2 include_once("../../globals.php");
3 include_once("$srcdir/api.inc");
4 formHeader("Form: Forms3_Cardiology");
5 $returnurl = $GLOBALS['concurrent_layout'] ?
'encounter_top.php' : 'patient_encounter.php';
8 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
10 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
11 <a href
='<?php echo $GLOBALS['webroot
']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick
='top.restoreSession()'> <?php
xl("[do not save]",'e') ?
> </a
>
12 <form method
=post action
="<?php echo $rootdir;?>/forms/Forms3_Cardiology/save.php?mode=new" name
="Forms3_Cardiology" onSubmit
="return top.restoreSession()">
14 <h1
> <?php
xl("Forms3_Cardiology",'e') ?
> </h1
>
16 <input type
="submit" name
="submit form" value
="submit form" />
18 <table width
="100%" cellpadding
="0" cellspacing
="0">
22 <td
class='text' valign
="top">
24 <table width
="100%" cellpadding
="0" cellspacing
="0">
28 <td
class='text' style
="border: 1px #000000 solid;">
32 <tr
><td
class='text' > date
</td
> <td
class='text' ><input type
="text" name
="_date" /></td
></tr
>
37 <td
class='text' style
="border: 1px #000000 solid;">
41 <tr
><td
class='text' > name
</td
> <td
class='text' ><input type
="text" name
="_name" /></td
></tr
>
51 <td
class='text' colspan
='2' style
="border: 1px #000000 solid;">
55 <tr
><td
class='text' > chief complaint
</td
> <td
class='text' ><input type
="text" name
="_chief_complaint" /></td
></tr
>
66 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
68 <table width
="100%" cellpadding
="0" cellspacing
="0">
74 <td
class='text' colspan
="2" style
="border: 1px #000000 solid;">
78 <tr
><td
class='text' > wt
</td
> <td
class='text' ><input type
="text" name
="_wt" /></td
></tr
>
83 <td
class='text' style
="border: 1px #000000 solid;">
87 <tr
><td
class='text' > bp
</td
> <td
class='text' ><input type
="text" name
="_bp" /></td
></tr
>
92 <td
class='text' style
="border: 1px #000000 solid;">
96 <tr
><td
class='text' > p
</td
> <td
class='text' ><input type
="text" name
="_p" /></td
></tr
>
101 <td
class='text' style
="border: 1px #000000 solid;">
105 <tr
><td
class='text' > t
</td
> <td
class='text' ><input type
="text" name
="_t" /></td
></tr
>
110 <td
class='text' style
="border: 1px #000000 solid;">
114 <tr
><td
class='text' > r
</td
> <td
class='text' ><input type
="text" name
="_r" /></td
></tr
>
119 <td
class='text' style
="border: 1px #000000 solid;">
123 <tr
><td
class='text' > ht
</td
> <td
class='text' ><input type
="text" name
="_ht" /></td
></tr
>
145 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
147 <table width
="100%" cellpadding
="0" cellspacing
="0">
151 <td
class='text' colspan
="5" align
="center" style
="border: 1px #000000 solid; height: 15px;">
165 <td
class='text' style
="border: 1px #000000 solid;">
169 <tr
><td
class='text' > location
</td
> <td
class='text' ><input type
="text" name
="_location" /></td
></tr
>
174 <td
class='text' style
="border: 1px #000000 solid;">
178 <tr
><td
class='text' > quality
</td
> <td
class='text' ><input type
="text" name
="_quality" /></td
></tr
>
183 <td
class='text' style
="border: 1px #000000 solid;">
187 <tr
><td
class='text' > severity
</td
> <td
class='text' ><input type
="text" name
="_severity" /></td
></tr
>
192 <td
class='text' style
="border: 1px #000000 solid;">
196 <tr
><td
class='text' > duration
</td
> <td
class='text' ><input type
="text" name
="_duration" /></td
></tr
>
201 <td
class='text' style
="border: 1px #000000 solid;"> 
;
209 <td
class='text' style
="border: 1px #000000 solid;">
213 <tr
><td
class='text' > timing
</td
> <td
class='text' ><input type
="text" name
="_timing" /></td
></tr
>
218 <td
class='text' style
="border: 1px #000000 solid;">
222 <tr
><td
class='text' > context
</td
> <td
class='text' ><input type
="text" name
="_context" /></td
></tr
>
227 <td
class='text' style
="border: 1px #000000 solid;">
231 <tr
><td
class='text' > modifying factors
</td
> <td
class='text' ><input type
="text" name
="_modifying_factors" /></td
></tr
>
236 <td
class='text' style
="border: 1px #000000 solid;">
240 <tr
><td
class='text' > signs symptoms
</td
> <td
class='text' ><input type
="text" name
="_signs_symptoms" /></td
></tr
>
245 <td
class='text' style
="border: 1px #000000 solid;">
249 <tr
><td
class='text' > status of chronic illness
</td
> <td
class='text' ><input type
="text" name
="_status_of_chronic_illness" /></td
></tr
>
266 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
268 <table width
="100%" cellpadding
="0" cellspacing
="0">
272 <td
class='text' align
="center" style
="border: 1px #000000 solid; height: 15px;">
279 <td
class='text' align
="center" style
="border: 1px #000000 solid; height: 15px;">
288 <td
class='text' align
="center" style
="border: 1px #000000 solid; height: 15px;">
300 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
302 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
305 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
307 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
311 <tr
><td
class='text' > systemic positive
</td
> <td
class='text' ><input type
="text" name
="_systemic_positive" /></td
></tr
>
316 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
318 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
322 <tr
><td
class='text' > systemic negative
</td
> <td
class='text' ><input type
="text" name
="_systemic_negative" /></td
></tr
>
330 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
332 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
335 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
337 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
341 <tr
><td
class='text' > ent positive
</td
> <td
class='text' ><input type
="text" name
="_ent_positive" /></td
></tr
>
346 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
348 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
352 <tr
><td
class='text' > ent negative
</td
> <td
class='text' ><input type
="text" name
="_ent_negative" /></td
></tr
>
360 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
362 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
365 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
367 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
371 <tr
><td
class='text' > eyes positive
</td
> <td
class='text' ><input type
="text" name
="_eyes_positive" /></td
></tr
>
376 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
378 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
382 <tr
><td
class='text' > eyes negative
</td
> <td
class='text' ><input type
="text" name
="_eyes_negative" /></td
></tr
