contrib/forms/habits/new.php

   1 <?php
   2
   3
   4 # file new.php
   5
   6 # this file made by andres@paglayan.com on 2004-05-03
   7
   8 # custom file for WHS forms.
   9
  10 # Habit form, part of main intake
  11
  12 ###################
  13
  14 ###  Habit Form ###
  15
  16 ###################
  17
  18
  19
  20  include_once("../../globals.php");
  21
  22  include_once("../../../library/api.inc");
  23
  24  formHeader("Habits");
  25
  26
  27
  28 ?>
  29
  30 <html><head>
  31 <?php html_header_show();?>
  32
  33 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  34
  35
  36
  37
  38
  39 </head>
  40
  41 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  42
  43
  44
  45 <!--REM note that every input method has the same name as a valid column, this will make things easier in save.php -->
  46
  47
  48
  49 <!-- main form starts here -->
  50
  51 <table>
  52
  53 <form method='post' action="<?php echo $rootdir;?>/forms/habits/save.php?mode=new" name='habits_form'>
  54
  55
  56
  57 <TR>
  58
  59         <TD>
  60
  61                 <!-- habits -->
  62
  63                 <TABLE span class=text>
  64
  65                 <th><H2><U>Habits</U></H2></th>
  66
  67                 <TR>
  68
  69                         <TD><b>Caffeine:</b></TD>
  70
  71                         <TD><INPUT TYPE="checkbox" NAME="coffee" VALUE="YES"> Coffee &nbsp;&nbsp;</TD>
  72
  73                         <TD><INPUT TYPE="checkbox" NAME="tea" VALUE="YES"> Tea</TD>
  74
  75                         <TD><INPUT TYPE="checkbox" NAME="soft_drinks" VALUE="YES"> Soft Drinks</TD>
  76
  77                         <TD><INPUT TYPE="checkbox" NAME="other_caffeine" VALUE="YES"> Other</TD>
  78
  79                         <TD><INPUT TYPE="text" NAME="caffeine_per_day" SIZE="2"> # per day</TD>
  80
  81                 </TR>
  82
  83                 <TR>
  84
  85                         <TD><B>Salt Usage:</B></TD>
  86
  87                         <TD><INPUT TYPE="radio" NAME="salt_usage" VALUE="Heavy"> Heavy</TD>
  88
  89                         <TD><INPUT TYPE="radio" NAME="salt_usage" VALUE="Moderate"> Moderate</TD>
  90
  91                         <TD><INPUT TYPE="radio" NAME="salt_usage" VALUE="Light"> Light</TD>
  92
  93                         <TD><INPUT TYPE="radio" NAME="salt_usage" VALUE="No salt"> No added salt</TD>
  94
  95                         <TD></TD>
  96
  97                 </TR>
  98
  99                 <TR>
 100
 101                         <TD><B>Sugar Usage</B></TD>
 102
 103                         <TD><INPUT TYPE="radio" NAME="sugar_usage" VALUE="Heavy"> Heavy </TD>
 104
 105                         <TD><INPUT TYPE="radio" NAME="sugar_usage" VALUE="Moderate"> Moderate </TD>
 106
 107                         <TD><INPUT TYPE="radio" NAME="sugar_usage" VALUE="Light"> Light </TD>
 108
 109                         <TD><INPUT TYPE="radio" NAME="sugar_usage" VALUE="No sugar"> No added sugar </TD>
 110
 111                         <TD></TD>
 112
 113                 </TR>
 114
 115                 <TR>
 116
 117                         <TD colspan="2"><B>You feel your diet is:</B> </TD>
 118
 119                         <TD><INPUT TYPE="radio" NAME="diet" VALUE="Healthy"> Healthy</TD>
 120
 121                         <TD><INPUT TYPE="radio" NAME="diet" VALUE="Fair"> Fair</TD>
 122
 123                         <TD><INPUT TYPE="radio" NAME="diet" VALUE="Poor"> Poor</TD>
 124
 125                         <TD></TD>
 126
 127                 </TR>
 128
 129                 <TR>
 130
 131                         <TD><B>Coments:</B> </TD>
 132
 133                         <TD Colspan="5"><INPUT TYPE="text" size="50" NAME="diet_comments"></TD>
 134
 135                 </TR>
 136
 137                 <TR>
 138
 139                         <TD><B>Alcohol:</B> </TD>
 140
 141                         <TD colspan="2"><INPUT TYPE="text" size="2" NAME="alc_per_day"> Glasses per day</TD>
 142
 143                         <TD colspan="2"><INPUT TYPE="text" size="2" NAME="alc_per_week"> Glasses per week</TD>
 144
 145                         <TD></TD>
 146
 147                 </TR>
 148
 149                 <TR>
 150
 151                         <TD colspan="2"><B>Recreational Drugs:</B> </TD>
 152
