contrib/forms/snellen/templates/general_new.html

   1 <html>
   2 <head>
   3 {php}html_header_show();{/php}
   4 {literal}
   5
   6  <style type="text/css" title="mystyles" media="all">
   7 <!--
   8 td {
   9         font-size:12pt;
  10         font-family:helvetica;
  11 }
  12 li{
  13         font-size:11pt;
  14         font-family:helvetica;
  15         margin-left: 15px;
  16 }
  17 a {
  18         font-size:11pt;
  19         font-family:helvetica;
  20 }
  21 .title {
  22         font-family: sans-serif;
  23         font-size: 12pt;
  24         font-weight: bold;
  25         text-decoration: none;
  26         color: #000000;
  27 }
  28
  29 .form_text{
  30         font-family: sans-serif;
  31         font-size: 9pt;
  32         text-decoration: none;
  33         color: #000000;
  34 }
  35
  36 -->
  37 </style>
  38 {/literal}
  39 </head>
  40 <body bgcolor="{$STYLE.BGCOLOR2}">
  41 <p><span class="title">Snellen Eye Exam</span></p>
  42 <form name="soap" method="post" action="{$FORM_ACTION}/interface/forms/snellen/save.php"
  43  onsubmit="return top.restoreSession()">
  44 <table border='1px' cellspacing='1px'; cellpadding='1px'>
  45
  46         <tr>
  47                 <td><b>Eye Vision</b></td>
  48                 <td><b>Without Correction</b></td>
  49                 <td><b>With Correction</b></td>
  50         </tr>
  51         <tr>
  52                 <td><b>Left Eye</b></td>
  53                 <td>20/<input type='text' size='15px' name='left_1' value='{$data->get_left_1()}'></td>
  54                 <td>20/<input type='text' size='15px' name='left_2' value='{$data->get_left_2()}'></td>
  55         </tr>
  56         <tr>
  57                 <td><b>Right Eye</b></td>
  58                 <td>20/<input type='text' size='15px' name='right_1' value='{$data->get_right_1()}'></td>
  59                 <td>20/<input type='text' size='15px' name='right_2' value='{$data->get_right_2()}'></td>
  60         </tr>
  61 </table>
  62
  63 </p>
  64 <table border='0' cellpadding='0' cellspacing='0' class='text'>
  65         <tr class='text'>
  66                 <td><b>NOTES</b></td>
  67         </tr>
  68         <tr class='text'>
  69                 <td><textarea cols='80' rows='5' name='notes'>{$data->get_notes()}</textarea></td>
  70         </tr>
  71 </table>
  72
  73 <table>
  74         <tr>
  75                 <td>
  76                         <input type="submit" name="Submit" value="Save Form">
  77                 </td>
  78                 <td>
  79                         <a href="{$DONT_SAVE_LINK}" class="link">[Don't Save]</a>
  80                 </td>
  81         </tr>
  82 </table>
  83 <input type="hidden" name="id" value="{$data->get_id()}" />
  84 <input type="hidden" name="pid" value="{$data->get_pid()}">
  85 <input type="hidden" name="process" value="true">
  86 </form>
  87 </body>
  88 </html>