contrib/forms/chiropractor_set/Chiro_personal_injury_form/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Chiro_personal_injury_form");
   5 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11
  12 <form method=post action="<?php echo $rootdir;?>/forms/Chiro_personal_injury_form/save.php?mode=new" name="Chiro_personal_injury_form" onSubmit="return top.restoreSession()">
  13 <hr>
  14 <h1> <?php xl("Chiro personal injury form",'e') ?> </h1>
  15 <hr>
  16 <input type="submit" name="submit form" value="submit form" /> <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  17
  18 <Table width="100%" cellpadding="0" cellspacing="0">
  19
  20     <tr>
  21
  22    <td class="text"    style="border:solid 1px #000000"   >
  23
  24 <table>
  25
  26 <tr><td class="text" > Patient Name/(Nombre):</td><td class="text"   ><input type="text" name="_patient_name"  /></td></tr>
  27
  28 </table>
  29     </td>
  30
  31    <td class="text"    style="border:solid 1px #000000"   >
  32
  33 <table>
  34
  35 <tr><td class="text" > Middle Name</td><td class="text"   ><input type="text" name="_middle_name"  /></td></tr>
  36
  37 </table>
  38     </td>
  39
  40    <td class="text"    style="border:solid 1px #000000"   >
  41
  42 <table>
  43
  44 <tr><td class="text" > Last Name</td><td class="text"   ><input type="text" name="_last_name"  /></td></tr>
  45
  46 </table>
  47     </td>
  48     </tr>
  49
  50     <tr>
  51
  52    <td class="text"    style="border:solid 1px #000000"    colspan="3">
  53
  54 <table>
  55
  56 <tr><td class="text" > Address/ (Direction)</td><td class="text"   ><input type="text" name="_address_direction"  /></td></tr>
  57
  58 </table>
  59     </td>
  60     </tr>
  61
  62     <tr>
  63
  64    <td class="text"    style="border:solid 1px #000000"    width="33%">
  65
  66 <table>
  67
  68 <tr><td class="text" > City:</td><td class="text"   ><input type="text" name="_city"  /></td></tr>
  69
  70 </table>
  71     </td>
  72
  73    <td class="text"    style="border:solid 1px #000000"    width="33%">
  74
  75 <table>
  76
  77 <tr><td class="text" > State:</td><td class="text"   ><input type="text" name="_state"  /></td></tr>
  78
  79 </table>
  80     </td>
  81
  82    <td class="text"    style="border:solid 1px #000000"    width="33%">
  83
  84 <table>
  85
  86 <tr><td class="text" > Zip:</td><td class="text"   ><input type="text" name="_zip"  /></td></tr>
  87
  88 </table>
  89     </td>
  90     </tr>
  91
  92     <tr>
  93
  94    <td class="text"    style="border:solid 1px #000000"   >
  95
  96 <table>
  97
  98 <tr><td class="text" > Phone #(Telefono) Home</td><td class="text"   ><input type="text" name="_phone_number_home"  /></td></tr>
  99
 100 </table>
 101     </td>
 102
 103     <td class="text"    style="border:solid 1px #000000"   >
 104
 105 <table>
 106
 107 <tr><td class="text" >Work</td><td class="text"   ><input type="text" name="_phone_number_work"  /></td></tr>
 108
 109 </table>
 110     </td>
 111
 112    <td class="text"    style="border:solid 1px #000000"   >&nbsp;
 113
 114
 115     </td>
 116     </tr>
 117
 118     <tr>
 119
 120    <td class="text"    style="border:solid 1px #000000"   >
 121
 122 <table>
 123
 124 <tr><td class="text" > Sex:(Sexo):</td><td class="text"   ><label><input type="checkbox" name="_sex[]" value="male" /> <?php Xl("male",'e') ?> </label> <label><input type="checkbox" name="_sex[]" value="female" /> <?php Xl("female",'e') ?> </label></td></tr>
 125
 126 </table>
 127     </td>
 128
 129    <td class="text"    style="border:solid 1px #000000"   >
 130
 131 <table>
 132
 133 <tr><td class="text" > Date of Birth:(Feeha de Nacimiento)</td><td class="text"   ><input type="text" name="_date_of_birth"  /></td></tr>
 134
 135 </table>
 136     </td>
 137
 138    <td class="text"    style="border:solid 1px #000000"   >
 139
 140 <table>
 141
 142 <tr><td class="text" > Social Security.#:(Seguro Social)</td><td class="text"   ><input type="text" name="_social_security"  /></td></tr>
 143
 144 </table>
 145     </td>
 146     </tr>
 147
 148     <tr>
 149
 150    <td class="text"    style="border:solid 1px #000000"     colspan="3">
 151
 152 <table>
 153
 154 <tr><td class="text" > Nature of Accident(Accidence):</td><td class="text"   ><label><input type="checkbox" name="_nature_of_accident[]" value="automobile" /> <?php Xl("Automobile(Auto)",'e') ?> </label> <label><input type="checkbox" name="_nature_of_accident[]" value="slip and fall" /> <?php Xl("Slip And Fall(Caida)",'e') ?> </label> <label><input type="checkbox" name="_nature_of_accident[]" value="work related" /> <?php Xl("Work Related(Trabajo)",'e') ?> </label></td></tr>
 155
 156 </table>
 157
 158 <table>
 159
