contrib/forms/vision/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: vision");
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <form method=post action="<?echo $rootdir;?>/forms/vision/save.php?mode=new" name="my_form">
  12 <span class="title">Vision</span><br><br>
  13 <span class=bold>Keratometry</span><br>
  14
  15
  16 <table>
  17 <tr>
  18 <td><span class=text>OD K1: </span></td><td><input size=3 type=entry name="od_k1" value="" ></td>
  19 <td><span class=text>OD K1 Axis: </span></td><td><input size=3 type=entry name="od_k1_axis" value="" ></td>
  20 <td><span class=text>OD K2: </span></td><td><input size=3 type=entry name="od_k2" value="" ></td>
  21 <td><span class=text>OD K2 Axis: </span></td><td><input size=3 type=entry name="od_k2_axis" value="" ></td>
  22 </tr>
  23 <tr>
  24 <td colspan=8>
  25
  26 <span class=text>OD Testing Status: </span><input type=entry name="od_testing_status" value="" >
  27 </td>
  28 </tr>
  29 </table>
  30
  31
  32
  33 <table>
  34 <tr>
  35 <td><span class=text>OS K1: </span></td><td><input size=3 type=entry name="os_k1" value="" ></td>
  36 <td><span class=text>OS K1 Axis: </span></td><td><input size=3 type=entry name="os_k1_axis" value="" ></td>
  37 <td><span class=text>OS K2: </span></td><td><input size=3 type=entry name="os_k2" value="" ></td>
  38 <td><span class=text>OS K2 Axis: </span></td><td><input size=3 type=entry name="os_k2_axis" value="" ></td>
  39 </tr>
  40 <tr>
  41 <td colspan=8>
  42
  43 <span class=text>OS Testing Status: </span><input type=entry name="os_testing_status" value="" >
  44 </td>
  45 </tr>
  46 </table>
  47
  48
  49 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea>
  50 <br>
  51 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  52 <br>
  53 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link">[Don't Save]</a>
  54 </form>
  55 <?php
  56 formFooter();
  57 ?>