Form: High risk screening record

+ + + \ No newline at end of file diff --git a/contrib/forms/high_risk_screening_record/printable.php b/contrib/forms/high_risk_screening_record/printable.php new file mode 100644 index 000000000..7319c8803 --- /dev/null +++ b/contrib/forms/high_risk_screening_record/printable.php @@ -0,0 +1,130 @@ + + + + + +Form: High risk screening record + + + + +> + +

High risk screening record*

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +EOL; +$rsi++; +} +?> +

Patient name:

Birth date:

ID No:

HEMO-
+ GLOBIN
+ TEST

BONE DENSITY
+ SCREENING

BACTERI-
+ URIA TEST

STD
+ TESTING

HIV test*

Genetic testing

Rubella titer

TB skin test

Lipid profile assessment

Mammo-
+ graphy

Fasting
+ GLUCOSE TEST

TSH
+ TEST

COLORECTAL
+ CANCER
+ SCREENING

HEPATITIS C
+ VIRUS TEST

Date:

${hemoglobin_date}

${bone_density_date}

${bacteriuria_date}

${std_date}

${hiv_date}

${genetic_date}

${rubella_date}

${tb_skin_date}

${lipid_date}

${mammography_date}

${fasting_glucose_date}

${tsh_date}

${cancer_date}

${hepatitis_c_date}

Result:

${hemoglobin_res}

${bone_density_res}

${bacteriuria_res}

${std_res}

${hiv_res}

${genetic_res}

${rubella_res}

${tb_skin_res}

${lipid_res}

${mammography_res}

${fasting_glucose_res}

${tsh_res}

${cancer_res}

${hepatitis_c_res}

^*See Table of High-Risk Factors.

^**Check state requirements before recording results.

+ + \ No newline at end of file diff --git a/contrib/forms/high_risk_screening_record/report.php b/contrib/forms/high_risk_screening_record/report.php new file mode 100644 index 000000000..b4a3116d3 --- /dev/null +++ b/contrib/forms/high_risk_screening_record/report.php @@ -0,0 +1,119 @@ + +> + +

High risk screening record*

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +EOL; +$rsi++; +} +?> +

Patient name:

Birth date:

ID No:

HEMO-
+ GLOBIN
+ TEST

BONE DENSITY
+ SCREENING

BACTERI-
+ URIA TEST

STD
+ TESTING

HIV test**

Genetic testing

Rubella titer

TB skin test

Lipid profile assessment

Mammo-
+ graphy

Fasting
+ GLUCOSE TEST

TSH
+ TEST

COLORECTAL
+ CANCER
+ SCREENING

HEPATITIS C
+ VIRUS TEST

Date:

${hemoglobin_date}

${bone_density_date}

${bacteriuria_date}

${std_date}

${hiv_date}

${genetic_date}

${rubella_date}

${tb_skin_date}

${lipid_date}

${mammography_date}

${fasting_glucose_date}

${tsh_date}

${cancer_date}

${hepatitis_c_date}

Result:

${hemoglobin_res}

${bone_density_res}

${bacteriuria_res}

${std_res}

${hiv_res}

${genetic_res}

${rubella_res}

${tb_skin_res}

${lipid_res}

${mammography_res}

${fasting_glucose_res}

${tsh_res}

${cancer_res}

${hepatitis_c_res}

^*See Table of High-Risk Factors.

^**Check state requirements before recording results.

