contrib/forms/vitalsigns/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: vitalsigns");
   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/vitalsigns/save.php?mode=new" name="my_form">
  12 <span class="title">Vital Signs</span><br><br>
  13 <span class=bold>Blood Pressure</span><br>
  14
  15 <table width=100%>
  16 <tr>
  17 <td>
  18 <span class=text>Standing: </span><input size=3 type=entry name="standing_bp_1" value="" >
  19 <input size=3 type=entry name="standing_bp_2" value="" >
  20 </td>
  21 <td>
  22 <span class=text>Sitting: </span><input size=3 type=entry name="sitting_bp_1" value="" >
  23 <input size=3 type=entry name="sitting_bp_2" value="" >
  24 </td>
  25 <td>
  26 <span class=text>Supine: </span><input size=3 type=entry name="supine_bp_1" value="" >
  27 <input size=3 type=entry name="supine_bp_2" value="" >
  28 </td>
  29 <td>
  30 <span class=text>Systolic: </span><input size=3 type=entry name="systolic_bp_1" value="" >
  31 <input size=3 type=entry name="systolic_bp_2" value="" >
  32 </td>
  33 <td>
  34 <span class=text>Diastolic: </span><input size=3 type=entry name="diastolic_bp_1" value="" >
  35 <input size=3 type=entry name="diastolic_bp_2" value="" >
  36 </td>
  37 </tr>
  38 </table>
  39
  40 <table><tr>
  41 <tr><td><span class=text>Heart Rate (Beats/Minute): </span></td><td><input size=3 type=entry name="heart_rate_beats_per_minute" value="" ></td>
  42 <td><span class=text>Respiration (Breaths/Minute): </span></td><td><input size=3 type=entry name="respiration_beats_per_minute" value="" ></td></tr>
  43 </table>
  44
  45 <table>
  46 <tr>
  47 <td><span class=text>Temperature: </span><input size=3 type=entry name="temperature_c" value="" ><span class=text> (C)</span></td>
  48 <td><input size=3 type=entry name="temperature_f" value="" ><span class=text> (F)</span></td>
  49 <td><span class=text>Temperature Method: </span><input type=entry name="temperature_method" value="" ></td>
  50
  51 </tr><tr>
  52
  53 <td><span class=text>Height (Feet): </span><input size=3 type=entry name="height_feet" value="" ></td>
  54 <td><span class=text>Height (Inches): </span><input size=3 type=entry name="height_inches" value="" ></td>
  55 <td><span class=text>Height (Centimeters): </span><input size=3 type=entry name="height_centimeters" value="" ></td>
  56
  57 </tr><tr>
  58
  59 <td><span class=text>Weight (Lbs): </span><input size=3 type=entry name="weight_lbs" value="" ></td>
  60 <td><span class=text>Weight (Ozs): </span><input size=3 type=entry name="weight_ozs" value="" ></td>
  61 <td><span class=text>Weight (Kgs): </span><input size=3 type=entry name="weight_kgs" value="" ></td>
  62
  63 </tr><tr>
  64
  65 </tr></table>
  66
  67 <span class=text>Body Mass Index: </span><input size=5 type=entry name="body_mass_index" value="" >
  68 <span class=text>Figure Shape (If Overweight): </span><input type=entry name="figure_shape" value="" >
  69
  70 <br>
  71 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea>
  72
  73 <br>
  74 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
  75 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  76 <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link">[Don't Save]</a>
  77 </form>
  78 <?php
  79 formFooter();
  80 ?>