contrib/forms/routine_screening_record/printable.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");formHeader("Form: Routine screening record");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <?php html_header_show();?>
  23
  24 <title>Form: Routine screening record</title>
  25
  26 <?php include("../../acog_printable_h.css"); ?>
  27 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  28
  29 </head>
  30
  31
  32
  33 <?php
  34
  35    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  36
  37    if ($fres){
  38
  39      $patient = sqlFetchArray($fres);
  40
  41    }
  42
  43    $fres=sqlStatement("select * from form_routine_screening_record where id=$id");
  44
  45    if ($fres){
  46
  47      $fdata = sqlFetchArray($fres);
  48
  49    }
  50
  51 ?>
  52
  53 <body class="body_top">
  54
  55 <div class="srvChapter">Routine screening record </div>
  56
  57 <div style="border: solid 2px black; background-color:#FFFFFF;">
  58
  59   <table  border="0" cellpadding="2" cellspacing="0">
  60
  61     <tr align="left" valign="bottom">
  62
  63       <td colspan="4" class="fibody2" id="bordR">Patient name: <?php  echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'}; ?></td>
  64
  65       <td colspan="4" class="fibody2" id="bordR">Birth date: <?php   echo $patient{'DOB'};  ?></td>
  66
  67       <td colspan="3" class="fibody2">ID No: <?php    echo $patient{'id'};   ?></td>
  68
  69     </tr>
  70
  71     <tr align="center" valign="middle">
  72
  73       <td class="ficaption2" id="bordR">age</td>
  74
  75       <td width="9%" class="ficaption2" id="bordR">Cervical cytology </td>
  76
  77       <td width="9%" class="ficaption2" id="bordR">Lipid profile assessment<sup>*</sup></td>
  78
  79       <td width="9%" class="ficaption2" id="bordR">Mammo-<br>
  80
  81         graphy<sup>*</sup></td>
  82
  83       <td width="9%" class="ficaption2" id="bordR">Colorectal cancer screening <sup>*</sup></td>
  84
  85       <td width="9%" class="ficaption2" id="bordR">Bone density screening<sup>*</sup> </td>
  86
  87       <td width="9%" class="ficaption2" id="bordR">Chlamydia screening<sup>*</sup> </td>
  88
  89       <td width="9%" class="ficaption2" id="bordR">Gonor-<br>
  90
  91         rhea screening <sup>*</sup> </td>
  92
  93       <td width="9%" class="ficaption2" id="bordR">Urinalysis</td>
  94
  95       <td width="9%" class="ficaption2" id="bordR">Fasting glucose test<sup>*</sup> </td>
  96
  97       <td width="9%" class="ficaption2">Thyroid stimulating hormone screening </td>
  98
  99     </tr>
 100
 101     <tr align="center" valign="middle">
 102
 103       <td class="fibody2" id="bordR">13-18</td>
 104
 105       <td class="fibody2" id="bordR">ANNUALLY BEGINNING
 106
 107         APPROXIMATELY 3 YEARS
 108
 109         AFTER INITIATION OF
 110
 111         SEXUAL INTERCOURSE</td>
 112
 113       <td class="fibody2" id="bordR">&nbsp; </td>
 114
 115       <td class="fibody2" id="bordR">&nbsp; </td>
 116
 117       <td class="fibody2" id="bordR">&nbsp; </td>
 118
 119       <td class="fibody2" id="bordR">&nbsp; </td>
 120
 121       <td class="fibody2" id="bordR">        SEXUALLY ACTIVE WOMEN
 122
 123         UNDER AGE 25</td>
 124
 125       <td class="fibody2" id="bordR">SEXUALLY ACTIVE
 126
 127         ADOLES-<br>
 128
 129         CENTS</td>
 130
 131       <td class="fibody2" id="bordR">&nbsp;</td>
 132
 133       <td class="fibody2" id="bordR">&nbsp;</td>
 134
 135       <td class="fibody2">&nbsp;</td>