+ \ No newline at end of file diff --git a/contrib/forms/high_risk_screening_record/save.php b/contrib/forms/high_risk_screening_record/save.php new file mode 100644 index 000000000..31491de3c --- /dev/null +++ b/contrib/forms/high_risk_screening_record/save.php @@ -0,0 +1,59 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + //echo "$var\n"; +} + +$ii = 0; +while ($ii<13){ + $ii++; + $data["record_".$ii] = +$_POST["hemoglobin_date_".$ii].';'.$_POST["hemoglobin_res_".$ii].'|~'. +$_POST["bone_density_date_".$ii].';'.$_POST["bone_density_res_".$ii].'|~'. +$_POST["bacteriuria_date_".$ii] .';'.$_POST["bacteriuria_res_".$ii].'|~'. +$_POST["std_date_".$ii] .';'.$_POST["std_res_".$ii].'|~'. +$_POST["hiv_date_".$ii] .';'.$_POST["hiv_res_".$ii].'|~'. +$_POST["genetic_date_".$ii].';'.$_POST["genetic_res_".$ii].'|~'. +$_POST["rubella_date_".$ii].';'.$_POST["rubella_res_".$ii].'|~'. +$_POST["tb_skin_date_".$ii].';'.$_POST["tb_skin_res_".$ii].'|~'. +$_POST["lipid_date_".$ii].';'.$_POST["lipid_res_".$ii].'|~'. +$_POST["mammography_date_".$ii].';'.$_POST["mammography_res_".$ii].'|~'. +$_POST["fasting_glucose_date_".$ii].';'.$_POST["fasting_glucose_res_".$ii] .'|~'. +$_POST["tsh_date_".$ii].';'. $_POST["tsh_res_".$ii].'|~'. +$_POST["cancer_date_".$ii].';'. $_POST["cancer_res_".$ii].'|~'. +$_POST["hepatitis_c_date_".$ii].';'.$_POST["hepatitis_c_res_".$ii]; +} + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_high_risk_screening_record", $data, $_GET["id"], $userauthorized); + addForm($encounter, "High risk screening record", $newid, "high_risk_screening_record", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_high_risk_screening_record set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/high_risk_screening_record/table.sql b/contrib/forms/high_risk_screening_record/table.sql new file mode 100644 index 000000000..b1cc697bc --- /dev/null +++ b/contrib/forms/high_risk_screening_record/table.sql @@ -0,0 +1,26 @@ +CREATE TABLE IF NOT EXISTS `form_high_risk_screening_record` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +record_1 longtext, +record_2 longtext, +record_3 longtext, +record_4 longtext, +record_5 longtext, +record_6 longtext, +record_7 longtext, +record_8 longtext, +record_9 longtext, +record_10 longtext, +record_11 longtext, +record_12 longtext, +record_13 longtext, + + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/high_risk_screening_record/view.php b/contrib/forms/high_risk_screening_record/view.php new file mode 100644 index 000000000..2b8a616d8 --- /dev/null +++ b/contrib/forms/high_risk_screening_record/view.php @@ -0,0 +1,156 @@ + + + + + +Form: High risk screening record + + + + + + + +> + +

+ +

High risk screening record

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +EOL; +$rsi++; +} +?> +

patient name: +

Birth date: +

ID No: +

HEMO-
+ GLOBIN
+ TEST

BONE DENSITY
+ SCREENING

BACTERI-
+ URIA TEST

STD
+ TESTING

HIV test

Genetic testing

Rubella titer

TB skin test

Lipid profile assessment

Mammo-
+ graphy

Fasting
+ GLUCOSE TEST

TSH
+ TEST

COLORECTAL
+ CANCER
+ SCREENING

HEPATITIS C
+ VIRUS TEST

Date:

Result:

+ + + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/immunization_record/info.txt b/contrib/forms/immunization_record/info.txt new file mode 100644 index 000000000..296a0f7ac --- /dev/null +++ b/contrib/forms/immunization_record/info.txt @@ -0,0 +1 @@ +ACOG / Immunization record \ No newline at end of file diff --git a/contrib/forms/immunization_record/new.php b/contrib/forms/immunization_record/new.php new file mode 100644 index 000000000..539cab2db --- /dev/null +++ b/contrib/forms/immunization_record/new.php @@ -0,0 +1,159 @@ + + + + + +Form: ACOG Immunization record + + + + + + + +> + + +

+ +

Immunization record

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

patient name: +				Birth date: +		ID No: +
age	Tetanus- + Diphteria + booster	Influenza + vaccine	Pneumococcal vaccine	MMR Vaccine	Hepatitis B vaccine	Hepatitis A vaccine	Varicella vaccine
13-18	Once between ages 11-16	Based on risk	Based on risk	Based on risk	One series for those not previously immunized	Based on risk	Based on risk
19-39	Every 10 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
40-64	Every 10 years	Annually beginning at age 50 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
65 and older	Every 10 years	Annually	Once		Based on risk	Based on risk	Based on risk

+ + + + + + + + + + + +EOL; +$vacci++; +} +?> +

Date

^*For immunizations based on risk refer to the Table of High-Risk Factors.

