contrib/forms/high_risk_screening_record/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8 ?>
   9
  10 <html>
  11 <head>
  12 <title>Form: High risk screening record</title>
  13 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  14 <link rel=stylesheet href="../../acog.css" type="text/css">
  15 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  16 <script language="JavaScript" type="text/JavaScript">
  17 window.onload = initialize;
  18 </script>
  19 </head>
  20
  21 <?
  22    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  23    if ($fres){
  24      $patient = sqlFetchArray($fres);
  25    }
  26    $fres=sqlStatement("select * from form_high_risk_screening_record where id=$id");
  27    if ($fres){
  28      $fdata = sqlFetchArray($fres);
  29    }
  30 ?>
  31 <body <?echo $top_bg_line;?>>
  32
  33 <form action="<?echo $rootdir;?>/forms/high_risk_screening_record/save.php?mode=update&id=<? echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
  34 <? include("../../acog_menu.inc"); ?>
  35 <div class="srvChapter">High risk screening  record <a href="#" onMouseOver="toolTip('See Table of High-Risk Factors.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  36 <div style="border: solid 2px black; background-color:#FFFFFF;">
  37   <table  border="0" cellpadding="2" cellspacing="0">
  38     <tr align="left" valign="bottom">
  39       <td colspan="6" class="fibody2" id="bordR">patient name:
  40         <input name="pname" type="text" class="fullin" id="pname" style="width: 70%" value="<?
  41           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  42           ?>"></td>
  43       <td colspan="5" class="fibody2" id="bordR">Birth date:
  44         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?
  45           echo $patient{'DOB'};
  46           ?>"></td>
  47       <td colspan="4" class="fibody2">ID No:
  48         <input name="hr_pid" type="text" class="fullin" id="hr_pid" style="width:80%" value="<?
  49           echo $patient{'id'};
  50           ?>"></td>
  51       </tr>
  52     <tr align="center" valign="middle">
  53       <td class="ficaption2" id="bordR">&nbsp;</td>
  54       <td width="6%" class="ficaption2" id="bordR">HEMO-<br>
  55         GLOBIN<br>
  56         TEST</td>
  57       <td width="6%" class="ficaption2" id="bordR">BONE DENSITY<br>
  58         SCREENING</td>
  59       <td width="6%" class="ficaption2" id="bordR">BACTERI-<br>
  60         URIA&nbsp;TEST</td>
  61       <td width="6%" class="ficaption2" id="bordR">STD<br>
  62         TESTING</td>
  63       <td width="6%" class="ficaption2" id="bordR">HIV test <a href="#" onMouseOver="toolTip('Check state requirements before recording results.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
  64       <td width="6%" class="ficaption2" id="bordR">Genetic testing </td>
  65       <td width="6%" class="ficaption2" id="bordR">Rubella titer </td>
  66       <td width="6%" class="ficaption2" id="bordR">TB skin test </td>
  67       <td width="6%" class="ficaption2" id="bordR">Lipid profile assessment </td>
  68       <td width="6%" class="ficaption2" id="bordR">Mammo-<br>
  69         graphy</td>
  70       <td width="6%" class="ficaption2" id="bordR">Fasting<br>
  71         GLUCOSE TEST</td>
  72       <td width="6%" class="ficaption2" id="bordR">TSH<br>
  73         TEST</td>
  74       <td width="6%" class="ficaption2" id="bordR">COLORECTAL<br>
  75         CANCER<br>
  76         SCREENING</td>
  77       <td width="6%" class="ficaption2">HEPATITIS C<br>
  78         VIRUS TEST</td>
  79     </tr>
  80 <?
  81 $rsi = 1;
  82 while ($rsi < 13){
  83 list(
  84 $hemoglobin, $bone_density, $bacteriuria, $std, $hiv, $genetic, $rubella, $tb_skin,
  85 $lipid, $mammography, $fasting_glucose, $tsh, $cancer, $hepatitis_c
  86 ) = explode("|~",$fdata["record_".$rsi]);
  87 list( $hemoglobin_date, $hemoglobin_res) = explode(';', $hemoglobin);
  88 list( $bone_density_date, $bone_density_res) = explode(';', $bone_density);
  89 list( $bacteriuria_date, $bacteriuria_res) = explode(';', $bacteriuria);
  90 list( $std_date, $std_res) = explode(';', $std);
  91 list( $hiv_date, $hiv_res) = explode(';', $hiv);
  92 list( $genetic_date, $genetic_res) = explode(';', $genetic);
  93 list( $rubella_date, $rubella_res) = explode(';', $rubella);
  94 list( $tb_skin_date, $tdb_skin_res) = explode(';', $tdb_skin);
  95 list( $lipid_date, $lipid_res) = explode(';', $lipid);
  96 list( $mammography_date, $mammography_res) = explode(';', $mammography);
  97 list( $fasting_glucose_date, $fasting_glucose_res) = explode(';', $fasting_glucose);
  98 list( $tsh_date, $tsh_res) = explode(';', $tsh);
  99 list( $cancer_date, $cancer_res) = explode(';', $cancer);