 136
 137     </tr>
 138
 139     <tr align="center" valign="middle">
 140
 141       <td class="fibody2" id="bordR">19-39</td>
 142
 143       <td class="fibody2" id="bordR">ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS</td>
 144
 145       <td class="fibody2" id="bordR">&nbsp; </td>
 146
 147       <td class="fibody2" id="bordR">&nbsp; </td>
 148
 149       <td class="fibody2" id="bordR">&nbsp; </td>
 150
 151       <td class="fibody2" id="bordR">&nbsp; </td>
 152
 153       <td class="fibody2" id="bordR"> SEXUALLY ACTIVE WOMEN<br>
 154
 155 UNDER AGE 25</td>
 156
 157       <td class="fibody2" id="bordR">&nbsp; </td>
 158
 159       <td class="fibody2" id="bordR">&nbsp;</td>
 160
 161       <td class="fibody2" id="bordR">&nbsp;</td>
 162
 163       <td class="fibody2">&nbsp;</td>
 164
 165     </tr>
 166
 167     <tr align="center" valign="middle">
 168
 169       <td class="fibody2" id="bordR">40-64</td>
 170
 171       <td class="fibody2" id="bordR">EVERY 2�3 YEARS AFTER 3
 172
 173         CONSECuTIVE NEGATIVE TEST
 174
 175         RESULTS IF NO HISTORY OF
 176
 177         CIN 2 OR 3,
 178
 179         IMMUNOSUP-<br>
 180
 181         PRESSION,
 182
 183         HIV INFECTION, OR DES
 184
 185         EXPOSURE IN UTERO</td>
 186
 187       <td class="fibody2" id="bordR">EVERY 5 YEARS
 188
 189         BEGINNING
 190
 191         AT AGE 45</td>
 192
 193       <td class="fibody2" id="bordR">EVERY 1�2 YEARS UNTIL
 194
 195         AGE 50; YEARLY
 196
 197         BEGINNING AT AGE 50</td>
 198
 199       <td class="fibody2" id="bordR">        BEGINNING AT AGE 50
 200
 201         YEARLY FOBT OR FLEXIBLE
 202
 203         SIGMOIDOSCOPY EVERY
 204
 205         5 YEARS OR YEARLY FOBT
 206
 207         PLUS FLEXIBLE
 208
 209         SIGMOIDOSCOPY EVERY 5
 210
 211         YEARS OR DCBE EVERY 5
 212
 213         YEARS OR COLONOSCOPY
 214
 215         EVERY 10 YEARS</td>
 216
 217       <td class="fibody2" id="bordR">&nbsp; </td>
 218
 219       <td class="fibody2" id="bordR">&nbsp; </td>
 220
 221       <td class="fibody2" id="bordR">&nbsp; </td>
 222
 223       <td class="fibody2" id="bordR">&nbsp;</td>
 224
 225       <td class="fibody2" id="bordR">EVERY 3 YEARS
 226
 227         AFTER AGE 45</td>
 228
 229       <td class="fibody2">EVERY 5 YEARS
 230
 231         BEGINNING AT AGE 50</td>
 232
 233     </tr>
 234
 235     <tr align="center" valign="middle">
 236
 237       <td class="fibody2" id="bordR">65 and older </td>
 238
 239       <td class="fibody2" id="bordR">EVERY 2�3 YEARS AFTER 3<br>
 240
 241         CONSECUTIVE NEGATIVE TEST
 242
 243         RESULTS IF NO HISTORY OF
 244
 245         CIN 2 OR 3,
 246
 247         IMMUNOSUP-<br>
 248
 249         PRESSION,
 250
 251         HIV INFECTION, OR DES
 252
 253         EXPOSURE IN UTERO</td>
 254
 255       <td class="fibody2" id="bordR">EVERY 5 YEARS</td>
 256
 257       <td class="fibody2" id="bordR">YEARLY OR AS
 258
 259         APPROPRIATE</td>
 260
 261       <td class="fibody2" id="bordR">        YEARLY FOBT OR FLEXIBLE
 262
 263         SIGMOIDOSCOPY EVERY
 264
 265         5 YEARS OR YEARLY FOBT
 266
 267         PLUS FLEXIBLE
 268
 269         SIGMOIDOSCOPY EVERY
 270
 271         YEARS OR DCBE EVERY
 272
 273         YEARS OR COLONOSCOPY
 274
 275         EVERY 10 YEARS</td>
 276
 277       <td class="fibody2" id="bordR">        IN THE ABSENCE OF
 278
 279         NEW RISK FACTORS,
 280
 281         SUBSEQUENT SCREENING
 282
 283         NOT MORE FREQUENTLY