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/immunization_record/printable.php b/contrib/forms/immunization_record/printable.php new file mode 100644 index 000000000..302d2755e --- /dev/null +++ b/contrib/forms/immunization_record/printable.php @@ -0,0 +1,118 @@ + + + + + +Form: ACOG Immunization record + + + + + + +

Immunization record^*

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Patient name:				Birth date:		ID No:
age	Tetanus-Diphteria booster	Influenza vaccine	Pneumococcal vaccine	MMR Vaccine	Hepatitis B vaccine	Hepatitis A vaccine	Varicella vaccine
13-18	Once between ages 11-16	Based on risk	Based on risk	Based on risk	One series for those not previously immunized	Based on risk	Based on risk
19-39	Every 10 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
40-64	Every 10 years	Annually beginning at age 50 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
65 and older	Every 10 years	Annually	Once		Based on risk	Based on risk	Based on risk

+ + + + + + + + + + + +EOL; +$vacci++; +} +?> +

Date

${vacc_tetanus[$vacci]}

${vacc_influenza[$vacci]}

${vacc_pneumococcal[$vacci]}

${vacc_mmr[$vacci]}

${vacc_hep_b[$vacci]}

${vacc_hep_a[$vacci]}

${vacc_varicella[$vacci]}

^*For immunizations based on risk refer to the Table of High-Risk Factors.

+ + \ No newline at end of file diff --git a/contrib/forms/immunization_record/report.php b/contrib/forms/immunization_record/report.php new file mode 100644 index 000000000..2f6e0ab90 --- /dev/null +++ b/contrib/forms/immunization_record/report.php @@ -0,0 +1,106 @@ + +

Immunization record^*

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Patient name:				Birth date:		ID No:
age	Tetanus-Diphteria booster	Influenza vaccine	Pneumococcal vaccine	MMR Vaccine	Hepatitis B vaccine	Hepatitis A vaccine	Varicella vaccine
13-18	Once between ages 11-16	Based on risk	Based on risk	Based on risk	One series for those not previously immunized	Based on risk	Based on risk
19-39	Every 10 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
40-64	Every 10 years	Annually beginning at age 50 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
65 and older	Every 10 years	Annually	Once		Based on risk	Based on risk	Based on risk

+ + + + + + + + + + + +EOL; +$vacci++; +} +?> +

Date

${vacc_tetanus[$vacci]}

${vacc_influenza[$vacci]}

${vacc_pneumococcal[$vacci]}

${vacc_mmr[$vacci]}

${vacc_hep_b[$vacci]}

${vacc_hep_a[$vacci]}

${vacc_varicella[$vacci]}

^*For immunizations based on risk refer to the Table of High-Risk Factors.