 153                         <TD colspan="2">Which Drugs? <INPUT TYPE="text" size="20" NAME="recr_drugs"></TD>
 154
 155                         <TD colspan="2">How often? <INPUT TYPE="text" size="20" NAME="recr_drugs_often"></TD>
 156
 157                 </TR>
 158
 159                 <TR>
 160
 161                         <TD colspan="4"><B>Do you feel you have a problem with alcohol or drugs?</B>
 162
 163                                 <SELECT NAME="alc_drug_problem"><option><option>YES<OPTION>NO</SELECT>
 164
 165                         </TD>
 166
 167                         <TD colspan="2">Explain:<INPUT TYPE="text" size="20" NAME="alc_drug_problem_explain"></TD>
 168
 169                 </TR>
 170
 171                 <TR>
 172
 173                         <TD colspan="2"><B>Tobacco:</B> </TD>
 174
 175                         <TD colspan="2">Do you smoke? <SELECT NAME="current_smoke"><option><option>YES<OPTION>NO</SELECT> </TD>
 176
 177                         <TD colspan="2">Have you ever smoked? <SELECT NAME="ever_smoked"><option><option>YES<OPTION>NO</SELECT> </TD>
 178
 179                 </TR>
 180
 181                 <TR>
 182
 183                         <TD><INPUT TYPE="text" size="2" NAME="cig_per_day_now"> per day now.</TD>
 184
 185                         <TD colspan="2"><INPUT TYPE="text" size="2" NAME="cig_per_day_past"> per day in the past.</TD>
 186
 187                         <TD colspan="3">How long have you been smoking? <INPUT TYPE="text" size="2" NAME="how_long_smoke">Years </TD>
 188
 189                 </TR>
 190
 191                 <TR>
 192
 193                         <TD colspan="4">If you no longer smoke, when did you quit? <INPUT TYPE="text" size="10" maxlength="10" NAME="smoke_quit" VALUE="mm/dd/yyyy" maxlength="10">
 194
 195
 196
 197
 198
 199                         </TD>
 200
 201                         <TD colspan="2">Would you like to quit? <SELECT NAME="like_to_quit"><option><option>YES<OPTION>NO</SELECT></TD>
 202
 203                 </TR>
 204
 205                 <TR>
 206
 207                         <TD><B>exercise:</B></TD>
 208
 209                         <TD colspan="2">Do you exercise regularly? <SELECT NAME="exercise_reg"><option><option>YES<OPTION>NO</SELECT></TD>
 210
 211                         <TD colspan ="3">What types? <INPUT TYPE="text" size="40" NAME="exercise_types"></TD>
 212
 213                 </TR>
 214
 215                 <TR>
 216
 217                         <TD></TD>
 218
 219                         <TD colspan="2">How many times per week? <INPUT TYPE="text" size="2" NAME="exercise_per_week"></TD>
 220
 221                         <TD colspan ="2">For how long each time? <INPUT TYPE="text" size="3" NAME="exercise_minutes">Minutes</TD>
 222
 223                 </TR>
 224
 225                 <TR>
 226
 227                         <TD><B>Seat belt use:</B></TD>
 228
 229                         <TD colspan="5"><SELECT NAME="seat_belt"><option><option>Always<OPTION>Usually<OPTION>Seldom<OPTION>Never</SELECT></TD>
 230
 231                 </TR>
 232
 233                 <TR>
 234
 235                         <TD colspan="5">Have you ever been pushed, shoved, slapped, hit, or verbally abused by anyone?</TD>
 236
 237                         <TD><SELECT NAME="ever_been_molested"><option><option>YES<OPTION>NO</SELECT></TD>
 238
 239                 </TR>
 240
 241                 <TR>
 242
 243                         <TD colspan="5">Have you ever pushed, shoved, slapped, hit, or verbally abused another individual?</TD>
 244
 245                         <TD><SELECT NAME="ever_molested_other"><option><option>YES<OPTION>NO</SELECT></TD>
 246
 247                 </TR>
 248
 249                 </TABLE>
 250
 251                 <!-- eof habits -->
 252
 253
 254
 255         </TD>
 256
 257 </TR>
 258
 259 <TR>
 260
 261         <TD>
 262
 263 <a href="javascript:top.restoreSession();document.habits_form.submit();" class="link_submit">[Save]</a>
 264
 265 <br>
 266
 267
 268
 269 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save]</a>
 270
 271
 272
 273         </TD>
 274
 275 </TR>
 276
 277 <TR>
 278
 279         <TD>
 280
 281         </TD>
 282
 283 </TR>
 284
 285 </form>
 286
 287 </table>
 288
 289 <!-- ends main form -->
 290
 291
 292
 293 <?php
 294
 295 formFooter();
 296
 297 ?>
 298