contrib/forms/physical_examination/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17 <html>
  18
  19 <head>
  20 <?php html_header_show();?>
  21
  22 <title>Physical examination</title>
  23
  24 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  25
  26 <link rel="stylesheet" href="../../acog.css" type="text/css">
  27
  28 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  29
  30 <script language="JavaScript" type="text/JavaScript">
  31
  32 window.onload = initialize;
  33
  34 </script>
  35
  36 </head>
  37
  38
  39
  40 <body class="body_top">
  41
  42
  43
  44 <?php
  45
  46 $tip1 = <<<EOL
  47
  48 The <b>Physical Examination</b> section
  49
  50 should be completed by the physician each time a
  51
  52 physical examination is provided. The form offers prompts to
  53
  54 aid in documenting the services that are provided. This form
  55
  56 is based on the 1997 CMS (formerly, HCFA) guidelines for
  57
  58 the female genitourinary system examination and can be
  59
  60 used to document any level of examination.<br><br>
  61
  62
  63
  64 The female genitourinary examination template includes 9 organ systems/body areas with 3 shaded boxes and 6 unshaded boxes. The shading only becomes important when a comprehensive
  65
  66 examination is performed. For all other levels of examination, the total number of bulleted elements documented in the medical record will determine the level that can be
  67
  68 reported.<br><br>
  69
  70 <table border=1>
  71
  72 <tr><td>LEVEL OF EXAMINATION</td><td>PERFORM AND DOCUMENT</td></tr>
  73
  74 <tr><td>PROBLEM FOCUSED</td><td>15 ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  75
  76 <tr><td>EXPANDED PROBLEM FOCUSED</td><td>611 ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  77
  78 <tr><td>DETAILED</td><td>12 OR MORE ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  79
  80 <tr><td>COMPREHENSIVE</td><td>ALL ELEMENTS IDENTIFIED BY A BULLET IN CONSTITUTIONAL AND GASTROINTESTINAL,
  81
  82 ANY 7 BULLETS IN GYNECOLOGIC, AT LEAST 1 BULLET IN ALL OTHER SYSTEMS</td></tr>
  83
  84 </table>
  85
  86 EOL;
  87
  88 $tip1 = strtr($tip1, "\n\r", "  ");
  89
  90 ?>
  91
  92 <div class="srvChapter">Physical examination <a href="#" onMouseOver="toolTip('<?php echo $tip1; ?>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  93
  94 <?php
  95
  96    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  97
  98    if ($fres){
  99
 100      $patient = sqlFetchArray($fres);
 101
 102    }
 103
 104    $fres=sqlStatement("select * from form_physical_examination where id=$id");
 105
 106    if ($fres){
 107
 108      $fdata = sqlFetchArray($fres);
 109
 110    }
 111
 112 ?>
 113
 114 <form action="<?php echo $rootdir;?>/forms/physical_examination/save.php?mode=update&id=<?php echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
 115
 116 <?php include("../../acog_menu.inc"); ?>
 117
 118 <div style="border: solid 2px black; background-color: white;">
 119
 120 <table width="100%"  border="0" cellspacing="0" cellpadding="3">
 121
 122   <tr>
 123
 124     <td align="left" valign="top" style="border-bottom: 2px solid black;"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
 125
 126       <tr align="left" valign="bottom" class="fibody">
 127
 128         <td width="40%" class="bordR">Patient name <br>
 129
 130           <input name="pname" type="text" class="fullin" id="pname" value="<?php
 131
 132           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
 133
 134           ?>"></td>
 135
 136         <td width="20%" class="bordR">birth date
 137
 138           <br>
 139
 140           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
 141
 142           echo $patient{'DOB'};
 143
 144           ?>" size="12"> </td>
 145
 146         <td width="20%" class="bordR">ID No<br>
 147
 148           <input name="pe_id" type="text" class="fullin" id="pe_id" size="12" value="<?php
 149
 150           echo $patient{'id'};
 151
 152           ?>"></td>
 153
 154         <td width="20%">date<br>
 155
 156         <input name="pe_date" type="text" class="fullin" id="pe_date" value="<?php
 157
 158         echo date('Y-m-d');
 159
 160         ?>" size="12"></td>
 161