+ \ No newline at end of file diff --git a/contrib/forms/immunization_record/save.php b/contrib/forms/immunization_record/save.php new file mode 100644 index 000000000..936b1b9e6 --- /dev/null +++ b/contrib/forms/immunization_record/save.php @@ -0,0 +1,68 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + //echo "$var\n"; +} + $vaccs = array( + "vacc_tetanus"=>1, "vacc_influenza"=>1, + "vacc_pneumococcal"=>1, "vacc_mmr"=>1, + "vacc_hep_a"=>1, "vacc_hep_b"=>1, + "vacc_varicella"=>1 + ); + $hdrimmrecord = array( + "vacc_tetanus"=> "Tetanus-Diphteria booster", + "vacc_influenza"=> "Influenza vaccine", + "vacc_pneumococcal"=> "Pneumococcal vaccine", + "vacc_mmr"=> "MMR Vaccine", + "vacc_hep_a"=> "Hepatitis A vaccine", + "vacc_hep_b"=> "Hepatitis B vaccine", + "vacc_varicella"=> "Varicella vaccine" + ); + + + + foreach ($vaccs as $key => $val){ + $si = 0; + $data[$key] = ""; + while ($si < 20){ + $data[$key] .= $_POST["${key}_${si}"].'|~'; + if ($_POST["${key}_${si}"] != ''){ + $data["last_${key}"] = $_POST["${key}_${si}"]; + } + $si++; + } + } + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_immunization_record", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Immunization record", $newid, "immunization_record", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_immunization_record set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/immunization_record/table.sql b/contrib/forms/immunization_record/table.sql new file mode 100644 index 000000000..faf88e452 --- /dev/null +++ b/contrib/forms/immunization_record/table.sql @@ -0,0 +1,25 @@ +CREATE TABLE IF NOT EXISTS `form_immunization_record` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, +vacc_tetanus longtext, +vacc_influenza longtext, +vacc_pneumococcal longtext, +vacc_mmr longtext, +vacc_hep_a longtext, +vacc_hep_b longtext, +vacc_varicella longtext, +last_vacc_tetanus longtext, +last_vacc_influenza longtext, +last_vacc_pneumococcal longtext, +last_vacc_mmr longtext, +last_vacc_hep_a longtext, +last_vacc_hep_b longtext, +last_vacc_varicella longtext, + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/immunization_record/view.php b/contrib/forms/immunization_record/view.php new file mode 100644 index 000000000..69ed7e91f --- /dev/null +++ b/contrib/forms/immunization_record/view.php @@ -0,0 +1,154 @@ + + + + + +Form: ACOG Immunization record + + + + + + + +> + + +

+ +

Immunization record

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

patient name: +				Birth date: +		ID No: +
age	Tetanus- + Diphteria + booster	Influenza + vaccine	Pneumococcal vaccine	MMR Vaccine	Hepatitis B vaccine	Hepatitis A vaccine	Varicella vaccine
13-18	Once between ages 11-16	Based on risk	Based on risk	Based on risk	One series for those not previously immunized	Based on risk	Based on risk
19-39	Every 10 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
40-64	Every 10 years	Annually beginning at age 50 years	Based on risk	Based on risk	Based on risk	Based on risk	Based on risk
65 and older	Every 10 years	Annually	Once		Based on risk	Based on risk	Based on risk

+ + + + + + + + + + + +EOL; +$vacci++; +} +?> +

Date

^*For immunizations based on risk refer to the Table of High-Risk Factors.

+ + + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/medical_decision/info.txt b/contrib/forms/medical_decision/info.txt new file mode 100644 index 000000000..68d2e5b04 --- /dev/null +++ b/contrib/forms/medical_decision/info.txt @@ -0,0 +1 @@ +ACOG / Medical Decision Making \ No newline at end of file diff --git a/contrib/forms/medical_decision/new.php b/contrib/forms/medical_decision/new.php new file mode 100644 index 000000000..73224295e --- /dev/null +++ b/contrib/forms/medical_decision/new.php @@ -0,0 +1,234 @@ + + + + + +Medical decision making + + + + + + +> + +

Medical decision making

+ +

+ + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

Amount and complexility of data reviewed

+ + + + + + + + + +

Tests ordered

review of records

+ + Laboratory

+
+ + cervical cytology
+
+ + HPV test
+
+ + wet mount
+
+ + chlamydia
+
+ + gonorrhea
+
+ + other + +
+

+ + Radiology / Ultrasound

+
+ + mammogram
+
+ + other + +
+

+ + previous test results:

+ +

+ + discussion of test results with performing physician:

+ +

+ + old records reviewed and summarized:

+ +

+ + history obtained from other source:

+ +

+ + independent review of image/specimen:

+ +

Diagnoses / Management option

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ Established problem + + New problem

Assessment and plan:

Risk of complications and/or morbidity/mortality:

