1 <!DOCTYPE HTML
PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
3 "http://www.w3.org/TR/html4/loose.dtd">
7 include_once("../../globals.php");
9 include_once("$srcdir/api.inc");
11 include_once("$srcdir/forms.inc");
13 include_once("$srcdir/calendar.inc");
22 <?php
html_header_show();?
>
24 <title
>Form
: ACOG Immunization record
</title
>
26 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
28 <link rel
=stylesheet href
="../../acog.css" type
="text/css">
30 <script language
="JavaScript" src
="../../acog.js" type
="text/JavaScript"></script
>
32 <script language
="JavaScript" type
="text/JavaScript">
36 window
.onload
= initialize
;
48 $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
52 $patient = sqlFetchArray($fres);
56 $fres=sqlStatement("select * from form_immunization_record where id='".$id."'");
60 $ir = sqlFetchArray($fres);
66 <body
<?php
echo $top_bg_line;?
>>
72 <form action
="<?php echo $rootdir;?>/forms/immunization_record/save.php?mode=update&id=<?php echo $id;?>" method
="post" enctype
="multipart/form-data" name
="my_form">
74 <?php
include("../../acog_menu.inc"); ?
>
76 <div
class="srvChapter">Immunization record
<sup
><a href
="#" onClick
="toolTip('The Immunization Record lists immunization services recommended by ACOG for either routine use or in high-risk patients, as defined in the enclosed table of high-risk factors. space for listing problems and immunization services allows the same form to be used for years.<br><br>For immunizations based on risk refer to the Table of High-Risk Factors')" onMouseOut
="toolTip();"><img src
="../../pic/mark_q.png" width
="13" height
="13" border
="0"></a
></sup
></div
>
78 <div style
="border: solid 2px black; background-color:#FFFFFF;">
80 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
82 <tr align
="left" valign
="bottom">
84 <td colspan
="4" class="fibody2" id
="bordR">patient name
:
86 <input name
="pname" type
="text" class="fullin" id
="pname" style
="width: 74%" value
="<?php
89 echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
93 <td colspan
="2" class="fibody2" id
="bordR">Birth date
:
95 <input name
="pbdate" type
="text" class="fullin" id
="pbdate" style
="width: 65%" value
="<?php
102 <td colspan
="2" class="fibody2">ID No
:
104 <input name
="pl_pid" type
="text" class="fullin" id
="pl_pid" style
="width:80%" value
="<?php
113 <tr align
="center" valign
="middle">
115 <td width
="9%" class="ficaption2" id
="bordR">age
</td
>
117 <td width
="13%" class="ficaption2" id
="bordR">Tetanus
-<br
>
123 <td width
="13%" class="ficaption2" id
="bordR">Influenza
<br
>
127 <td width
="13%" class="ficaption2" id
="bordR">Pneumococcal vaccine
</td
>
129 <td width
="13%" class="ficaption2" id
="bordR">MMR Vaccine
</td
>
131 <td width
="13%" class="ficaption2" id
="bordR">Hepatitis B vaccine
</td
>
133 <td width
="13%" class="ficaption2" id
="bordR">Hepatitis A vaccine
</td
>
135 <td width
="13%" class="ficaption2">Varicella vaccine
</td
>
139 <tr align
="center" valign
="middle">
141 <td
class="fibody2" id
="bordR">13-18</td
>
143 <td
class="fibody2" id
="bordR">Once between ages
11-16 </td
>
145 <td
class="fibody2" id
="bordR">Based on risk
</td
>
147 <td
class="fibody2" id
="bordR">Based on risk
</td
>
149 <td
class="fibody2" id
="bordR">Based on risk
</td
>
151 <td
class="fibody2" id
="bordR">One series
for those not previously immunized
</td
>
153 <td
class="fibody2" id
="bordR">Based on risk
</td
>
155 <td
class="fibody2">Based on risk
</td
>
159 <tr align
="center" valign
="middle">
161 <td
class="fibody2" id
="bordR">19-39</td
