                 <option <? if ($obj["previous_hospitalization"]=='yes') print 'selected'; ?>>yes
 128                 </SELECT>
 129         </TD>
 130         <TD>Siblings affected?:</TD>
 131         <TD>
 132                 <SELECT NAME="siblings_affected">
 133                 <option <? if ($obj["siblings_affected"]=='no') print 'selected'; ?>>no
 134                 <option <? if ($obj["siblings_affected"]=='yes') print 'selected'; ?>>yes
 135                 </SELECT>
 136         </TD>
 137 </TR>
 138 <TR>
 139         <TD colspan=2>Immunization up to date:
 140                 <SELECT NAME="immunization_up_to_date">
 141                 <option <? if ($obj["immunization_up_to_date"]=='yes') print 'selected'; ?>>yes
 142                 <option <? if ($obj["immunization_up_to_date"]=='no') print 'selected'; ?>>no
 143                 </SELECT>
 144         </TD>
 145         <TD colspan=4 align=left valign=top>Notes:
 146         <TEXTAREA NAME="notes" ROWS="3" COLS="40">
 147         <? if ($obj["notes"]!='') print $obj["notes"]; ?>
 148         </TEXTAREA></TD>
 149 </TR>
 150 </TABLE>