contrib/forms/hearingtest/view.php

   1 <!-- Forms generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 ?>
   5 <html><head>
   6 <?php html_header_show();?>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_hearingtest", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?echo $rootdir?>/forms/hearingtest/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  15 <span class="title">Hearing Test</span><Br><br>
  16 <input type=checkbox name="with_hearing_aid"  <?if ($obj{"with_hearing_aid"} == "on") {echo "checked";};?>><span class=text>With hearing Aid?</span><br>
  17 <table>
  18 <tr>
  19 <td>
  20 <span class=text>Right Ear 250: </span><input type=entry name="right_ear_250" value="<?echo $obj{"right_ear_250"};?>" ><br>
  21 <span class=text>Right Ear 500: </span><input type=entry name="right_ear_500" value="<?echo $obj{"right_ear_500"};?>" ><br>
  22 <span class=text>Right Ear 1000: </span><input type=entry name="right_ear_1000" value="<?echo $obj{"right_ear_1000"};?>" ><br>
  23 <span class=text>Right Ear 2000: </span><input type=entry name="right_ear_2000" value="<?echo $obj{"right_ear_2000"};?>" ><br>
  24 <span class=text>Right Ear 3000: </span><input type=entry name="right_ear_3000" value="<?echo $obj{"right_ear_3000"};?>" ><br>
  25 <span class=text>Right Ear 4000: </span><input type=entry name="right_ear_4000" value="<?echo $obj{"right_ear_4000"};?>" ><br>
  26 <span class=text>Right Ear 5000: </span><input type=entry name="right_ear_5000" value="<?echo $obj{"right_ear_5000"};?>" ><br>
  27 <span class=text>Right Ear 6000: </span><input type=entry name="right_ear_6000" value="<?echo $obj{"right_ear_6000"};?>" ><br>
  28 </td>
  29 <td>
  30 <span class=text>Left Ear 250: </span><input type=entry name="left_ear_250" value="<?echo $obj{"left_ear_250"};?>" ><br>
  31 <span class=text>Left Ear 500: </span><input type=entry name="left_ear_500" value="<?echo $obj{"left_ear_500"};?>" ><br>
  32 <span class=text>Left Ear 1000: </span><input type=entry name="left_ear_1000" value="<?echo $obj{"left_ear_1000"};?>" ><br>
  33 <span class=text>Left Ear 2000: </span><input type=entry name="left_ear_2000" value="<?echo $obj{"left_ear_2000"};?>" ><br>
  34 <span class=text>Left Ear 3000: </span><input type=entry name="left_ear_3000" value="<?echo $obj{"left_ear_3000"};?>" ><br>
  35 <span class=text>Left Ear 4000: </span><input type=entry name="left_ear_4000" value="<?echo $obj{"left_ear_4000"};?>" ><br>
  36 <span class=text>Left Ear 5000: </span><input type=entry name="left_ear_5000" value="<?echo $obj{"left_ear_5000"};?>" ><br>
  37 <span class=text>Left Ear 6000: </span><input type=entry name="left_ear_6000" value="<?echo $obj{"left_ear_6000"};?>" ><br>
  38 </td>
  39 </tr>
  40 </table>
  41 <br>
  42 <table>
  43 <tr>
  44 <td valign=top>
  45 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ><?echo $obj{"additional_notes"};?></textarea><br>
  46 </td>
  47 </tr>
  48 </table>
  49
  50 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  51 <br>
  52 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
  53 </form>
  54 <?php
  55 formFooter();
  56 ?>