contrib/forms/high_risk_screening_record/view.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");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <?php html_header_show();?>
  23
  24 <title>Form: High risk screening record</title>
  25
  26 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  27
  28 <link rel=stylesheet href="../../acog.css" type="text/css">
  29
  30 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  31
  32 <script language="JavaScript" type="text/JavaScript">
  33
  34 window.onload = initialize;
  35
  36 </script>
  37
  38 </head>
  39
  40
  41
  42 <?php
  43
  44    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  45
  46    if ($fres){
  47
  48      $patient = sqlFetchArray($fres);
  49
  50    }
  51
  52    $fres=sqlStatement("select * from form_high_risk_screening_record where id=$id");
  53
  54    if ($fres){
  55
  56      $fdata = sqlFetchArray($fres);
  57
  58    }
  59
  60 ?>
  61
  62 <body <?php echo $top_bg_line;?>>
  63
  64
  65
  66 <form action="<?php echo $rootdir;?>/forms/high_risk_screening_record/save.php?mode=update&id=<?php echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
  67
  68 <?php include("../../acog_menu.inc"); ?>
  69
  70 <div class="srvChapter">High risk screening  record <a href="#" onMouseOver="toolTip('See Table of High-Risk Factors.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  71
  72 <div style="border: solid 2px black; background-color:#FFFFFF;">
  73
  74   <table  border="0" cellpadding="2" cellspacing="0">
  75
  76     <tr align="left" valign="bottom">
  77
  78       <td colspan="6" class="fibody2" id="bordR">patient name:
  79
  80         <input name="pname" type="text" class="fullin" id="pname" style="width: 70%" value="<?php
  81
  82
  83           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  84
  85           ?>"></td>
  86
  87       <td colspan="5" class="fibody2" id="bordR">Birth date:
  88
  89         <input name="pbdate" type="text" class="fullin" id="pbdate" style="width: 65%" value="<?php
  90
  91
  92           echo $patient{'DOB'};
  93
  94           ?>"></td>
  95
  96       <td colspan="4" class="fibody2">ID No:
  97
  98         <input name="hr_pid" type="text" class="fullin" id="hr_pid" style="width:80%" value="<?php
  99
 100
 101           echo $patient{'id'};
 102
 103           ?>"></td>
 104
 105       </tr>
 106
 107     <tr align="center" valign="middle">
 108
 109       <td class="ficaption2" id="bordR">&nbsp;</td>
 110
 111       <td width="6%" class="ficaption2" id="bordR">HEMO-<br>
 112
 113         GLOBIN<br>
 114
 115         TEST</td>
 116
 117       <td width="6%" class="ficaption2" id="bordR">BONE DENSITY<br>
 118
 119         SCREENING</td>
 120
 121       <td width="6%" class="ficaption2" id="bordR">BACTERI-<br>
 122
 123         URIA&nbsp;TEST</td>
 124
 125       <td width="6%" class="ficaption2" id="bordR">STD<br>
 126
 127         TESTING</td>
 128
 129       <td width="6%" class="ficaption2" id="bordR">HIV test <a href="#" onMouseOver="toolTip('Check state requirements before recording results.')" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></td>
 130
 131       <td width="6%" class="ficaption2" id="bordR">Genetic testing </td>
 132
 133       <td width="6%" class="ficaption2" id="bordR">Rubella titer </td>
 134
 135       <td width="6%" class="ficaption2" id="bordR">TB skin test </td>
 136
 137       <td width="6%" class="ficaption2" id="bordR">Lipid profile assessment </td>
 138
 139       <td width="6%" class="ficaption2" id="bordR">Mammo-<br>
 140
 141         graphy</td>
 142
 143       <td width="6%" class="ficaption2" id="bordR">Fasting<br>
 144
 145         GLUCOSE TEST</td>
 146
 147       <td width="6%" class="ficaption2" id="bordR">TSH<br>
 148
 149         TEST</td>
 150
 151       <td width="6%" class="ficaption2" id="bordR">COLORECTAL<br>
 152
 153         CANCER<br>
 154
 155         SCREENING</td>
 156
 157       <td width="6%" class="ficaption2">HEPATITIS C<br>
 158
 159         VIRUS TEST</td>
 160
 161     </tr>
 162
 163 <?
