interface/forms/ankleinjury/view.php

   1 <?php
   2
   3 /**
   4  * ankleinjury view.php
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    Nikolai Vitsyn
   9  * @author    cfapress <cfapress>
  10  * @author    Robert Down <robertdown@live.com>
  11  * @author    Brady Miller <brady.g.miller@gmail.com>
  12  * @copyright Copyright (c) 2004 Nikolai Vitsyn
  13  * @copyright Copyright (c) 2008 cfapress <cfapress>
  14  * @copyright Copyright (c) 2017-2023 Robert Down <robertdown@live.com>
  15  * @copyright Copyright (c) 2019 Brady Miller <brady.g.miller@gmail.com>
  16  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  17  */
  18
  19 require_once(__DIR__ . "/../../globals.php");
  20
  21 use OpenEMR\Common\Csrf\CsrfUtils;
  22 use OpenEMR\Core\Header;
  23
  24 ?>
  25 <html><head>
  26     <?php Header::setupHeader(); ?>
  27 </head>
  28 <body class="body_top">
  29 <?php
  30 require_once("$srcdir/api.inc.php");
  31 $obj = formFetch("form_ankleinjury", $_GET["id"]);
  32 ?>
  33 <form method=post action="<?php echo $rootdir?>/forms/ankleinjury/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form">
  34 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
  35
  36 <span class="title"><?php echo xlt('Ankle Evaluation Form'); ?></span><br /><br />
  37
  38 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php echo xlt('Save'); ?>]</a>
  39 <br />
  40 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  41  onclick="top.restoreSession()">[<?php echo xlt('Don\'t Save Changes'); ?>]</a>
  42 <br /><br />
  43
  44 <span class=text>Date of Injury: </span><input type="text" name="ankle_date_of_injuary" value="<?php echo attr($obj["ankle_date_of_injuary"]); ?>" >
  45 <td align="right"><?php echo xlt('Work related?'); ?>:</td>
  46 <td><input type=checkbox name="ankle_work_related" <?php if ($obj["ankle_work_related"] == "on") {
  47     echo "checked";
  48                                                    }
  49
  50                                                    ;?>><span class=text></span><br /></td>
  51
  52 <table >
  53 <tr>
  54 <td align="right"><?php echo xlt('Foot:'); ?></td>
  55 <td><input type=radio name="ankle_foot" value="Left" <?php if ($obj["ankle_foot"] == "Left") {
  56     echo "checked";
  57                                                      };?>><span class=text></span><br /></td>
  58 <td align="right"><?php echo xlt('Left:'); ?></td>
  59 <td><input type=radio name="ankle_foot" value="Right" <?php if ($obj["ankle_foot"] == "Right") {
  60     echo "checked";
  61                                                       };?>><span class=text></span><br /></td>
  62 <td align="right"><?php echo xlt('Right:'); ?></td>
  63 </tr>
  64 </table>
  65
  66 <table >
  67 <tr>
  68 <td align="right"><?php echo xlt('Severity of Pain:'); ?></td>
  69 <td align="right">1:</td>
  70 <td><input type=radio name="ankle_severity_of_pain" value="1" <?php if ($obj["ankle_severity_of_pain"] == "1") {
  71     echo "checked";
  72                                                               };?>><span class=text></span><br /></td>
  73
  74 <td align="right">2:</td>
  75 <td><input type=radio name="ankle_severity_of_pain" value="2" <?php if ($obj["ankle_severity_of_pain"] == "2") {
  76     echo "checked";
  77                                                               };?>><span class=text></span><br /></td>
  78
  79 <td align="right">3:</td>
  80 <td><input type=radio name="ankle_severity_of_pain" value="3" <?php if ($obj["ankle_severity_of_pain"] == "3") {
  81     echo "checked";
  82                                                               };?>><span class=text></span><br /></td>
  83 </tr>
  84 </table>
  85
  86 <table><tr>
  87 <td align="right"><?php echo xlt('Significant Swelling:'); ?></td>
  88 <td><input type=checkbox name="ankle_significant_swelling" <?php if ($obj["ankle_significant_swelling"] == "on") {
  89     echo "checked";
  90                                                            };?>><span class=text></span><br />
  91 </tr>
  92 </table>
  93
  94
  95 <table >
  96 <tr>
  97 <td align="right"><?php echo xlt('Onset of Swelling:'); ?></td>
  98 <td><input type=radio name="ankle_onset_of_swelling" value="within minutes" <?php if ($obj["ankle_onset_of_swelling"] == "within minutes") {
  99     echo "checked";
 100                                                                             };?>><span class=text></span><br /></td>
 101 <td align="right"><?php echo xlt('within minutes:'); ?></td>
 102 <td><input type=radio name="ankle_onset_of_swelling" value="within hours" <?php if ($obj["ankle_onset_of_swelling"] == "within hours") {
 103     echo "checked";
 104                                                                           };?>><span class=text></span><br /></td>