+
+ + Minimal (EG, cold, aches and pains, over-the-counter medications)
+
+ + low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors)
+
+ + moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)
+
+ + high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)
+

+ + + + + + + + + + + + + + + + + + + +

Patient counseled about:	+ smoking cessation	+ contraception
	+ weight management	+ safe sex
	+ exercise	+ other

+ Patient education materials provided

Minutes counseled: +

Total encounter time: +

Signature:

Date: +

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/medical_decision/printable.php b/contrib/forms/medical_decision/printable.php new file mode 100644 index 000000000..c404c7de8 --- /dev/null +++ b/contrib/forms/medical_decision/printable.php @@ -0,0 +1,203 @@ + + + + + + +Medical decision making + + + +

Medical decision making

+ + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

date:

Amount and complexility of data reviewed

+ + + + + + + + + +

Tests ordered

review of records

+ ':' '); ?> + Laboratory

+
+ ':' '); ?> + cervical cytology
+
+ ':' '); ?> + HPV test
+
+ ':' '); ?> + wet mount
+
+ ':' '); ?> + chlamydia
+
+ ':' '); ?> + gonorrhea
+
+ ':' '); ?> + other + +
+

+ ':' '); ?> + Radiology / Ultrasound

+
+ ':' '); ?> + mammogram
+
+ ':' '); ?> + other + +
+

+ ':' '); ?> + previous test results:

+ +

+ ':' '); ?> + discussion of test results with performing physician:

+ +

+ ':' '); ?> + old records reviewed and summarized:

+ +

+ ':' '); ?> + history obtained from other source:

+ +

+ ':' '); ?> + independent review of image/specimen:

+ +

Diagnoses / Management option

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

':'

'); ?> + Established problem + ':'

'); ?> + New problem

Assessment and plan:

Risk of complications and/or morbidity/mortality:

+
+ ':' '); ?> + Minimal (EG, cold, aches and pains, over-the-counter medications)
+
+ ':' '); ?> + low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors)
+
+ ':' '); ?> + moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)
+
+ ':' '); ?> + high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)
+

+ + + + + + + + + + + + + + + + + + + +

Patient counseled about:	':' '); ?> + smoking cessation	':' '); ?> + contraception
	':' '); ?> + weight management	':' '); ?> + safe sex
	':' '); ?> + exercise	':' '); ?> + other

':'

'); ?> + Patient education materials provided

Minutes counseled: +

Total encounter time: +

Signature:

Date:

+ + \ No newline at end of file diff --git a/contrib/forms/medical_decision/report.php b/contrib/forms/medical_decision/report.php new file mode 100644 index 000000000..1d66a5d19 --- /dev/null +++ b/contrib/forms/medical_decision/report.php @@ -0,0 +1,191 @@ + +

Medical decision making

+ + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

date:

Amount and complexility of data reviewed

+ + + + + + + + + +

Tests ordered

review of records

+ ':' '); ?> + Laboratory

+
+ ':' '); ?> + cervical cytology
+
+ ':' '); ?> + HPV test
+
+ ':' '); ?> + wet mount
+
+ ':' '); ?> + chlamydia
+
+ ':' '); ?> + gonorrhea
+
+ ':' '); ?> + other + +
+

+ ':' '); ?> + Radiology / Ultrasound

+
+ ':' '); ?> + mammogram
+
+ ':' '); ?> + other + +
+

+ ':' '); ?> + previous test results:

+ +

+ ':' '); ?> + discussion of test results with performing physician:

+ +

+ ':' '); ?> + old records reviewed and summarized:

+ +

+ ':' '); ?> + history obtained from other source:

+ +

+ ':' '); ?> + independent review of image/specimen:

+ +

Diagnoses / Management option

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

':'

'); ?> + Established problem + ':'

'); ?> + New problem

Assessment and plan:

Risk of complications and/or morbidity/mortality:

+
+ ':' '); ?> + Minimal (EG, cold, aches and pains, over-the-counter medications)
+
+ ':' '); ?> + low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors)
+
+ ':' '); ?> + moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)
+
+ ':' '); ?> + high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)
+