 164
 165 $rsi = 1;
 166
 167 while ($rsi < 13){
 168
 169 list(
 170
 171 $hemoglobin, $bone_density, $bacteriuria, $std, $hiv, $genetic, $rubella, $tb_skin,
 172
 173 $lipid, $mammography, $fasting_glucose, $tsh, $cancer, $hepatitis_c
 174
 175 ) = explode("|~",$fdata["record_".$rsi]);
 176
 177 list( $hemoglobin_date, $hemoglobin_res) = explode(';', $hemoglobin);
 178
 179 list( $bone_density_date, $bone_density_res) = explode(';', $bone_density);
 180
 181 list( $bacteriuria_date, $bacteriuria_res) = explode(';', $bacteriuria);
 182
 183 list( $std_date, $std_res) = explode(';', $std);
 184
 185 list( $hiv_date, $hiv_res) = explode(';', $hiv);
 186
 187 list( $genetic_date, $genetic_res) = explode(';', $genetic);
 188
 189 list( $rubella_date, $rubella_res) = explode(';', $rubella);
 190
 191 list( $tb_skin_date, $tdb_skin_res) = explode(';', $tdb_skin);
 192
 193 list( $lipid_date, $lipid_res) = explode(';', $lipid);
 194
 195 list( $mammography_date, $mammography_res) = explode(';', $mammography);
 196
 197 list( $fasting_glucose_date, $fasting_glucose_res) = explode(';', $fasting_glucose);
 198
 199 list( $tsh_date, $tsh_res) = explode(';', $tsh);
 200
 201 list( $cancer_date, $cancer_res) = explode(';', $cancer);
 202
 203 list( $hepatitis_c_date, $hepatitis_c_res) = explode(';', $hepatitis_c);
 204
 205
 206
 207 print <<<EOL
 208
 209     <tr align="left" valign="bottom">
 210
 211       <td class="fibody3" id="bordR">Date:</td>
 212
 213       <td class="fibody3" id="bordR"><input name="hemoglobin_date_${rsi}" type="text" value="${hemoglobin_date}" class="fullin2"></td>
 214
 215       <td class="fibody3" id="bordR"><input name="bone_density_date_${rsi}" type="text" value="${bone_density_date}"  class="fullin2"></td>
 216
 217       <td class="fibody3" id="bordR"><input name="bacteriuria_date_${rsi}" type="text" value="${bacteriuria_date}"  class="fullin2"></td>
 218
 219       <td class="fibody3" id="bordR"><input name="std_date_${rsi}" type="text" value="${std_date}"  class="fullin2"></td>
 220
 221       <td class="fibody3" id="bordR"><input name="hiv_date_${rsi}" type="text" value="${hiv_date}"  class="fullin2"></td>
 222
 223       <td class="fibody3" id="bordR"><input name="genetic_date_${rsi}" type="text" value="${genetic_date}"  class="fullin2"></td>
 224
 225       <td class="fibody3" id="bordR"><input name="rubella_date_${rsi}" type="text" value="${rubella_date}"  class="fullin2"></td>
 226
 227       <td class="fibody3" id="bordR"><input name="tb_skin_date_${rsi}" type="text" value="${tb_skin_date}"  class="fullin2"></td>
 228
 229       <td class="fibody3" id="bordR"><input name="lipid_date_${rsi}" type="text" value="${lipid_date}"  class="fullin2"></td>
 230
 231       <td class="fibody3" id="bordR"><input name="mammography_date_${rsi}" type="text" value="${mammography_date}"  class="fullin2"></td>
 232
 233       <td class="fibody3" id="bordR"><input name="fasting_glucose_date_${rsi}" type="text" value="${fasting_glucose_date}"  class="fullin2"></td>
 234
 235       <td class="fibody3" id="bordR"><input name="tsh_date_${rsi}" type="text" value="${tsh_date}"  class="fullin2"></td>