>
163 <td
class="fibody2" id
="bordR">Every
10 years
</td
>
165 <td
class="fibody2" id
="bordR">Based on risk
</td
>
167 <td
class="fibody2" id
="bordR">Based on risk
</td
>
169 <td
class="fibody2" id
="bordR">Based on risk
</td
>
171 <td
class="fibody2" id
="bordR">Based on risk
</td
>
173 <td
class="fibody2" id
="bordR">Based on risk
</td
>
175 <td
class="fibody2">Based on risk
</td
>
179 <tr align
="center" valign
="middle">
181 <td
class="fibody2" id
="bordR">40-64</td
>
183 <td
class="fibody2" id
="bordR">Every
10 years
</td
>
185 <td
class="fibody2" id
="bordR">Annually beginning at age
50 years
</td
>
187 <td
class="fibody2" id
="bordR">Based on risk
</td
>
189 <td
class="fibody2" id
="bordR">Based on risk
</td
>
191 <td
class="fibody2" id
="bordR">Based on risk
</td
>
193 <td
class="fibody2" id
="bordR">Based on risk
</td
>
195 <td
class="fibody2">Based on risk
</td
>
199 <tr align
="center" valign
="middle">
201 <td
class="fibody2" id
="bordR">65 and older
</td
>
203 <td
class="fibody2" id
="bordR">Every
10 years
</td
>
205 <td
class="fibody2" id
="bordR">Annually
</td
>
207 <td
class="fibody2" id
="bordR">Once
</td
>
209 <td
class="fibody2" id
="bordR"> 
;</td
>
211 <td
class="fibody2" id
="bordR">Based on risk
</td
>
213 <td
class="fibody2" id
="bordR">Based on risk
</td
>
215 <td
class="fibody2">Based on risk
</td
>
225 <div style
="border: solid 2px black; background-color:#FFFFFF;">
227 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
234 $vacc_tetanus = explode("|~", $ir["vacc_tetanus"]);
236 $vacc_influenza = explode("|~", $ir["vacc_influenza"]);
238 $vacc_pneumococcal = explode("|~", $ir["vacc_pneumococcal"]);
240 $vacc_mmr = explode("|~", $ir["vacc_mmr"]);
242 $vacc_hep_a = explode("|~", $ir["vacc_hep_a"]);
244 $vacc_hep_b = explode("|~", $ir["vacc_hep_b"]);
246 $vacc_varicella= explode("|~", $ir["vacc_varicella"]);
252 <tr align="left" valign="bottom">
254 <td width="9%" class="fibody2" id="bordR">Date</td>
256 <td width="13%" class="fibody2" id="bordR"><input name="vacc_tetanus_${vacci}" type="text" class="fullin2" value="${vacc_tetanus[$vacci]}"></td>
258 <td width="13%" class="fibody2" id="bordR"><input name="vacc_influenza_${vacci}" type="text" class="fullin2" value="${vacc_influenza[$vacci]}"></td>
260 <td width="13%" class="fibody2" id="bordR"><input name="vacc_pneumococcal_${vacci}" type="text" class="fullin2" value="${vacc_pneumococcal[$vacci]}"></td>
262 <td width="13%" class="fibody2" id="bordR"><input name="vacc_mmr_${vacci}" type="text" class="fullin2" value="${vacc_mmr[$vacci]}"></td>
264 <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_b_${vacci}" type="text" class="fullin2" value="${vacc_hep_b[$vacci]}"></td>
266 <td width="13%" class="fibody2" id="bordR"><input name="vacc_hep_a_${vacci}" type="text" class="fullin2" value="${vacc_hep_a[$vacci]}"></td>
268 <td width="13%" class="fibody2"><input name="vacc_varicella_${vacci}" type="text" class="fullin2" value="${vacc_varicella[$vacci]}"></td>
284 <p
><sup
>*</sup
>For immunizations based on risk refer to the Table of High
-Risk Factors
.</p
>
288 <table width
="100%" border
="0">
292 <td align
="left" width
="100"> <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data
]</a
> </td
>
294 <td align
="left" nowrap
> <a href
="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>" target
="_blank" class="link_submit"
296 onclick
="top.restoreSession()">[Printable form
]</a
> </td
>
298 <td align
="right"> <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
300 onclick
="top.restoreSession()">[Don
't Save]</a> </td>