1 <!-- Ankle Injury View Form created by Nikolai Vitsyn by
2004/02/19 -->
3 include_once("../../globals.php");
6 <link rel
=stylesheet href
="<?echo $css_header;?>" type
="text/css">
8 <body
<?
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
10 include_once("$srcdir/api.inc");
11 $obj = formFetch("form_ankleinjury", $_GET["id"]);
13 <form method
=post action
="<?echo $rootdir?>/forms/ankleinjury/save.php?mode=update&id=<?echo $_GET["id
"];?>" name
="my_form">
14 <span
class="title"><?php
xl('Ankle Evaluation Form','e');?
></span
><br
></br
>
16 <a href
="javascript:document.my_form.submit();" class="link_submit">[<?php
xl('Save','e');?
>]</a
>
18 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[<?php
xl('Don\'t Save Changes','e');?
>]</a
>
21 <span
class=text
>Date of Injury
: </span
><input type
=entry name
="ankle_date_of_injuary" value
="<?echo stripslashes($obj{"ankle_date_of_injuary
"});?>" >
22 <td align
="right"><?php
xl('Work related?','e');?
>:</td
>
23 <td
><input type
=checkbox name
="ankle_work_related" <?
if ($obj{"ankle_work_related"} == "on")
24 echo "checked";;?
>><span
class=text
></span
><br
></td
>
28 <td align
="right"><?php
xl('Foot:','e');?
></td
>
29 <td
><input type
=radio name
="ankle_foot" value
="Left" <?
if ($obj{"ankle_foot"} == "Left")
30 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
31 <td align
="right"><?php
xl('Left:','e');?
></td
>
32 <td
><input type
=radio name
="ankle_foot" value
="Right" <?
if ($obj{"ankle_foot"} == "Right")
33 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
34 <td align
="right"><?php
xl('Right:','e');?
></td
>
40 <td align
="right"><?php
xl('Severity of Pain:','e');?
></td
>
41 <td align
="right">1:</td
>
42 <td
><input type
=radio name
="ankle_severity_of_pain" value
="1" <?
if ($obj{"ankle_severity_of_pain"} == "1")
43 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
45 <td align
="right">2:</td
>
46 <td
><input type
=radio name
="ankle_severity_of_pain" value
="2" <?
if ($obj{"ankle_severity_of_pain"} == "2")
47 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
49 <td align
="right">3:</td
>
50 <td
><input type
=radio name
="ankle_severity_of_pain" value
="3" <?
if ($obj{"ankle_severity_of_pain"} == "3")
51 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
56 <td align
="right"><?php
xl('Significant Swelling:','e');?
></td
>
57 <td
><input type
=checkbox name
="ankle_significant_swelling" <?
if ($obj{"ankle_significant_swelling"} == "on")
58 {echo "checked";};?
>><span
class=text
></span
><br
>
65 <td align
="right"><?php
xl('Onset of Swelling:','e');?
></td
>
66 <td
><input type
=radio name
="ankle_onset_of_swelling" value
="within minutes" <?
if ($obj{"ankle_onset_of_swelling"} == "within minutes")
67 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
68 <td align
="right"><?php
xl('within minutes:','e');?
></td
>
69 <td
><input type
=radio name
="ankle_onset_of_swelling" value
="within hours" <?
if ($obj{"ankle_onset_of_swelling"} == "within hours")
70 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
71 <td align
="right"><?php
xl('within hours:','e');?
></td
>
75 <span
class="text"><?php
xl('How did Injury Occur?:','e');?
></span
></br
>
76 <textarea name
="ankle_how_did_injury_occur" cols
="67" rows
="4" wrap
="virtual name">
77 <?
echo stripslashes($obj{"ankle_how_did_injury_occur"});?
></textarea
>
80 <table
><th colspan
="5"><?php
xl('Ottawa Ankle Rules','e');?
></th
>
82 <td align
="right"><?php
xl('Bone Tenderness:','e');?