 236
 237       <td class="fibody3" id="bordR"><input name="cancer_date_${rsi}" type="text" value="${cancer_date}"  class="fullin2"></td>
 238
 239       <td class="fibody3"><input name="hepatitis_c_date_${rsi}" type="text" value="${hepatitis_c_date}"  class="fullin2"></td>
 240
 241     </tr>
 242
 243     <tr align="left" valign="bottom">
 244
 245       <td class="fibody2" id="bordR">Result:</td>
 246
 247       <td class="fibody2" id="bordR"><input name="hemoglobin_res_${rsi}" type="text" value="${hemoglobin_res}"  class="fullin2"></td>
 248
 249       <td class="fibody2" id="bordR"><input name="bone_density_res_${rsi}" type="text" value="${bone_density_res}"  class="fullin2"></td>
 250
 251       <td class="fibody2" id="bordR"><input name="bacteriuria_res_${rsi}" type="text" value="${bacteriuria_res}"  class="fullin2"></td>
 252
 253       <td class="fibody2" id="bordR"><input name="std_res_${rsi}" type="text" value="${std_res}"  class="fullin2"></td>
 254
 255       <td class="fibody2" id="bordR"><input name="hiv_res_${rsi}" type="text" value="${hiv_res}"  class="fullin2"></td>
 256
 257       <td class="fibody2" id="bordR"><input name="genetic_res_${rsi}" type="text" value="${genetic_res}"  class="fullin2"></td>
 258
 259       <td class="fibody2" id="bordR"><input name="rubella_res_${rsi}" type="text" value="${rubella_res}"  class="fullin2"></td>
 260
 261       <td class="fibody2" id="bordR"><input name="tb_skin_res_${rsi}" type="text" value="${tb_skin_res}"  class="fullin2"></td>
 262
 263       <td class="fibody2" id="bordR"><input name="lipid_res_${rsi}" type="text" value="${lipid_res}"  class="fullin2"></td>
 264
 265       <td class="fibody2" id="bordR"><input name="mammography_res_${rsi}" type="text" value="${mammography_res}"  class="fullin2"></td>
 266
 267       <td class="fibody2" id="bordR"><input name="fasting_glucose_res_${rsi}" type="text" value="${fasting_glucose_res}"  class="fullin2"></td>
 268
 269       <td class="fibody2" id="bordR"><input name="tsh_res_${rsi}" type="text" value="${tsh_res}"  class="fullin2"></td>
 270
 271       <td class="fibody2" id="bordR"><input name="cancer_res_${rsi}" type="text" value="${cancer_res}"  class="fullin2"></td>
 272
 273       <td class="fibody2"><input name="hepatitis_c_res_${rsi}" type="text" value="${hepatitis_c_res}"  class="fullin2"></td>
 274
 275     </tr>
 276
 277 EOL;
 278
 279 $rsi++;
 280
 281 }
 282
 283 ?>
 284
 285   </table>
 286
 287 </div>
 288
 289 <p>&nbsp;</p>
 290
 291   <table width="100%" border="0">
 292
 293     <tr>
 294
 295       <td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
 296
 297       <td align="left" nowrap> <a href="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>" target="_blank" class="link_submit"
 298
 299        onclick="top.restoreSession()">[Printable form]</a> </td>
 300
 301       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 302
 303        onclick="top.restoreSession()">[Don't Save]</a> </td>
 304
 305     </tr>
 306
 307   </table>
 308
 309 </form>
 310
 311 <?php
 312
 313 formFooter();
 314
 315 ?>
 316
 317 </body>
 318
 319 </html>