 105 <td align="right"><?php echo xlt('within hours:');?></td>
 106 </tr>
 107 </table>
 108
 109 <span class="text"><?php echo xlt('How did Injury Occur?:'); ?></span><br />
 110 <textarea name="ankle_how_did_injury_occur" cols ="67" rows="4"  wrap="virtual name">
 111 <?php echo text($obj["ankle_how_did_injury_occur"]); ?></textarea>
 112 <br />
 113
 114 <table><th colspan="5"><?php echo xlt('Ottawa Ankle Rules'); ?></th>
 115 <tr>
 116 <td align="right"><?php echo xlt('Bone Tenderness:'); ?></td>
 117 <td align="right"><?php echo xlt('Medial malleolus:'); ?></td>
 118 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Medial malleolus" <?php if ($obj["ankle_ottawa_bone_tenderness"] == "Medial malleolus") {
 119     echo "checked";
 120                                                                                    };?>><span class=text></span><br /></td>
 121 <td align="right"><?php echo xlt('Lateral malleolus:'); ?></td>
 122 <td><input type=radio name="ankle_ottawa_bone_tenderness"  value="Lateral malleolus" <?php if ($obj["ankle_ottawa_bone_tenderness"] == "Lateral malleolus") {
 123     echo "checked";
 124                                                                                      };?>><span class=text></span><br /></td>
 125 <td align="right"><?php echo xlt('Base of fifth (5th) Metarsal:'); ?></td>
 126 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="Base of fifth (5th) Metarsal" <?php if ($obj["ankle_ottawa_bone_tenderness"] == "Base of fifth (5th) Metarsal") {
 127     echo "checked";
 128                                                                                                };?>><span class=text></span><br /></td>
 129 <td align="right"><?php echo xlt('At the Navicular:'); ?></td>
 130 <td><input type=radio name="ankle_ottawa_bone_tenderness" value="At the Navicular" <?php if ($obj["ankle_ottawa_bone_tenderness"] == "At the Navicular") {
 131     echo "checked";
 132                                                                                    };?>><span class=text></span><br /></td>
 133 </tr>
 134 </table>
 135
 136 <table >
 137 <tr>
 138 <td align="right"><?php echo xlt('Able to Bear Weight four (4) steps:'); ?></td>
 139 <td align="right"><?php echo xlt('Yes:'); ?></td>
 140 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="Yes" <?php if ($obj["ankle_able_to_bear_weight_steps"] == "Yes") {
 141     echo "checked";
 142                                                                          };?>><span class=text></span><br /></td>
 143 <td align="right"><?php echo xlt('No:'); ?></td>
 144 <td><input type=radio name="ankle_able_to_bear_weight_steps" value="No" <?php if ($obj["ankle_able_to_bear_weight_steps"] == "No") {
 145     echo "checked";
 146                                                                         };?>><span class=text></span><br /></td>
 147 </tr>
 148 </table>
 149
 150 <table>
 151 <tr><th><?php echo xlt('X-Ray Interpretation:'); ?></th> <th><?php echo xlt('Additional X-RAY Notes:'); ?></th></tr>
 152 <tr>
 153 <td>
 154 <input type="text" name="ankle_x_ray_interpretation" value="<?php echo
 155 attr($obj["ankle_x_ray_interpretation"]); ?>" size="50">
 156 </td>
 157 <td rowspan=2>
 158 <textarea name="ankle_additional_x_ray_notes" cols ="30" rows="1" wrap="virtual name">
 159 <?php echo attr($obj["ankle_additional_x_ray_notes"]); ?></textarea>
 160 <td>
 161 </tr>
 162 </table>
 163
 164 <table>
 165 <tr><th><?php echo xlt('Diagnosis:'); ?></th><th><?php echo xlt('Additional Diagnosis:'); ?></th></tr>
 166 <tr>
 167 <td><input type="text" name="ankle_diagnosis1" value="<?php echo
 168 attr($obj["ankle_diagnosis1"]); ?>" size="50">
 169 </td>
 170 <td rowspan=2>
 171 <textarea name="ankle_additional_diagnisis" rows="2" cols="30" wrap="virtual name">
 172 <?php echo attr($obj["ankle_additional_diagnisis"]); ?></textarea>
 173 </td>
 174
 175 <tr>
 176 <td><input type="text" name="ankle_diagnosis2" value="<?php echo
 177 attr($obj["ankle_diagnosis2"]); ?>" size="50"></td>
 178 </tr>
 179 <td><input type="text" name="ankle_diagnosis3" value="<?php echo
 180 attr($obj["ankle_diagnosis3"]); ?>" size="50"></td>
 181 </tr>
 182 <td><input type="text" name="ankle_diagnosis4" value="<?php echo
 183 attr($obj["ankle_diagnosis4"]); ?>" size="50"></td>
 184 </tr>
 185 </table>
 186
 187 <table><tr><th><?php echo xlt('Plan:'); ?></th><tr>
 188 <tr><td>
 189 <textarea name="ankle_plan" rows="4" cols="67" wrap="virtual name">
 190 <?php echo text($obj["ankle_plan"]); ?></textarea>
 191 </td></tr></table>
 192
 193 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[<?php echo xlt('Save'); ?>]</a>
 194 <br />
 195 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
 196  onclick="top.restoreSession()">[<?php echo xlt('Don\'t Save Changes'); ?>]</a>
 197 </form>
 198 <?php
 199 formFooter();
 200 ?>