 162       </tr>
 163
 164     </table></td>
 165
 166   </tr>
 167
 168   <tr>
 169
 170     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Constitutional</h2>
 171
 172       <li>Vital signs (record <u><strong>&gt;</strong></u> 3 vital signs)</li>
 173
 174       <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 175
 176         <tr align="left" valign="top" class="fibody">
 177
 178           <td width="14%" nowrap>Height<br>
 179
 180             <input name="height" type="text" class="fullin"  value="<?php echo $fdata{'height'}; ?>"></td>
 181
 182           <td width="14%" nowrap>Weight<br>
 183
 184             <input name="weight" type="text" class="fullin"  value="<?php echo $fdata{'weight'}; ?>"></td>
 185
 186           <td width="14%" nowrap>BMI<br>
 187
 188             <input name="bmi" type="text" class="fullin"  value="<?php echo $fdata{'bmi'}; ?>"></td>
 189
 190           <td nowrap>Blood pressure (sitting) <br>
 191
 192             <input name="blood_pressure" type="text" class="fullin"  value="<?php echo $fdata{'blood_pressure'}; ?>"></td>
 193
 194           <td width="14%" nowrap>Temperature<br>
 195
 196             <input name="temperature" type="text" class="fullin"  value="<?php echo $fdata{'temperature'}; ?>"></td>
 197
 198           <td width="14%" nowrap>Pulse<br>
 199
 200             <input name="pulse" type="text" class="fullin"  value="<?php echo $fdata{'pulse'}; ?>"></td>
 201
 202           <td width="14%" nowrap>Respiration<br>
 203
 204             <input name="respiration" type="text" class="fullin"  value="<?php echo $fdata{'respiration'}; ?>"></td>
 205
 206         </tr>
 207
 208       </table>
 209
 210       <li>General appearance (Note all that apply):</li> <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 211
 212         <tr class="fibody">
 213
 214           <td width="150" nowrap><input name="general_well_developed" type="radio" value="0"  <?php echo (($fdata{'general_well_developed'} == '0')?' checked ':''); ?>>
 215
 216             Well-developed
 217
 218 </td>
 219
 220           <td width="90" nowrap><input name="general_well_developed" type="radio" value="1" <?php echo (($fdata{'general_well_developed'} == '1')?' checked ':''); ?>>
 221
 222             Other
 223
 224 </td>
 225
 226           <td width="100" nowrap>&nbsp;</td>
 227
 228           <td>&nbsp;</td>
 229
 230           <td width="120"><input name="general_no_deformities" type="radio" value="0"  <?php echo (($fdata{'general_no_deformities'} == '0')?' checked ':''); ?>>
 231
 232             No deformities
 233
 234 </td>
 235
 236           <td width="100"><input name="general_no_deformities" type="radio" value="1" <?php echo (($fdata{'general_no_deformities'} == '1')?' checked ':''); ?>>
 237
 238             Other
 239
 240 </td>
 241
 242           <td>&nbsp;</td>
 243
 244         </tr>
 245
 246         <tr class="fibody">
 247
 248           <td width="150" nowrap><input name="general_well_nourished" type="radio" value="0"  <?php echo (($fdata{'general_well_nourished'} == '0')?' checked ':''); ?>>
 249
 250             Well-nourished
 251
 252 </td>
 253
 254           <td width="90" nowrap><input name="general_well_nourished" type="radio" value="1" <?php echo (($fdata{'general_well_nourished'} == '1')?' checked ':''); ?>>
 255
 256             Other
 257
 258 </td>
 259
 260           <td width="100" nowrap>&nbsp;</td>
 261
 262           <td>&nbsp;</td>
 263
 264           <td width="120"><input name="general_well_groomed" type="radio" value="0"  <?php echo (($fdata{'general_well_groomed'} == '0')?' checked ':''); ?>>
 265
 266             Well-groomed
 267
 268 </td>
 269
 270           <td width="100"><input name="general_well_groomed" type="radio" value="1" <?php echo (($fdata{'general_well_groomed'} == '1')?' checked ':''); ?>>
 271
 272             Other
 273
 274 </td>
 275
 276           <td>&nbsp;</td>
 277
 278         </tr>
 279
 280         <tr class="fibody">
 281
 282           <td width="150" nowrap><input name="general_normal_habitus" type="radio" value="0"  <?php echo (($fdata{'general_normal_habitus'} == '0')?' checked ':''); ?>>
 283
 284             Normal habitus</td>
 285