+ + + + + + + + + + + + + + + + + + + +

Patient counseled about:	':' '); ?> + smoking cessation	':' '); ?> + contraception
	':' '); ?> + weight management	':' '); ?> + safe sex
	':' '); ?> + exercise	':' '); ?> + other

':'

'); ?> + Patient education materials provided

Minutes counseled: +

Total encounter time: +

Signature:

Date:

+ \ No newline at end of file diff --git a/contrib/forms/medical_decision/save.php b/contrib/forms/medical_decision/save.php new file mode 100644 index 000000000..5a9d409d3 --- /dev/null +++ b/contrib/forms/medical_decision/save.php @@ -0,0 +1,45 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + if (($k != 'pname')&&($k != 'pbdate')&&($k != 'md_pid')){ + $data[$k] = $_POST[$k]; + if ($data[$k] == "YYYY-MM-DD") { + $data[$k] = ''; + } + } + //echo "$var\n"; +} + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_medical_decision", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Medical decision", $newid, "medical_decision", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_medical_decision set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/medical_decision/table.sql b/contrib/forms/medical_decision/table.sql new file mode 100644 index 000000000..d90672fd1 --- /dev/null +++ b/contrib/forms/medical_decision/table.sql @@ -0,0 +1,50 @@ +CREATE TABLE IF NOT EXISTS `form_medical_decision` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +pname varchar(255), +pbdate varchar(255), +md_pid varchar(255), +md_date varchar(64), +test_lab tinyint(1), +test_lab_cervical tinyint(1), +test_lab_hpv tinyint(1), +test_lab_wet_mount tinyint(1), +test_lab_chlamydia tinyint(1), +test_lab_gonorrhea tinyint(1), +test_lab_other tinyint(1), +test_lab_other_data varchar(255), +test_rad tinyint(1), +test_rad_mammogram tinyint(1), +test_rad_other tinyint(1), +test_rad_other_data varchar(255), +previous_test_results tinyint(1), +previous_test_results_data varchar(255), +test_results_discussion tinyint(1), +test_results_discussion_data varchar(255), +old_records_reviewed tinyint(1), +old_records_reviewed_data varchar(255), +history_other_source tinyint(1), +history_other_source_data varchar(255), +independent_review tinyint(1), +independent_review_data varchar(255), +established_problem tinyint(1), +assessment_and_plan longtext, +md_risk varchar(16), +pc_smoking tinyint(1), +pc_contraception tinyint(1), +pc_weight tinyint(1), +pc_safe_sex tinyint(1), +pc_exercise tinyint(1), +pc_other tinyint(1), +patient_education tinyint(1), +minutes_counseled varchar(255), +total_encounter_time varchar(255), + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/medical_decision/view.php b/contrib/forms/medical_decision/view.php new file mode 100644 index 000000000..21d5bb0e0 --- /dev/null +++ b/contrib/forms/medical_decision/view.php @@ -0,0 +1,237 @@ + + + + + +Medical decision making + + + + + + +> + +

Medical decision making

+ +

+ + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

Amount and complexility of data reviewed

+ + + + + + + + + +

Tests ordered

review of records

+ > + Laboratory

+
+ > + cervical cytology
+
+ > + HPV test
+
+ > + wet mount
+
+ > + chlamydia
+
+ > + gonorrhea
+
+ > + other + +
+

+ > + Radiology / Ultrasound

+
+ > + mammogram
+
+ > + other + +
+

+ > + previous test results:

+ +

+ > + discussion of test results with performing physician:

+ +

+ > + old records reviewed and summarized:

+ +

+ > + history obtained from other source:

+ +

+ > + independent review of image/specimen:

+ +

Diagnoses / Management option

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> + Established problem + > + New problem

Assessment and plan:

Risk of complications and/or morbidity/mortality:

+
+ > + Minimal (EG, cold, aches and pains, over-the-counter medications)
+
+ > + low (EG, cystitis, vaginitis, prescription renewal, minor surgery without risk factors)
+
+ > + moderate (EG, breast mass, irregular bleeding, headaches, minor surgery with risk factors, major surgery without risk factors, new prescription)
+
+ > + high (EG, pelvic pain, rectal bleeding, multiple complaints, major surgery with risk factors, chemotherapy, emergency surgery)
+

+ + + + + + + + + + + + + + + + + + + +

Patient counseled about:	> + smoking cessation	> + contraception
	> + weight management	> + safe sex
	> + exercise	> + other

> + Patient education materials provided

Minutes counseled: +

Total encounter time: +

Signature:

Date: +

+ + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/info.txt b/contrib/forms/patient_intake_history/info.txt new file mode 100644 index 000000000..0106cf51d --- /dev/null +++ b/contrib/forms/patient_intake_history/info.txt @@ -0,0 +1 @@ +ACOG / Patient Intake History \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/new.php b/contrib/forms/patient_intake_history/new.php new file mode 100644 index 000000000..fa4a0cf6f --- /dev/null +++ b/contrib/forms/patient_intake_history/new.php @@ -0,0 +1,1881 @@ + + + + + + + + + + + +> + + +

For office use only

+ New patient

+ Established patient

+ Consultation

+ Report sent +

+Patient Intake History is an optional form +giving practices the flexibility to have patients complete +their own history at or before the visit. It uses language +that a patient is likely to understand and includes ample +space for physician notes. Space at the end of the form +allows physicians to review the history and sign off for 4 +years. At year 5, the patient should be asked to complete +a new Patient Intake History. +EOL; +$tip1 = strtr($tip1, "\n\r", " "); +?> +

Patient Intake history

+ + + + + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

+ + + + + + + + + + + + + + + + + + + + +

Address: +
City: +	State/ZIP: +
Home telephone: + + +	Work telephone: +
Employer: +	Insurance +	Policy No: +
Name you would like us to use:	Primary language: +

+ + + + + + + + + + + + +

Name of spouse/partner:	Emergency contact: +
	Relationship: +
	Home telephone: +	Work telephone: +

+ + + + + + + + + + + + + + + +

Referred by: +

Why have you come to the office today? +

If you are here for the annual examination is this a + + Primary care visit or + + Gynecology only

Is this a new problem? + + yes + + no

Please, describe your problem, including, where it is, how severe it is, and how long it has lasted
+

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

Gynecologic history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	Physicians notes
Last normal menstrual period (first day) +
Age periods began: +
Length of periods (number of days of bleeding): +
Number of days between periods: +
Any recent changes in periods? + +Yes + +No
Are you currently sexually active? + +Yes + +No
have you ever had sex? + +Yes + +No
Number of sexual partners (Lifetime): +
Sexual partners are + + Men + + Women + + Both
Present method of birth control: +
Have you ever used an intrauterine device (IUD) or birth control pills ? + +Yes + +No
if yes, for how long? +
When was your last PAP test? +
Do you do breast self examinations? + + Yes + + No
Have you been exposed to diethylstilbestrol (DES)? + +Yes + +No

Obstetric history
+

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.

+ + + + +

Any pregnancy complications?

+ + + + + + + +

+ diabetes + + hypertension/high blood pressure + + preeclampsia/foxemia + + other
any history of depression before or after pregnancy? + + no + + yes, How treated

Current medications
+ (Including hormones, vitamins, herbs, nonprescription medications)
+

+ + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

Drug name	Dosage	Who prescribed	Drug name	Dosage	Who prescribed

Family history
+

+ + + + + + + +

+ + + + + + + + + + + + +

Mother: + + living + + deceased - cause: + + Age: +	father: + +living + +deceased - cause: + +Age: +
Siblings: Num.living: + + , num.deceased: + + , cause(s)/age(s):
Children: Num.living: + +, num.deceased: + +, cause(s)/age(s):