>
390 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
392 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
395 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
397 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
401 <tr
><td
class='text' > lymph positive
</td
> <td
class='text' ><input type
="text" name
="_lymph_positive" /></td
></tr
>
406 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
408 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
412 <tr
><td
class='text' > lymph negative
</td
> <td
class='text' ><input type
="text" name
="_lymph_negative" /></td
></tr
>
420 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
422 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
425 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
427 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
431 <tr
><td
class='text' > resp positive
</td
> <td
class='text' ><input type
="text" name
="_resp_positive" /></td
></tr
>
436 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
438 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
442 <tr
><td
class='text' > resp negative
</td
> <td
class='text' ><input type
="text" name
="_resp_negative" /></td
></tr
>
450 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
452 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
455 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
457 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
461 <tr
><td
class='text' > cv positive
</td
> <td
class='text' ><input type
="text" name
="_cv_positive" /></td
></tr
>
466 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
468 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
472 <tr
><td
class='text' > cv negative
</td
> <td
class='text' ><input type
="text" name
="_cv_negative" /></td
></tr
>
480 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
482 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
485 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
487 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
491 <tr
><td
class='text' > gi positive
</td
> <td
class='text' ><input type
="text" name
="_gi_positive" /></td
></tr
>
496 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
498 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
502 <tr
><td
class='text' > gi negative
</td
> <td
class='text' ><input type
="text" name
="_gi_negative" /></td
></tr
>
510 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
512 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
515 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
517 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
521 <tr
><td
class='text' > gu positive
</td
> <td
class='text' ><input type
="text" name
="_gu_positive" /></td
></tr
>
526 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
528 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
532 <tr
><td
class='text' > gu negative
</td
> <td
class='text' ><input type
="text" name
="_gu_negative" /></td
></tr
>
540 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
542 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
545 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
547 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
551 <tr
><td
class='text' > skin positive
</td
> <td
class='text' ><input type
="text" name
="_skin_positive" /></td
></tr
>
556 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
558 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
562 <tr
><td
class='text' > skin negative
</td
> <td
class='text' ><input type
="text" name
="_skin_negative" /></td
></tr
>
570 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
572 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
575 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
577 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
582 <tr
><td
class='text' > ms positive
</td
> <td
class='text' ><input type
="text" name
="_ms_positive" /></td
></tr
>
586 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
588 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
592 <tr
><td
class='text' > ms negative
</td
> <td
class='text' ><input type
="text" name
="_ms_negative" /></td
></tr
>
600 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
602 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
605 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
607 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
611 <tr
><td
class='text' > psych positive
</td
> <td
class='text' ><input type
="text" name
="_psych_positive" /></td
></tr
>
616 <td
class='text' align
="center" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
618 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
622 <tr
><td
class='text' > psych negative
</td
> <td
class='text' ><input type
="text" name
="_psych_negative" /></td
></tr
>
630 <td
class='text' align
="left" colspan
="3" style
="border-right: #000000 1px solid; border-top: #000000 1px solid;
632 border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
636 <tr
><td
class='text' > all other ros negative
</td
> <td
class='text' ><textarea name
="_all_other_ros_negative_" rows
="4" cols
="40"></textarea
></td
></tr
>
658 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
660 <table width
="100%" cellpadding
="0" cellspacing
="0">
664 <td
class='text' colspan
="3" align
="center" style
="border: 1px #000000 solid; height: 15px;">
668 <tr
><td
class='text' > past famiy social history
</td
> <td
class='text' ><textarea name
="_past_famiy_social_history" rows
="4" cols
="40"></textarea
></td
></tr
>
680 <td
class='text' style
="border: 1px #000000 solid; height: 27px;">
684 <tr
><td
class='text' > ph no change since
</td
> <td
class='text' ><input type
="text" name
="_ph_no_change_since" /></td
></tr
>
689 <td
class='text' style
="border: 1px #000000 solid; height: 27px;">
693 <tr
><td
class='text' > fh no change since
</td
> <td
class='text' ><input type
="text" name
="_fh_no_change_since" /></td
></tr
>
698 <td
class='text' style
="border: 1px #000000 solid; height: 27px;">
702 <tr
><td
class='text' > sh no change since
</td
> <td
class='text' ><input type
="text" name
="_sh_no_change_since" /></td
></tr
>
708 <tr
><td
class='text' colspan
='3'>
712 <tr
><td
class='text' ><?php
xl("Examination",'e') ?
></td
>
713 <td
class='text' ><textarea name
="examination" rows
="4" cols
="40"></textarea
></td
></tr
>
725 <table
></table
><input type
="submit" name
="submit form" value
="submit form" />
727 <a href
='<?php echo $GLOBALS['webroot
']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick
='top.restoreSession()'> <?php
xl("[do not save]",'e') ?
> </a
>