 286           <td width="90" nowrap><input name="general_normal_habitus" type="radio" value="2" <?php echo (($fdata{'general_normal_habitus'} == '2')?' checked ':''); ?>>
 287
 288             Obese</td>
 289
 290           <td width="100" nowrap><input name="general_normal_habitus" type="radio" value="1" <?php echo (($fdata{'general_normal_habitus'} == '1')?' checked ':''); ?>>
 291
 292             Other</td>
 293
 294           <td>&nbsp;</td>
 295
 296           <td width="120">&nbsp;</td>
 297
 298           <td width="100">&nbsp;</td>
 299
 300           <td>&nbsp;</td>
 301
 302         </tr>
 303
 304       </table> </td>
 305
 306   </tr>
 307
 308   <tr>
 309
 310     <td align="left" valign="top"><h2>Neck</h2>
 311
 312       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 313
 314         <tr align="left" valign="bottom" class="fibody">
 315
 316           <td width="150" nowrap><li>Neck</li></td>
 317
 318           <td width="90" nowrap> <input name="neck_neck" type="radio" value="0"  <?php echo (($fdata{'neck_neck'} == '0')?' checked ':''); ?>>
 319
 320       Normal</td>
 321
 322           <td width="100" nowrap><input name="neck_neck" type="radio" value="1" <?php echo (($fdata{'neck_neck'} == '1')?' checked ':''); ?>>
 323
 324             ABNormal</td>
 325
 326           <td><input name="neck_neck_data" type="text" class="fullin"  value="<?php echo $fdata{'neck_neck_data'}; ?>"></td>
 327
 328           </tr>
 329
 330         <tr align="left" valign="bottom" class="fibody">
 331
 332           <td width="150" nowrap><li>Thyroid</li></td>
 333
 334           <td width="90" nowrap>
 335
 336             <input name="neck_thyroid" type="radio" value="0"  <?php echo (($fdata{'neck_thyroid'} == '0')?' checked ':''); ?>>
 337
 338   Normal</td>
 339
 340           <td width="100" nowrap><input name="neck_thyroid" type="radio" value="1" <?php echo (($fdata{'neck_thyroid'} == '1')?' checked ':''); ?>>
 341
 342 ABNormal</td>
 343
 344           <td><input name="neck_thyroid_data" type="text" class="fullin"  value="<?php echo $fdata{'neck_thyroid_data'}; ?>"></td>
 345
 346           </tr>
 347
 348       </table> </td>
 349
 350   </tr>
 351
 352   <tr>
 353
 354     <td align="left" valign="top"><h2>Respiratory</h2>
 355
 356       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 357
 358         <tr align="left" valign="bottom" class="fibody">
 359
 360           <td width="150" nowrap><li>Respiratory effort </li></td>
 361
 362           <td nowrap>
 363
 364             <input name="respiratory_effort" type="radio" value="0"  <?php echo (($fdata{'respiratory_effort'} == '0')?' checked ':''); ?>>
 365
 366   Normal</td>
 367
 368           <td nowrap><input name="respiratory_effort" type="radio" value="1" <?php echo (($fdata{'respiratory_effort'} == '1')?' checked ':''); ?>>
 369
 370   ABNormal</td>
 371
 372           <td><input name="respiratory_effort_data" type="text" class="fullin"  value="<?php echo $fdata{'respiratory_effort_data'}; ?>"></td>
 373
 374         </tr>
 375
 376         <tr align="left" valign="bottom" class="fibody">
 377
 378           <td width="150" nowrap><li>Auscultated lungs </li></td>
 379
 380           <td width="90" nowrap><input name="auscultated_lungs" type="radio" value="0"  <?php echo (($fdata{'auscultated_lungs'} == '0')?' checked ':''); ?>>
 381
 382 Normal</td>
 383
 384           <td width="100" nowrap><input name="auscultated_lungs" type="radio" value="1" <?php echo (($fdata{'auscultated_lungs'} == '1')?' checked ':''); ?>>
 385
 386 ABNormal</td>
 387
 388           <td><input name="auscultated_lungs_data" type="text" class="fullin"  value="<?php echo $fdata{'auscultated_lungs_data'}; ?>"></td>
 389
 390         </tr>
 391
 392       </table> </td>
 393
 394   </tr>
 395
 396   <tr>
 397
 398     <td align="left" valign="top"><h2>Cardiovascular</h2>
 399
 400       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 401
 402         <tr align="left" valign="bottom" class="fibody">
 403
 404           <td width="150" nowrap><li>Auscultated heart </li></td>
 405
 406           <td width="90" nowrap>&nbsp;</td>
 407
 408           <td width="100" nowrap>&nbsp;</td>
 409
 410           <td>&nbsp;</td>
 411
