contrib/forms/neurologicalreview/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="<?php echo $css_header;?>" type="text/css">
   8 </head>
   9 <body class="body_top">
  10 <?php
  11 include_once("$srcdir/api.inc");
  12 $obj = formFetch("form_neurologicalreview", $_GET["id"]);
  13 ?>
  14 <form method=post action="<?php echo $rootdir?>/forms/neurologicalreview/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form">
  15 <span class="title">Neurological Review</span><Br><br>
  16 <table>
  17 <tr>
  18 <td valign=top>
  19 <table>
  20 <tr><td><span class=text>Burning: </span></td><td><input type=entry name="burning" value="<?php echo $obj{"burning"};?>" ></td></tr>
  21 <tr><td><span class=text>Confusion: </span></td><td><input type=entry name="confusion" value="<?php echo $obj{"confusion"};?>" ></td></tr>
  22 <tr><td><span class=text>Dizziness: </span></td><td><input type=entry name="dizziness" value="<?php echo $obj{"dizziness"};?>" ></td></tr>
  23 <tr><td><span class=text>Dysphasia: </span></td><td><input type=entry name="dysphasia" value="<?php echo $obj{"dysphasia"};?>" ></td></tr>
  24 <tr><td><span class=text>Facial tic: </span></td><td><input type=entry name="facial_tic" value="<?php echo $obj{"facial_tic"};?>" ></td></tr>
  25 <tr><td><span class=text>Focal weakness: </span></td><td><input type=entry name="focal_weakness" value="<?php echo $obj{"focal_weakness"};?>" ></td></tr>
  26 <tr><td><span class=text>Forgetfulness: </span></td><td><input type=entry name="forgetfulness" value="<?php echo $obj{"forgetfulness"};?>" ></td></tr>
  27 </table>
  28 </td>
  29 <td valign=top>
  30 <table>
  31 <tr><td><span class=text>Headache: </span></td><td><input type=entry name="headache" value="<?php echo $obj{"headache"};?>" ></td></tr>
  32 <tr><td><span class=text>Hyperesthesia: </span></td><td><input type=entry name="hyperesthesia" value="<?php echo $obj{"hyperesthesia"};?>" ></td></tr>
  33 <tr><td><span class=text>Lightheadedness: </span></td><td><input type=entry name="lightheadedness" value="<?php echo $obj{"lightheadedness"};?>" ></td></tr>
  34 <tr><td><span class=text>Numbness: </span></td><td><input type=entry name="numbness" value="<?php echo $obj{"numbness"};?>" ></td></tr>
  35 <tr><td><span class=text>Paralysis: </span></td><td><input type=entry name="paralysis" value="<?php echo $obj{"paralysis"};?>" ></td></tr>
  36 <tr><td><span class=text>Paresthesia: </span></td><td><input type=entry name="paresthesia" value="<?php echo $obj{"paresthesia"};?>" ></td></tr>
  37 </table>
  38 </td>
  39 </td>
  40 </table>
  41
  42 <table>
  43 <tr>
  44 <td>
  45 <span class=text>Symptoms of Problems: </span><br><textarea cols=40 rows=8 name="symptoms_of_problems" wrap=virtual><?php echo $obj{"symptoms_of_problems"};?></textarea>
  46 </td><td>
  47 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 name="additional_notes"  wrap=virtual><?php echo $obj{"additional_notes"};?></textarea><br>
  48 </td></tr></table>
  49 <br>
  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"
  53  onclick="top.restoreSession()">[Don't Save Changes]</a>
  54 </form>
  55 <?php
  56 formFooter();
  57 ?>