contrib/forms/individual_treatment_plan/view.php

   1 <?php
   2 include_once("../../globals.php");
   3 ?>
   4 <html><head>
   5 <? html_header_show();?>
   6 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   7 </head>
   8 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
   9 <?php
  10 include_once("$srcdir/api.inc");
  11
  12
  13 $obj = formFetch("form_individual_treatment_plan", $_GET["id"]);
  14
  15
  16 ?>
  17 <form method=post action="<?echo $rootdir?>/forms/individual_treatment_plan/save.php?mode=update&id=<?echo $_GET["id"];?>" name="my_form">
  18 <span class="title"><center><b>Individual Treatment Plan</b></center></span><br><br>
  19 <center>
  20 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
  21 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a></center>
  22 <br></br>
  23
  24 <? /* From New */ ?>
  25
  26 <?php $res = sqlStatement("SELECT fname,mname,lname,ss,street,city,state,postal_code,phone_home,DOB FROM patient_data WHERE pid = $pid");
  27 $result = SqlFetchArray($res); ?>
  28
  29 <b>Date of Referral:</b>&nbsp;<input type="text" name="date_of_referal" value="<? echo stripslashes($obj{"date_of_referal"});?>">
  30 <img src="../../../images/space.gif" width="260" height="1">
  31 <b>Date of Plan:</b>&nbsp; <?php print date('m/d/y'); ?><br><br>
  32
  33 <img src="../../../images/space.gif" width="28" height="1">
  34 <b>Client Name:</b>&nbsp; <?php echo $result['fname'] . '&nbsp' . $result['mname'] . '&nbsp;' . $result['lname'];?>
  35 <img src="../../../images/space.gif" width="292" height="1">
  36 <b>DCN:</b>
  37 <img src="../../../images/space.gif" width="1" height="1">
  38 <input type="text" name="dcn" value="<? echo stripslashes($obj{"dcn"});?>"> <br><br>
  39
  40 <b>ICD/9/CM Code:</b>&nbsp;<input type="text" name="icd9" value="<? echo stripslashes($obj{"icd9"});?>">
  41 <img src="../../../images/space.gif" width="200" height="1">
  42 <b>Prognosis:</b>&nbsp;<input type="text" name="prognosis" value="<? echo stripslashes($obj{"prognosis"});?>"><br><br>
  43
  44 <b>Diagnosis Description:</b><br>
  45 <textarea cols=85 rows=2 wrap=virtual name="diagnosis_description" ><? echo stripslashes($obj{"diagnosis_description"});?></textarea><br><br>
  46
  47 <b>Presenting Problem Description and Psychosocial Information:</b><br>
  48 <textarea cols=85 rows=3 wrap=virtual name="presenting_problem" ><? echo stripslashes($obj{"presenting_problem"});?></textarea><br><br>
  49
  50 <b>Frequency:</b>&nbsp;<input type="text" name="frequency" size="12" maxlength="10" value="<? echo stripslashes($obj{"frequency"});?>">
  51 <img src="../../../images/space.gif" width="40" height="1">
  52 <b>Duration:</b>&nbsp;<input type="text" name="duration" size="12" maxlength="10" value="<? echo stripslashes($obj{"duration"});?>">
  53 <img src="../../../images/space.gif" width="40" height="1">
  54 <b>Scope:</b>&nbsp;<input type="text" name="scope" size="12" maxlength="10" value="<? echo stripslashes($obj{"scope"});?>"><br><br>
  55
  56 <b>Short Term Goals:</b>
  57 <img src="../../../images/space.gif" width="162" height="1">
  58 <b>Time Frame:</b><br>
  59 <input type="text" name="short_term_goals_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_1"});?>">
  60 <img src="../../../images/space.gif" width="6" height="1">
  61 <input type="text" name="time_frame_1" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_1"});?>"><br>
  62
  63 <input type="text" name="short_term_goals_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_2"});?>">
  64 <img src="../../../images/space.gif" width="6" height="1">