 412         </tr>
 413
 414         <tr align="left" valign="bottom" class="fibody">
 415
 416           <td width="150" nowrap><blockquote> Sounds</blockquote></td>
 417
 418           <td width="90" nowrap><input name="auscultated_heart_sounds" type="radio" value="0"  <?php echo (($fdata{'auscultated_heart_sounds'} == '0')?' checked ':''); ?>>
 419
 420 Normal</td>
 421
 422           <td width="100" nowrap><input name="auscultated_heart_sounds" type="radio" value="1" <?php echo (($fdata{'auscultated_heart_sounds'} == '1')?' checked ':''); ?>>
 423
 424 ABNormal</td>
 425
 426           <td><input name="auscultated_heart_sounds_data" type="text" class="fullin"  value="<?php echo $fdata{'auscultated_heart_sounds_data'}; ?>"></td>
 427
 428         </tr>
 429
 430         <tr align="left" valign="bottom" class="fibody">
 431
 432           <td nowrap><blockquote> Murmurs</blockquote></td>
 433
 434           <td nowrap><input name="auscultated_heart_murmurs" type="radio" value="0"  <?php echo (($fdata{'auscultated_heart_murmurs'} == '0')?' checked ':''); ?>>
 435
 436 Normal</td>
 437
 438           <td nowrap><input name="auscultated_heart_murmurs" type="radio" value="1" <?php echo (($fdata{'auscultated_heart_murmurs'} == '1')?' checked ':''); ?>>
 439
 440 ABNormal</td>
 441
 442           <td><input name="auscultated_heart_murmurs_data" type="text" class="fullin"  value="<?php echo $fdata{'auscultated_heart_murmurs_data'}; ?>"></td>
 443
 444         </tr>
 445
 446         <tr align="left" valign="bottom" class="fibody">
 447
 448           <td nowrap><li>Perirheral vascular </li></td>
 449
 450           <td nowrap><input name="peripheral_vascular" type="radio" value="0"  <?php echo (($fdata{'peripheral_vascular'} == '0')?' checked ':''); ?>>
 451
 452 Normal</td>
 453
 454           <td nowrap><input name="peripheral_vascular" type="radio" value="1" <?php echo (($fdata{'peripheral_vascular'} == '1')?' checked ':''); ?>>
 455
 456 ABNormal</td>
 457
 458           <td><input name="peripheral_vascular_data" type="text" class="fullin"  value="<?php echo $fdata{'peripheral_vascular_data'}; ?>"></td>
 459
 460         </tr>
 461
 462       </table> </td>
 463
 464   </tr>
 465
 466   <tr>
 467
 468     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Gastrointestinal</h2>
 469
 470       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 471
 472         <tr align="left" valign="bottom" class="fibody">
 473
 474           <td width="150" nowrap><li>Abdomen</li></td>
 475
 476           <td width="90" nowrap><input name="gastr_abdomen" type="radio" value="0"  <?php echo (($fdata{'gastr_abdomen'} == '0')?' checked ':''); ?>>
 477
 478 Normal</td>
 479
 480           <td width="100" nowrap><input name="gastr_abdomen" type="radio" value="1" <?php echo (($fdata{'gastr_abdomen'} == '1')?' checked ':''); ?>>
 481
 482 ABNormal</td>
 483
 484           <td><input name="gastr_abdomen_data" type="text" class="fullin"  value="<?php echo $fdata{'gastr_abdomen_data'}; ?>"></td>
 485
 486         </tr>
 487
 488         <tr align="left" valign="bottom" class="fibody">
 489
 490           <td width="150" nowrap><li>Hernia</li></td>
 491
 492           <td width="90" nowrap><input name="gastr_hernia" type="radio" value="0"  <?php echo (($fdata{'gastr_hernia'} == '0')?' checked ':''); ?>>
 493
 494       none</td>
 495
 496           <td width="100" nowrap><input name="gastr_hernia" type="radio" value="1" <?php echo (($fdata{'gastr_hernia'} == '1')?' checked ':''); ?>>
 497
 498       present</td>
 499
 500           <td><input name="gastr_hernia_data" type="text" class="fullin"  value="<?php echo $fdata{'gastr_hernia_data'}; ?>"></td>
 501
 502         </tr>
 503
 504         <tr align="left" valign="bottom" class="fibody">
 505
 506           <td nowrap><li>Liver/Spleen</li></td>
 507
 508           <td nowrap>&nbsp;</td>
 509
 510           <td nowrap>&nbsp;</td>
 511
 512           <td>&nbsp;</td>
 513
 514         </tr>
 515
 516         <tr align="left" valign="bottom" class="fibody">
 517
 518           <td nowrap><blockquote> Liver </blockquote></td>
 519
 520           <td nowrap><input name="gastr_liver" type="radio" value="0"  <?php echo (($fdata{'gastr_liver'} == '0')?' checked ':''); ?>>