 160 <tr><td class="text" > Other(Otros)</td><td class="text"   ><input type="text" name="_other"  /></td></tr>
 161
 162 </table>
 163     </td>
 164     </tr>
 165
 166     <tr>
 167
 168    <td class="text"    colspan="3" >
 169
 170     <table width="100%" cellpadding="0" cellspacing="0">
 171
 172     <tr>
 173
 174    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 175
 176 <table>
 177
 178 <tr><td class="text" > Date of Accident: (Feeha da Accidente)</td><td class="text"   ><input type="text" name="_date_of_accident"  /></td></tr>
 179
 180 </table>
 181     </td>
 182     </tr>
 183
 184     <tr>
 185
 186    <td class="text"    style="border:solid 1px #000000"    width="50%">
 187
 188 <table>
 189
 190 <tr><td class="text" > Insurance Name:</td><td class="text"   ><input type="text" name="_insurance_name"  /></td></tr>
 191
 192 </table>
 193     </td>
 194
 195    <td class="text"    style="border:solid 1px #000000"    width="50%">
 196
 197 <table>
 198
 199 <tr>
 200  <td class="text"   > Phone #:</td>
 201  <td class="text"   ><input type="text" name="_phone_no"  /></td></tr>
 202
 203 </table>
 204     </td>
 205     </tr>
 206
 207     <tr>
 208
 209    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 210
 211 <table>
 212
 213 <tr><td class="text" > Address (Direction):</td><td class="text"   ><input type="text" name="_address_of_insurance_company"  /></td></tr>
 214
 215 </table>
 216     </td>
 217     </tr>
 218
 219     <tr>
 220
 221    <td class="text"    style="border:solid 1px #000000"   >
 222
 223 <table>
 224
 225 <tr><td class="text" > Claim # (Numerom de Recalmo):</td><td class="text"   ><input type="text" name="_claim_number"  /></td></tr>
 226
 227 </table>
 228     </td>
 229
 230    <td class="text"    style="border:solid 1px #000000"   >
 231
 232 <table>
 233
 234 <tr><td class="text" > Policy (Numero de Poliza):</td><td class="text"   ><input type="text" name="_policy_number"  /></td></tr>
 235
 236 </table>
 237     </td>
 238     </tr>
 239
 240     <tr>
 241
 242    <td class="text"    style="border:solid 1px #000000"   >
 243
 244 <table>
 245
 246 <tr><td class="text" > Attorney Name(Nombre de Abogado):</td><td class="text"   ><input type="text" name="_attorney_name"  /></td></tr>
 247
 248 </table>
 249     </td>
 250
 251    <td class="text"    style="border:solid 1px #000000"   >
 252
 253 <table>
 254
 255 <tr>
 256  <td class="text"   > Attorney Phone#(Telefone de Abogado)</td>
 257  <td class="text"   ><input type="text" name="_attorney_phone_number"  /></td></tr>
 258
 259 </table>
 260     </td>
 261     </tr>
 262
 263     <tr>
 264
 265    <td class="text"    style="border:solid 1px #000000"    colspan="2">
 266
 267 <table>
 268
 269 <tr><td class="text" > Attorney address / (Direccion):</td><td class="text"   ><input type="text" name="_attorney_address"  /></td></tr>
 270
 271 </table>
 272     </td>
 273     </tr>
 274
 275     </table>
 276     </td>
 277     </tr>
 278
 279     <tr>
 280
 281    <td class="text"       colspan="3" >
 282
 283     <table width="100%" cellpadding="0" cellspacing="0">
 284
 285     <tr>
 286
 287
 288
 289    <td class="text"    style="border:solid 1px #000000"    width="50%">
 290
 291 <table>
 292
 293 <tr><td class="text" > Health Insurance(Plan Medico):</td><td class="text"   ><input type="text" name="_health_insurance"  /></td></tr>
 294
 295 </table>
 296     </td>
 297
 298    <td class="text"    style="border:solid 1px #000000"    width="50%">
 299
 300 <table>
 301
 302 <tr><td class="text" >Phone#</td><td class="text"   ><input type="text" name="_health_insurance_phone_number"  /></td></tr>
 303
 304 </table>
 305         </td>
 306     </tr>
 307
 308     <tr>
 309
 310    <td class="text"    style="border:solid 1px #000000"    colspan="3">
 311
 312 <table>
 313
 314 <tr><td class="text" > Address: </td><td class="text"   ><input type="text" name="_address_of_health_insurance"  /></td></tr>
 315
 316 </table>
 317     </td>
 318
 319
 320     </tr>
 321
 322     <tr>
 323
 324    <td class="text"    style="border:solid 1px #000000"   >
 325
 326 <table>
 327
 328 <tr><td class="text" > Subscriber ID #</td><td class="text"   ><input type="text" name="_subscriber_id_number"  /></td></tr>
 329
 330 </table>
 331     </td>
 332
 333    <td class="text"    style="border:solid 1px #000000"   >
 334
 335 <table>
 336
 337 <tr><td class="text" > Group #</td><td class="text"   ><input type="text" name="_group_number"  /></td></tr>
 338
 339 </table>
 340     </td>
 341     </tr>
 342
 343
 344
 345     </table>
 346     </td>
 347     </tr>
 348
 349
 350
 351     </table>
 352
 353 <table></table><input type="submit" name="submit form" value="submit form" /> <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 354
 355 </form>
 356 <?php
 357 formFooter();
 358 ?>