></td
>
83 <td align
="right"><?php
xl('Medial malleolus:','e');?
></td
>
84 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Medial malleolus" <?
if ($obj{"ankle_ottawa_bone_tenderness"} == "Medial malleolus")
85 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
86 <td align
="right"><?php
xl('Lateral malleolus:','e');?
></td
>
87 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Lateral malleolus" <?
if ($obj{"ankle_ottawa_bone_tenderness"} == "Lateral malleolus")
88 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
89 <td align
="right"><?php
xl('Base of fifth (5th) Metarsal:','e');?
></td
>
90 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="Base of fifth (5th) Metarsal" <?
if ($obj{"ankle_ottawa_bone_tenderness"} == "Base of fifth (5th) Metarsal")
91 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
92 <td align
="right"><?php
xl('At the Navicular:','e');?
></td
>
93 <td
><input type
=radio name
="ankle_ottawa_bone_tenderness" value
="At the Navicular" <?
if ($obj{"ankle_ottawa_bone_tenderness"} == "At the Navicular")
94 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
100 <td align
="right"><?php
xl('Able to Bear Weight four (4) steps:','e');?
></td
>
101 <td align
="right"><?php
xl('Yes:','e');?
></td
>
102 <td
><input type
=radio name
="ankle_able_to_bear_weight_steps" value
="Yes" <?
if ($obj{"ankle_able_to_bear_weight_steps"} == "Yes")
103 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
104 <td align
="right"><?php
xl('No:','e');?
></td
>
105 <td
><input type
=radio name
="ankle_able_to_bear_weight_steps" value
="No" <?
if ($obj{"ankle_able_to_bear_weight_steps"} == "No")
106 {echo "checked";};?
>><span
class=text
></span
><br
></td
>
111 <tr
><th
><?php
xl('X-Ray Interpretation:','e');?
></th
> <th
><?php
xl('Additional X-RAY Notes:','e');?
></th
></tr
>
114 <input type
=entry name
="ankle_x_ray_interpretation" value
="<?echo
115 stripslashes($obj{"ankle_x_ray_interpretation
"});?>" size
="50">
118 <textarea name
="ankle_additional_x_ray_notes" cols
="30" rows
="1" wrap
="virtual name">
119 <?
echo stripslashes($obj{"ankle_additional_x_ray_notes"});?
></textarea
>
125 <tr
><th
><?php
xl('Diagnosis:','e');?
></th
><th
><?php
xl('Additional Diagnosis:','e');?
></th
></tr
>
127 <td
><input type
=entry name
="ankle_diagnosis1" value
="<?echo
128 stripslashes($obj{"ankle_diagnosis1
"});?>" size
="50">
131 <textarea name
="ankle_additional_diagnisis" rows
="2" cols
="30" wrap
="virtual name">
132 <?
echo stripslashes($obj{"ankle_additional_diagnisis"});?
></textarea
>
136 <td
><input type
=entry name
="ankle_diagnosis2" value
="<?echo
137 stripslashes($obj{"ankle_diagnosis2
"});?>" size
="50"></td
>
139 <td
><input type
=entry name
="ankle_diagnosis3" value
="<?echo
140 stripslashes($obj{"ankle_diagnosis3
"});?>" size
="50"></td
>
142 <td
><input type
=entry name
="ankle_diagnosis4" value
="<?echo
143 stripslashes($obj{"ankle_diagnosis4
"});?>" size
="50"></td
>
147 <table
><tr
><th
><?php
xl('Plan:','e');?
></th
><tr
>
149 <textarea name
="ankle_plan" rows
="4" cols
="67" wrap
="virtual name">
150 <?
echo stripslashes($obj{"ankle_plan"});?
></textarea
>
153 <a href
="javascript:document.my_form.submit();" class="link_submit">[<?php
xl('Save','e');?
>]</a
>
155 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[<?php
xl('Don\'t Save Changes','e');?
>]</a
>