 521
 522     Normal</td>
 523
 524           <td nowrap><input name="gastr_liver" type="radio" value="1" <?php echo (($fdata{'gastr_liver'} == '1')?' checked ':''); ?>>
 525
 526     ABNormal</td>
 527
 528           <td><input name="gastr_liver_data" type="text" class="fullin"  value="<?php echo $fdata{'gastr_liver_data'}; ?>"></td>
 529
 530         </tr>
 531
 532         <tr align="left" valign="bottom" class="fibody">
 533
 534           <td nowrap><blockquote> Spleen </blockquote></td>
 535
 536           <td nowrap><input name="gastr_spleen" type="radio" value="0"  <?php echo (($fdata{'gastr_spleen'} == '0')?' checked ':''); ?>>
 537
 538     Normal</td>
 539
 540           <td nowrap><input name="gastr_spleen" type="radio" value="1" <?php echo (($fdata{'gastr_spleen'} == '1')?' checked ':''); ?>>
 541
 542     ABNormal</td>
 543
 544           <td><input name="gastr_spleen_data" type="text" class="fullin"  value="<?php echo $fdata{'gastr_spleen_data'}; ?>"></td>
 545
 546         </tr>
 547
 548         <tr align="left" valign="bottom" class="fibody">
 549
 550           <td nowrap><li><a name="sg"></a>Stool guaIac, if indic.</li></td>
 551
 552           <td nowrap><input name="gastr_stool_guaiac" type="radio" value="0"  <?php echo (($fdata{'gastr_stool_guaiac'} == '0')?' checked ':''); ?>>
 553
 554     positive</td>
 555
 556           <td nowrap><input name="gastr_stool_guaiac" type="radio" value="1" <?php echo (($fdata{'gastr_stool_guaiac'} == '1')?' checked ':''); ?>>
 557
 558     negative</td>
 559
 560           <td><input name="gastr_stool_guaiac_data" type="text" class="fullin"  value="<?php echo $fdata{'gastr_stool_guaiac_data'}; ?>"></td>
 561
 562         </tr>
 563
 564       </table> </td>
 565
 566   </tr>
 567
 568   <tr>
 569
 570     <td align="left" valign="top"><h2>Lymphatic</h2>
 571
 572       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 573
 574         <tr align="left" valign="bottom" class="fibody">
 575
 576           <td colspan="4" nowrap><li>Palpation of nodes (Choose all, that are applicable) </li></td>
 577
 578           </tr>
 579
 580         <tr align="left" valign="bottom" class="fibody">
 581
 582           <td width="150" nowrap><blockquote> Neck </blockquote></td>
 583
 584           <td width="90" nowrap><input name="lymph_neck" type="radio" value="0"  <?php echo (($fdata{'lymph_neck'} == '0')?' checked ':''); ?>>
 585
 586       Normal</td>
 587
 588           <td width="100" nowrap><input name="lymph_neck" type="radio" value="1" <?php echo (($fdata{'lymph_neck'} == '1')?' checked ':''); ?>>
 589
 590       ABNormal</td>
 591
 592           <td><input name="lymph_neck_data" type="text" class="fullin"  value="<?php echo $fdata{'lymph_neck_data'}; ?>"></td>
 593
 594         </tr>
 595
 596         <tr align="left" valign="bottom" class="fibody">
 597
 598           <td nowrap><blockquote> Axilla </blockquote></td>
 599
 600           <td nowrap><input name="lymph_axilla" type="radio" value="0"  <?php echo (($fdata{'lymph_axilla'} == '0')?' checked ':''); ?>>
 601
 602       Normal</td>
 603
 604           <td nowrap><input name="lymph_axilla" type="radio" value="1" <?php echo (($fdata{'lymph_axilla'} == '1')?' checked ':''); ?>>
 605
 606       ABNormal</td>
 607
 608           <td><input name="lymph_axilla_data" type="text" class="fullin"  value="<?php echo $fdata{'lymph_axilla_data'}; ?>"></td>
 609
 610         </tr>
 611
 612         <tr align="left" valign="bottom" class="fibody">
 613
 614           <td nowrap><blockquote> Groin </blockquote></td>
 615
 616           <td nowrap><input name="lymph_groin" type="radio" value="0"  <?php echo (($fdata{'lymph_groin'} == '0')?' checked ':''); ?>>
 617
 618     Normal</td>
 619
 620           <td nowrap><input name="lymph_groin" type="radio" value="1" <?php echo (($fdata{'lymph_groin'} == '1')?' checked ':''); ?>>
 621
 622     ABNormal</td>
 623
 624           <td><input name="lymph_groin_data" type="text" class="fullin"  value="<?php echo $fdata{'lymph_groin_data'}; ?>"></td>
 625
 626         </tr>
 627
 628         <tr align="left" valign="bottom" class="fibody">
 629
 630           <td nowrap><blockquote> Other site </blockquote></td>
