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';
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 <form method
=post action
="<?php echo $rootdir;?>/forms/Chiro_personal_injury_form/save.php?mode=new" name
="my_form" onSubmit
="return top.restoreSession()">
12 <h1
> Chiro personal injury form
</h1
>
14 <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
>
16 <Table width
="100%" cellpadding
="0" cellspacing
="0">
20 <td
class="text" style
="border:solid 1px #000000" >
24 <tr
><td
class="text" > Patient Name
/(Nombre
):</td
><td
class="text" ><input type
="text" name
="_patient_name" /></td
></tr
>
29 <td
class="text" style
="border:solid 1px #000000" >
33 <tr
><td
class="text" > Middle Name
</td
><td
class="text" ><input type
="text" name
="_middle_name" /></td
></tr
>
38 <td
class="text" style
="border:solid 1px #000000" >
42 <tr
><td
class="text" > Last Name
</td
><td
class="text" ><input type
="text" name
="_last_name" /></td
></tr
>
50 <td
class="text" style
="border:solid 1px #000000" colspan
="3">
54 <tr
><td
class="text" > Address
/ (Direction
)</td
><td
class="text" ><input type
="text" name
="_address_direction" /></td
></tr
>
62 <td
class="text" style
="border:solid 1px #000000" width
="33%">
66 <tr
><td
class="text" > City
:</td
><td
class="text" ><input type
="text" name
="_city" /></td
></tr
>
71 <td
class="text" style
="border:solid 1px #000000" width
="33%">
75 <tr
><td
class="text" > State
:</td
><td
class="text" ><input type
="text" name
="_state" /></td
></tr
>
80 <td
class="text" style
="border:solid 1px #000000" width
="33%">
84 <tr
><td
class="text" > Zip
:</td
><td
class="text" ><input type
="text" name
="_zip" /></td
></tr
>
92 <td
class="text" style
="border:solid 1px #000000" >
96 <tr
><td
class="text" > Phone
#(Telefono) Home</td><td class="text" ><input type="text" name="_phone_number_home" /></td></tr>
101 <td
class="text" style
="border:solid 1px #000000" >
105 <tr
><td
class="text" >Work
</td
><td
class="text" ><input type
="text" name
="_phone_number_work" /></td
></tr
>
110 <td
class="text" style
="border:solid 1px #000000" > 
;
118 <td
class="text" style
="border:solid 1px #000000" >
122 <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
>
127 <td
class="text" style
="border:solid 1px #000000" >
131 <tr
><td
class="text" > Date of Birth
:(Feeha de Nacimiento
)</td
><td
class="text" ><input type
="text" name
="_date_of_birth" /></td
></tr
>
136 <td
class="text" style
="border:solid 1px #000000" >
140 <tr
><td
class="text" > Social Security
.#:(Seguro Social)</td><td class="text" ><input type="text" name="_social_security" /></td></tr>
148 <td
class="text" style
="border:solid 1px #000000" colspan
="3">
152 <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
>
158 <tr
><td
class="text" > Other(Otros
)</td
><td
class="text" ><input type
="text" name
="_other" /></td
></tr
>
166 <td
class="text" colspan
="3" >
168 <table width
="100%" cellpadding
="0" cellspacing
="0">
172 <td
class="text" style
="border:solid 1px #000000" colspan
="2">
176 <tr
><td
class="text" > Date of Accident
: (Feeha da Accidente
)</td
><td
class="text" ><input type
="text" name
="_date_of_accident" /></td
></tr
>
184 <td
class="text" style
="border:solid 1px #000000" width
="50%">
188 <tr
><td
class="text" > Insurance Name
:</td
><td
class="text" ><input type
="text" name
="_insurance_name" /></td
></tr
>
193 <td
class="text" style
="border:solid 1px #000000" width
="50%">
198 <td
class="text" > Phone
#:</td>
199 <td
class="text" ><input type
="text" name
="_phone_no" /></td
></tr
>
207 <td
class="text" style
="border:solid 1px #000000" colspan
="2">
211 <tr
><td
class="text" > Address (Direction
):</td
><td
class="text" ><input type
="text" name
="_address_of_insurance_company" /></td
></tr
>
219 <td
class="text" style
="border:solid 1px #000000" >
223 <tr
><td
class="text" > Claim
# (Numerom de Recalmo):</td><td class="text" ><input type="text" name="_claim_number" /></td></tr>
228 <td
class="text" style
="border:solid 1px #000000" >
232 <tr
><td
class="text" > Policy (Numero de Poliza
):</td
><td
class="text" ><input type
="text" name
="_policy_number" /></td
></tr
>
240 <td
class="text" style
="border:solid 1px #000000" >
244 <tr
><td
class="text" > Attorney
Name(Nombre de Abogado
):</td
><td
class="text" ><input type
="text" name
="_attorney_name" /></td
></tr
>
249 <td
class="text" style
="border:solid 1px #000000" >
254 <td
class="text" > Attorney Phone
#(Telefone de Abogado)</td>
255 <td
class="text" ><input type
="text" name
="_attorney_phone_number" /></td
></tr
>
263 <td
class="text" style
="border:solid 1px #000000" colspan
="2">
267 <tr
><td
class="text" > Attorney address
/ (Direccion
):</td
><td
class="text" ><input type
="text" name
="_attorney_address" /></td
></tr
>
279 <td
class="text" colspan
="3" >
281 <table width
="100%" cellpadding
="0" cellspacing
="0">
287 <td
class="text" style
="border:solid 1px #000000" width
="50%">
291 <tr
><td
class="text" > Health
Insurance(Plan Medico
):</td
><td
class="text" ><input type
="text" name
="_health_insurance" /></td
></tr
>
296 <td
class="text" style
="border:solid 1px #000000" width
="50%">
300 <tr
><td
class="text" >Phone
#</td><td class="text" ><input type="text" name="_health_insurance_phone_number" /></td></tr>
308 <td
class="text" style
="border:solid 1px #000000" colspan
="3">
312 <tr
><td
class="text" > Address
: </td
><td
class="text" ><input type
="text" name
="_address_of_health_insurance" /></td
></tr
>
322 <td
class="text" style
="border:solid 1px #000000" >
326 <tr
><td
class="text" > Subscriber ID
#</td><td class="text" ><input type="text" name="_subscriber_id_number" /></td></tr>
331 <td
class="text" style
="border:solid 1px #000000" >
335 <tr
><td
class="text" > Group
#</td><td class="text" ><input type="text" name="_group_number" /></td></tr>
350 <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
>