contrib/forms/obstetrical/new.php

   1 <!-- Form generated from formsWiz -->
   2 <?php
   3 include_once("../../globals.php");
   4 include_once("$srcdir/api.inc");
   5 formHeader("Form: obstetrical");
   6 ?>
   7 <html><head>
   8 <?php html_header_show();?>
   9 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  10 </head>
  11 <body class="body_top">
  12 <form method=post action="<?php echo $rootdir;?>/forms/obstetrical/save.php?mode=new" name="my_form">
  13 <span class="title">Obstetrical Form</span><br><br>
  14
  15 <table>
  16 <tr><td><span class=text>Name: </span></td><td><input type=entry name="name" value="" ></td>
  17 <td><span class=text>Birthdate: </span></td><td><input type=entry name='birthdate' size=10 value='YYYY-MM-DD' ></td>
  18 <td><span class=text>Birth Status: </span></td><td><input type=entry name="birth_status" value="" ></td>
  19 <td><span class=text>Gender: </span></td><td><input type=entry name="gender" value="" ></td>
  20 <td><input type=checkbox name='circumcised'  ></td><td><span class=text>Circumcised</span></td></tr>
  21 </table>
  22
  23
  24 <table>
  25 <tr><td><span class=text>Pediatrician: </span></td><td><input type=entry name="pediatrician" value="" ></td>
  26 <td><span class=text>Birth Weight: </span></td><td><input type=entry name="birth_weight" value="" ></td></tr>
  27 <tr><td><span class=text>Length (Inches): </span></td><td><input type=entry name="length_inches" value="" ></td>
  28 <td><span class=text>Head Circumference (Inches): </span></td><td><input type=entry name="head_circumference_inches" value="" ></td></tr>
  29
  30 <tr><td><span class=text>Feeding: </span></td><td><input type=entry name="feeding" value="" ></td>
  31 <td><span class=text>Delivery Method: </span></td><td><input type=entry name="delivery_method" value="" ></td></tr>
  32 <tr><td><span class=text>Labor Hours: </span></td><td><input type=entry name="labor_hours" value="" ></td>
  33 <td><span class=text>Pregnancy (Weeks): </span></td><td><input type=entry name="pregnancy_weeks" value="" ></td></tr>
  34 <tr><td><span class=text>Anesthesia: </span></td><td colspan=3><input type=entry name="anesthesia" value="" ></td></tr>
  35 </table>
  36
  37
  38 <table>
  39 <tr><td>
  40 <span class=text>Reactions to Medications and Immunizations: </span><br><textarea cols=40 rows=4 wrap=virtual name="reactions_to_medications_and_immunizations" ></textarea></td>
  41 <td><span class=text>Birth Complications: </span><br><textarea cols=40 rows=4 wrap=virtual name="birth_complications" ></textarea></td></tr>
  42 <tr><td>
  43 <span class=text>Developmental Problems: </span><br><textarea cols=40 rows=4 wrap=virtual name="developmental_problems" ></textarea></td>
  44 <td><span class=text>Chronic Illness: </span><br><textarea cols=40 rows=4 wrap=virtual name="chronic_illness" ></textarea></td></tr>
  45 <tr><td>
  46 <span class=text>Chronic Medication: </span><br><textarea cols=40 rows=4 wrap=virtual name="chronic_medication" ></textarea></td>
  47 <td><span class=text>Hospitalization: </span><br><textarea cols=40 rows=4 wrap=virtual name="hospitalization" ></textarea></td></tr>
  48 <tr><td>
  49 <span class=text>Surgery: </span><br><textarea cols=40 rows=4 wrap=virtual name="surgery" ></textarea></td>
  50 <td><span class=text>Injury: </span><br><textarea cols=40 rows=4 wrap=virtual name="injury" ></textarea></td></tr>
  51 <tr><td>
  52 <span class=text>Day Care: </span><br><textarea cols=40 rows=4 wrap=virtual name="day_care" ></textarea></td>
  53 <td><span class=text>Additional Notes: </span><br><textarea cols=40 rows=4 wrap=virtual name="additional_notes" ></textarea></td></tr>
  54 </table>
  55 <br>
  56 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  57 <br>
  58 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
  59  onclick="top.restoreSession()">[Don't Save]</a>
  60 </form>
  61 <?php
  62 formFooter();
  63 ?>