 631
 632           <td nowrap><input name="lymph_other" type="radio" value="0"  <?php echo (($fdata{'lymph_other'} == '0')?' checked ':''); ?>>
 633
 634     Normal</td>
 635
 636           <td nowrap><input name="lymph_other" type="radio" value="1" <?php echo (($fdata{'lymph_other'} == '1')?' checked ':''); ?>>
 637
 638     ABNormal</td>
 639
 640           <td><input name="lymph_other_data" type="text" class="fullin"  value="<?php echo $fdata{'lymph_other_data'}; ?>"></td>
 641
 642         </tr>
 643
 644       </table> </td>
 645
 646   </tr>
 647
 648   <tr>
 649
 650     <td align="left" valign="top"><h2>Skin</h2>
 651
 652       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 653
 654         <tr align="left" valign="bottom" class="fibody">
 655
 656           <td width="150" nowrap><li>inspected/palpated</li></td>
 657
 658           <td width="90" nowrap><input name="skin_inspected" type="radio" value="0"  <?php echo (($fdata{'skin_inspected'} == '0')?' checked ':''); ?>>
 659
 660       Normal</td>
 661
 662           <td width="100" nowrap><input name="skin_inspected" type="radio" value="1" <?php echo (($fdata{'skin_inspected'} == '1')?' checked ':''); ?>>
 663
 664       ABNormal</td>
 665
 666           <td><input name="skin_inspected_data" type="text" class="fullin"  value="<?php echo $fdata{'skin_inspected_data'}; ?>"></td>
 667
 668         </tr>
 669
 670       </table> </td>
 671
 672   </tr>
 673
 674   <tr>
 675
 676     <td align="left" valign="top"><h2>Neurologic/psychiatric</h2>
 677
 678       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 679
 680         <tr align="left" valign="bottom" class="fibody">
 681
 682           <td width="150" nowrap><li>Orientation</li></td>
 683
 684           <td width="90" nowrap><input name="neur_orient_time" type="checkbox"  value="1" <?php echo (($fdata{'neur_orient_time'} == '1')?' checked ':''); ?>>
 685
 686       Time</td>
 687
 688           <td width="100" nowrap><input name="neur_orient_place" type="checkbox"  value="1" <?php echo (($fdata{'neur_orient_place'} == '1')?' checked ':''); ?>>
 689
 690       Place</td>
 691
 692           <td width="100"><input name="neur_orient_person" type="checkbox"  value="1" <?php echo (($fdata{'neur_orient_person'} == '1')?' checked ':''); ?>>
 693
 694             Person
 695
 696 </td>
 697
 698           <td width="100"><input name="neur_orient_comments" type="checkbox"  value="1" <?php echo (($fdata{'neur_orient_comments'} == '1')?' checked ':''); ?>>
 699
 700             Comments
 701
 702 </td>
 703
 704           <td>&nbsp;</td>
 705
 706           </tr>
 707
 708         <tr align="left" valign="bottom" class="fibody">
 709
 710           <td width="150" nowrap><li>Mood and affect </li></td>
 711
 712           <td width="90" nowrap><input name="neur_mood_normal" type="checkbox"  value="1" <?php echo (($fdata{'neur_mood_normal'} == '1')?' checked ':''); ?>>
 713
 714       Normal</td>
 715
 716           <td width="100" nowrap><input name="neur_mood_depressed" type="checkbox"  value="1" <?php echo (($fdata{'neur_mood_depressed'} == '1')?' checked ':''); ?>>
 717
 718       Depressed</td>
 719
 720           <td width="100"><input name="neur_mood_anxious" type="checkbox"  value="1" <?php echo (($fdata{'neur_mood_anxious'} == '1')?' checked ':''); ?>>
 721
 722             Anxious
 723
 724 </td>
 725
 726           <td width="100"><input name="neur_mood_agitated" type="checkbox"  value="1" <?php echo (($fdata{'neur_mood_agitated'} == '1')?' checked ':''); ?>>
 727
 728             Agitated
 729
 730 </td>
 731
 732           <td><input name="neur_mood_other" type="checkbox"  value="1" <?php echo (($fdata{'neur_mood_other'} == '1')?' checked ':''); ?>>
 733
 734             Other
 735
 736 </td>
 737
 738           </tr>
 739
 740       </table> </td>
 741
 742   </tr>
 743
 744   <tr>
 745
 746     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Gynecologic (at least 7) </h2>
 747
 748       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 749
 750         <tr align="left" valign="bottom" class="fibody">
 751
 752           <td width="150" nowrap><li>Breasts</li></td>
 753