  65 <input type="text" name="time_frame_2" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_2"});?>"><br>
  66
  67 <input type="text" name="short_term_goals_3" size="42" maxlength="40" value="<? echo stripslashes($obj{"short_term_goals_3"});?>">
  68 <img src="../../../images/space.gif" width="6" height="1">
  69 <input type="text" name="time_frame_3" size="16" maxlength="15" value="<? echo stripslashes($obj{"time_frame_3"});?>"><br><br>
  70
  71 <b>Long Term Goals:</b><br>
  72 <textarea cols=85 rows=3 wrap=virtual name="long_term_goals" ><? echo stripslashes($obj{"long_term_goals"});?></textarea><br><br>
  73
  74 <b>Discharge Criteria:</b><br>
  75 <textarea cols=85 rows=2 wrap=virtual name="discharge_criteria" ><? echo stripslashes($obj{"discharge_criteria"});?></textarea><br><br>
  76
  77 <b>Recommendations:</b><br>
  78 <input type="checkbox" name="individual_family_therapy" <? if ($obj{"individual_family_therapy"} == "on") {echo "checked";};?>>&nbsp;<b>Individual and / or Family Therapy</b></input>
  79 <img src="../../../images/space.gif" width="6" height="1">
  80 <input type="checkbox" name="substance_abuse" <? if ($obj{"substance_abuse"} == "on") {echo "checked";};?>>&nbsp;<b>Substance Abuse</b></input><br>
  81
  82 <input type="checkbox" name="group_therapy" <? if ($obj{"group_therapy"} == "on") {echo "checked";};?>>&nbsp;<b>Group Therapy - psychoeducational group</b></input>
  83 <img src="../../../images/space.gif" width="6" height="1">
  84 <input type="checkbox" name="parenting" <? if ($obj{"parenting"} == "on") {echo "checked";};?>>&nbsp;<b>Parenting</b></input><br><br>
  85
  86 <b>Action Steps by supports - family:</b><br>
  87 <textarea cols=85 rows=3 wrap=virtual name="action_steps_by_supports" ><? echo stripslashes($obj{"action_steps_by_supports"});?></textarea><br><br>
  88
  89 <b>Other supports - agencies</b>
  90 <b>Name:</b>
  91 <img src="../../../images/space.gif" width="38" height="1">
  92 <b>Contact Information</b><br>
  93 <input type="text" name="other_supports_name_1" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_name_1"});?>">
  94 <img src="../../../images/space.gif" width="6" height="1">
  95 <input type="text" name="other_supports_contact_1" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_contact_1"});?>"><br>
  96
  97 <input type="text" name="other_supports_name_2" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_name_2"});?>">
  98 <img src="../../../images/space.gif" width="6" height="1">
  99 <input type="text" name="other_supports_contact_2" size="37" maxlength="35" value="<? echo stripslashes($obj{"other_supports_contact_2"});?>"><br><br>
 100
 101 <b>Medications</b>
 102 <img src="../../../images/space.gif" width="204" height="1">
 103 <b>Referrals</b><br>
 104
 105 <input type="text" name="medications_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"medications_1"});?>">
 106 <img src="../../../images/space.gif" width="6" height="1">
 107 <input type="text" name="referrals_1" size="42" maxlength="40" value="<? echo stripslashes($obj{"referrals_1"});?>"><br>
 108
 109 <input type="text" name="medications_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"medications_2"});?>">
 110 <img src="../../../images/space.gif" width="6" height="1">
 111 <input type="text" name="referrals_2" size="42" maxlength="40" value="<? echo stripslashes($obj{"referrals_2"});?>"><br><br>
 112
 113 <? /* From New */ ?>
 114 <br>
 115 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
 116 <br>
 117 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save Changes]</a>
 118 </form>
 119 <?php
 120 formFooter();
 121 ?>