 100 list( $hepatitis_c_date, $hepatitis_c_res) = explode(';', $hepatitis_c);
 101
 102 print <<<EOL
 103     <tr align="left" valign="bottom">
 104       <td class="fibody3" id="bordR">Date:</td>
 105       <td class="fibody3" id="bordR"><input name="hemoglobin_date_${rsi}" type="text" value="${hemoglobin_date}" class="fullin2"></td>
 106       <td class="fibody3" id="bordR"><input name="bone_density_date_${rsi}" type="text" value="${bone_density_date}"  class="fullin2"></td>
 107       <td class="fibody3" id="bordR"><input name="bacteriuria_date_${rsi}" type="text" value="${bacteriuria_date}"  class="fullin2"></td>
 108       <td class="fibody3" id="bordR"><input name="std_date_${rsi}" type="text" value="${std_date}"  class="fullin2"></td>
 109       <td class="fibody3" id="bordR"><input name="hiv_date_${rsi}" type="text" value="${hiv_date}"  class="fullin2"></td>
 110       <td class="fibody3" id="bordR"><input name="genetic_date_${rsi}" type="text" value="${genetic_date}"  class="fullin2"></td>
 111       <td class="fibody3" id="bordR"><input name="rubella_date_${rsi}" type="text" value="${rubella_date}"  class="fullin2"></td>
 112       <td class="fibody3" id="bordR"><input name="tb_skin_date_${rsi}" type="text" value="${tb_skin_date}"  class="fullin2"></td>
 113       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" value="${lipid_date}"  class="fullin2"></td>
 114       <td class="fibody3" id="bordR"><input name="mammography_date_${rsi}" type="text" value="${mammography_date}"  class="fullin2"></td>
 115       <td class="fibody3" id="bordR"><input name="fasting_glucose_date_${rsi}" type="text" value="${fasting_glucose_date}"  class="fullin2"></td>
 116       <td class="fibody3" id="bordR"><input name="tsh_date_${rsi}" type="text" value="${tsh_date}"  class="fullin2"></td>
 117       <td class="fibody3" id="bordR"><input name="cancer_date_${rsi}" type="text" value="${cancer_date}"  class="fullin2"></td>
 118       <td class="fibody3"><input name="hepatitis_c_date_${rsi}" type="text" value="${hepatitis_c_date}"  class="fullin2"></td>
 119     </tr>
 120     <tr align="left" valign="bottom">
 121       <td class="fibody2" id="bordR">Result:</td>
 122       <td class="fibody2" id="bordR"><input name="hemoglobin_res_${rsi}" type="text" value="${hemoglobin_res}"  class="fullin2"></td>
 123       <td class="fibody2" id="bordR"><input name="bone_density_res_${rsi}" type="text" value="${bone_density_res}"  class="fullin2"></td>
 124       <td class="fibody2" id="bordR"><input name="bacteriuria_res_${rsi}" type="text" value="${bacteriuria_res}"  class="fullin2"></td>
 125       <td class="fibody2" id="bordR"><input name="std_res_${rsi}" type="text" value="${std_res}"  class="fullin2"></td>
 126       <td class="fibody2" id="bordR"><input name="hiv_res_${rsi}" type="text" value="${hiv_res}"  class="fullin2"></td>
 127       <td class="fibody2" id="bordR"><input name="genetic_res_${rsi}" type="text" value="${genetic_res}"  class="fullin2"></td>
 128       <td class="fibody2" id="bordR"><input name="rubella_res_${rsi}" type="text" value="${rubella_res}"  class="fullin2"></td>
 129       <td class="fibody2" id="bordR"><input name="tb_skin_res_${rsi}" type="text" value="${tb_skin_res}"  class="fullin2"></td>
 130       <td class="fibody2" id="bordR"><input name="lipid_res_${rsi}" type="text" value="${lipid_res}"  class="fullin2"></td>
 131       <td class="fibody2" id="bordR"><input name="mammography_res_${rsi}" type="text" value="${mammography_res}"  class="fullin2"></td>
 132       <td class="fibody2" id="bordR"><input name="fasting_glucose_res_${rsi}" type="text" value="${fasting_glucose_res}"  class="fullin2"></td>
 133       <td class="fibody2" id="bordR"><input name="tsh_res_${rsi}" type="text" value="${tsh_res}"  class="fullin2"></td>
 134       <td class="fibody2" id="bordR"><input name="cancer_res_${rsi}" type="text" value="${cancer_res}"  class="fullin2"></td>
 135       <td class="fibody2"><input name="hepatitis_c_res_${rsi}" type="text" value="${hepatitis_c_res}"  class="fullin2"></td>
 136     </tr>
 137 EOL;
 138 $rsi++;
 139 }
 140 ?>
 141   </table>
 142 </div>
 143 <p>&nbsp;</p>
 144   <table width="100%" border="0">
 145     <tr>
 146       <td align="left" width="120"> <a href="javascript:document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 147       <td align="left" nowrap> <a href="<? echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<? echo $id; ?>&formname=<? echo $formname; ?>" target="_blank" class="link_submit">[Printable form]</a> </td>
 148       <td align="right"> <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link_submit">[Don't Save]</a> </td>
 149     </tr>
 150   </table>
 151 </form>
 152 <?php
 153 formFooter();
 154 ?>
 155 </body>
 156 </html>