 754           <td width="90" nowrap><input name="gynec_breasts" type="radio" value="0"  <?php echo (($fdata{'gynec_breasts'} == '0')?' checked ':''); ?>>
 755
 756       Normal</td>
 757
 758           <td width="100" nowrap><input name="gynec_breasts" type="radio" value="1" <?php echo (($fdata{'gynec_breasts'} == '1')?' checked ':''); ?>>
 759
 760       ABNormal</td>
 761
 762           <td><input name="gynec_breasts_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_breasts_data'}; ?>"></td>
 763
 764           <td width="231" rowspan="12" align="center" valign="middle">
 765
 766           <img src="<?php
 767
 768           echo "$rootdir/forms/$formname/";
 769
 770           ?>genit01.gif" width="231" height="222"></td>
 771
 772         </tr>
 773
 774         <tr align="left" valign="bottom" class="fibody">
 775
 776           <td nowrap><li>External genitalia </li></td>
 777
 778           <td nowrap><input name="gynec_ext_genitalia" type="radio" value="0"  <?php echo (($fdata{'gynec_ext_genitalia'} == '0')?' checked ':''); ?>>
 779
 780   Normal</td>
 781
 782           <td nowrap><input name="gynec_ext_genitalia" type="radio" value="1" <?php echo (($fdata{'gynec_ext_genitalia'} == '1')?' checked ':''); ?>>
 783
 784   ABNormal</td>
 785
 786           <td><input name="gynec_ext_genitalia_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_ext_genitalia_data'}; ?>"></td>
 787
 788           </tr>
 789
 790         <tr align="left" valign="bottom" class="fibody">
 791
 792           <td nowrap><li>Urethral meatus </li></td>
 793
 794           <td nowrap><input name="gynec_urethral_meatus" type="radio" value="0"  <?php echo (($fdata{'gynec_urethral_meatus'} == '0')?' checked ':''); ?>>
 795
 796   Normal</td>
 797
 798           <td nowrap><input name="gynec_urethral_meatus" type="radio" value="1" <?php echo (($fdata{'gynec_urethral_meatus'} == '1')?' checked ':''); ?>>
 799
 800   ABNormal</td>
 801
 802           <td><input name="gynec_urethral_meatus_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_urethral_meatus_data'}; ?>"></td>
 803
 804           </tr>
 805
 806         <tr align="left" valign="bottom" class="fibody">
 807
 808           <td width="150" nowrap><li>Urethra</li></td>
 809
 810           <td width="90" nowrap><input name="gynec_urethra" type="radio" value="0"  <?php echo (($fdata{'gynec_urethra'} == '0')?' checked ':''); ?>>
 811
 812   Normal</td>
 813
 814           <td width="100" nowrap><input name="gynec_urethra" type="radio" value="1" <?php echo (($fdata{'gynec_urethra'} == '1')?' checked ':''); ?>>
 815
 816   ABNormal</td>
 817
 818           <td><input name="gynec_urethra_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_urethra_data'}; ?>"></td>
 819
 820           </tr>
 821
 822         <tr align="left" valign="bottom" class="fibody">
 823
 824           <td nowrap><li>Bladder</li></td>
 825
 826           <td nowrap><input name="gynec_bladder" type="radio" value="0"  <?php echo (($fdata{'gynec_bladder'} == '0')?' checked ':''); ?>>
 827
 828   Normal</td>
 829
 830           <td nowrap><input name="gynec_bladder" type="radio" value="1" <?php echo (($fdata{'gynec_bladder'} == '1')?' checked ':''); ?>>
 831
 832   ABNormal</td>
 833
 834           <td><input name="gynec_bladder_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_bladder_data'}; ?>"></td>
 835
 836           </tr>
 837
 838         <tr align="left" valign="bottom" class="fibody">
 839
 840           <td nowrap><li>Vagina/Pelvic support</li></td>
 841
 842           <td nowrap><input name="gynec_vagina_support" type="radio" value="0"  <?php echo (($fdata{'gynec_vagina_support'} == '0')?' checked ':''); ?>>
 843
 844   Normal</td>
 845
 846           <td nowrap><input name="gynec_vagina_support" type="radio" value="1" <?php echo (($fdata{'gynec_vagina_support'} == '1')?' checked ':''); ?>>
 847
 848   ABNormal</td>
 849
 850           <td><input name="gynec_vagina_support_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_vagina_support_data'}; ?>"></td>
 851
 852           </tr>
 853
 854         <tr align="left" valign="bottom" class="fibody">
 855
 856           <td width="150" nowrap><li>Cervix</li></td>
 857