 284
 285         THAN EVERY 2 YEARS</td>
 286
 287       <td class="fibody2" id="bordR">&nbsp; </td>
 288
 289       <td class="fibody2" id="bordR">&nbsp; </td>
 290
 291       <td class="fibody2" id="bordR">YEARLY OR AS
 292
 293         APPROPRIATE</td>
 294
 295       <td class="fibody2" id="bordR">EVERY 3 YEARS</td>
 296
 297       <td class="fibody2">EVERY 5 YEARS</td>
 298
 299     </tr>
 300
 301     <tr align="left" valign="bottom">
 302
 303       <td colspan="11" class="fibody2" style="border-bottom: 2px solid black;">&nbsp;</td>
 304
 305     </tr>
 306
 307 <?php
 308
 309 $factors = array("cervical", "lipid", "mammo", "colorectal",
 310
 311 "bone", "chlamyd", "gonor", "urinal", "glucose", "thyroid");
 312
 313 $rsi = 1;
 314
 315 while ($rsi < 9){
 316
 317 $chunks = explode("|~", $fdata["record_$rsi"]);
 318
 319 list($cervical_date, $cervical_res) = explode('|', $chunks[0]);
 320
 321 list($lipid_date, $lipid_res) = explode('|', $chunks[1]);
 322
 323 list($mammo_date,$mammo_res) = explode('|', $chunks[2]);
 324
 325 list($colorectal_date,$colorectal_res) = explode('|', $chunks[3]);
 326
 327 list($bone_date,$bone_res) = explode('|', $chunks[4]);
 328
 329 list($chlamyd_date,$chlamyd_res) = explode('|', $chunks[5]);
 330
 331 list($gonor_date,$gonor_res) = explode('|', $chunks[6]);
 332
 333 list($urinal_date,$urinal_res) = explode('|', $chunks[7]);
 334
 335 list($glucose_date,$glucose_res) = explode('|', $chunks[8]);
 336
 337 list($thyroid_date,$thyroid_res) = explode('|', $chunks[9]);
 338
 339
 340
 341
 342
 343 print <<<EOL
 344
 345     <tr align="left" valign="bottom">
 346
 347       <td class="fibody2" id="bordR">Date</td>
 348
 349       <td class="fibody3" id="bordR">${cervical_date} &nbsp;</td>
 350
 351       <td class="fibody3" id="bordR">${lipid_date} &nbsp;</td>
 352
 353       <td class="fibody3" id="bordR">${mammo_date} &nbsp;</td>
 354
 355       <td class="fibody3" id="bordR">${colorectal_date} &nbsp;</td>
 356
 357       <td class="fibody3" id="bordR">${bone_date} &nbsp;</td>
 358
 359       <td class="fibody3" id="bordR">${chlamyd_date} &nbsp;</td>
 360
 361       <td class="fibody3" id="bordR">${gonor_date} &nbsp;</td>
 362
 363       <td class="fibody3" id="bordR">${urinal_date} &nbsp;</td>
 364
 365       <td class="fibody3" id="bordR">${glucose_date} &nbsp;</td>
 366
 367       <td class="fibody3">${thyroid_date} &nbsp;</td>
 368
 369     </tr>
 370
 371     <tr align="left" valign="bottom">
 372
 373       <td class="fibody2" id="bordR">result</td>
 374
 375       <td class="fibody5" id="bordR">${cervical_res} &nbsp;</td>
 376
 377       <td class="fibody5" id="bordR">${lipid_res} &nbsp;</td>
 378
 379       <td class="fibody5" id="bordR">${mammo_res} &nbsp;</td>
 380
 381       <td class="fibody5" id="bordR">${colorectal_res} &nbsp;</td>
 382
 383       <td class="fibody5" id="bordR">${bone_res} &nbsp;</td>
 384
 385       <td class="fibody5" id="bordR">${chlamyd_res} &nbsp;</td>
 386
 387       <td class="fibody5" id="bordR">${gonor_res} &nbsp;</td>
 388
 389       <td class="fibody5" id="bordR">${urinal_res} &nbsp;</td>
 390
 391       <td class="fibody5" id="bordR">${glucose_res} &nbsp;</td>
 392
 393       <td class="fibody5">${thyroid_res} &nbsp;</td>
 394
 395     </tr>
 396
 397 EOL;
 398
 399 $rsi++;
 400
 401 }
 402
 403 ?>
 404
 405   </table>
 406
 407 </div>
 408
 409 <p><sup>*</sup>This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)</p>
 410
 411 </body>
 412
 413 </html>