 858           <td width="90" nowrap><input name="gynec_cervix" type="radio" value="0"  <?php echo (($fdata{'gynec_cervix'} == '0')?' checked ':''); ?>>
 859
 860   Normal</td>
 861
 862           <td width="100" nowrap><input name="gynec_cervix" type="radio" value="1" <?php echo (($fdata{'gynec_cervix'} == '1')?' checked ':''); ?>>
 863
 864   ABNormal</td>
 865
 866           <td><input name="gynec_cervix_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_cervix_data'}; ?>"></td>
 867
 868           </tr>
 869
 870         <tr align="left" valign="bottom" class="fibody">
 871
 872           <td nowrap><li>Uterus</li></td>
 873
 874           <td nowrap><input name="gynec_uterus" type="radio" value="0"  <?php echo (($fdata{'gynec_uterus'} == '0')?' checked ':''); ?>>
 875
 876   Normal</td>
 877
 878           <td nowrap><input name="gynec_uterus" type="radio" value="1" <?php echo (($fdata{'gynec_uterus'} == '1')?' checked ':''); ?>>
 879
 880   ABNormal</td>
 881
 882           <td><input name="gynec_uterus_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_uterus_data'}; ?>"></td>
 883
 884           </tr>
 885
 886         <tr align="left" valign="bottom" class="fibody">
 887
 888           <td nowrap><li>Adnexa/Parametria</li></td>
 889
 890           <td nowrap><input name="gynec_adnexa" type="radio" value="0"  <?php echo (($fdata{'gynec_adnexa'} == '0')?' checked ':''); ?>>
 891
 892   Normal</td>
 893
 894           <td nowrap><input name="gynec_adnexa" type="radio" value="1" <?php echo (($fdata{'gynec_adnexa'} == '1')?' checked ':''); ?>>
 895
 896   ABNormal</td>
 897
 898           <td><input name="gynec_adnexa_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_adnexa_data'}; ?>"></td>
 899
 900           </tr>
 901
 902         <tr align="left" valign="bottom" class="fibody">
 903
 904           <td width="150" nowrap><li>Anus/Perineum</li></td>
 905
 906           <td width="90" nowrap><input name="gynec_anus" type="radio" value="0"  <?php echo (($fdata{'gynec_anus'} == '0')?' checked ':''); ?>>
 907
 908   Normal</td>
 909
 910           <td width="100" nowrap><input name="gynec_anus" type="radio" value="1" <?php echo (($fdata{'gynec_anus'} == '1')?' checked ':''); ?>>
 911
 912   ABNormal</td>
 913
 914           <td><input name="gynec_anus_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_anus_data'}; ?>"></td>
 915
 916           </tr>
 917
 918         <tr align="left" valign="bottom" class="fibody">
 919
 920           <td nowrap><li>Rectal</li></td>
 921
 922           <td nowrap><input name="gynec_rectal" type="radio" value="0"  <?php echo (($fdata{'gynec_rectal'} == '0')?' checked ':''); ?>>
 923
 924   Normal</td>
 925
 926           <td nowrap><input name="gynec_rectal" type="radio" value="1" <?php echo (($fdata{'gynec_rectal'} == '1')?' checked ':''); ?>>
 927
 928   ABNormal</td>
 929
 930           <td><input name="gynec_rectal_data" type="text" class="fullin"  value="<?php echo $fdata{'gynec_rectal_data'}; ?>"></td>
 931
 932           </tr>
 933
 934         <tr align="left" valign="bottom" class="fibody">
 935
 936           <td colspan="4" nowrap><br>
 937
 938             (See also &quot;<a href="#sg">Stool guaiac</a>&quot; above ) </td>
 939
 940           </tr>
 941
 942       </table> </td>
 943
 944   </tr>
 945
 946   <tr class="fibody">
 947
 948     <td align="left" valign="top" style="border-bottom:2px solid black;border-top:2px solid black;">Total number of bulleted elements examined
 949
 950       <input name="tot_num_examined" type="text"  value="<?php echo $fdata{'tot_num_examined'}; ?>"></td>
 951
 952   </tr>
 953
 954 </table>
 955
 956 <br>
 957
 958 </div>
 959
 960 <table width="100%" border="0">
 961
 962   <tr><td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 963
 964   <td align="left" nowrap> <a href="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>"
 965
 966    target="_blank" class="link_submit" onclick="top.restoreSession()">[Printable form]</a> </td>
 967
 968   <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 969
 970    onclick="top.restoreSession()">[Don't Save]</a> </td></tr>
 971
 972 </table>
 973
 974 </form>
 975
 976 <?php
 977
 978 formFooter();
 979
 980 ?>
 981
 982 </body>
 983
 984 </html>
 985