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Illness	yes	which relative(s) and age of onset	Physician's notes
diabetes
Stroke
Heart dIsease
Blood clots in lungs or legs
High blood pressure
High cholesterol
Osteoporosis (weak bones)
Hepatitis
HIV / AIDS
Tuberculosis
Birth defects
Alcohol or drug problems
Breast cancer
Colon cancer
Ovarian cancer
Uterine cancer
Mental illness/Depression
Alzheimer's disease
Other

Social history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	physician's notes
Ever smoked? current smoking: packs/day: + + , years: +
alcohol: drinks/day: + + , + drinks/week: + + , + type of drink: +
Drug use
seat belt use
regular exercise: how long and how often? +
Dairy product intake and/or calcium supplements: daily intake: +
health hazards at home or work?
have you been sexually abused, threatened or hurt by anyone?
do you have an advance directive (living will)?
Are you an organ donor?

Personal profile
+

+ + + + + + + + + + + + + + + + + + + + + + +

Sexual orientation: + + heterosexual + + homosexual + + bisexual

Marital status: + + married + + + living with partner + single + + + widowed + divorced

Number of living children: +

Number of people in household: +

School completed: + + high school + + some college/AA degree + + college + + graduate degree + + other

Current or most recent job: +

Travel outside the United States? + + yes + + no. Location(s): + +

Personal past history of illnesses
+

+ + + + +

major illnesses	yes (date)	no	Not sure	Physician's notes
Asthma	+
Pneumonia/lungs disease	+
Kidney infections/stones	+
Tuberculosis	+
Fibroids	+
Sexually transmitted disease/chlamydia	+
Infertility	+
HIV / AIDS	+
Heart attack / Disease	+
Diabetes	+
High blood pressure	+
Stroke	+
Rheumatic fever	+
Blood clots in lungs or legs	+
Eating disorders	+
Autoimmune disease (Lupus)	+
Chickenpox	+
Cancer	+
Reflux / Hiatal hernia / Ulcers	+
Depression / Anxiety	+
Anemia	+
Blood transfusions	+
Seizures / Convulsions /Epilepsy	+
Bowel problems	+
Glaucoma	+
Cataracts	+
Arthritis / Joint pain / Back problems	+
Broken bones	+
Hepatitis / Yellow jaundice / Liver disease	+
Thyroid disease	+
Gallbladder disease	+
Headaches	+
DES Exposure	+
Bleeding disorders	+
other	+

Operations/Hospitalizations
+

+ + + + + + + + + + + +EOL; +$ii++; +} +?> +

Reason	Date	Hospital

Injuries/Illnesses
+

+ + + + + + + + + + + + + +EOL; +$ii++; +} +?> +

Type	date	Type	date

Immunizations/Test
+

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Type	date	type	date
Tetanus-Diphteria booster	+ +	Influenza vaccine (Flu shot)	+ +
hepatitis a vaccine	+ +	Hepatitis B vaccine	+ +
varicella (Chickenpox) vaccine	+ +	pneumococcal (pneumonia) vaccine	+ +
Measles-Mumps-Rubella (MMR) Vaccine	+ +	Tuberculosis (TB) Skin test: + + , result: +	+ +

+ + + + +

Physician's notes:
+

+ +

Review of systems
+ Please check (x), if any of the following symptoms +apply to you now or since adulthood

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	now	past	not sure	physician's notes
1. Constitutional
Weight loss
Weight gain
Fever
Fatigue
Change in height
2. Eyes
Double vision
Spots before eyes
Vision changes
Glasses/contacts
3. Ear, nose and throat
Earaches
Ringing in ears
Hearing problems
Sinus problems
Sore throat
Mouth sores
Dental problems
4. Cardiovascular
Chest pain on pressure
Difficulty breathing on exertion
Swelling on legs
Rapid or irregular heartbeat
5. Respiratory
Painful breathing
Wheezing
Spitting up blood
Shortness of breath
Chronic cough
6. Gastrointestinal
Frequent diarrhea
Bloody stool
Nausea / vomiting indigestion
Constipation
Involuntary loss of gas or stool
7. Genitourinary
Blood in urine
Pain with urination
Strong urgency to urinate
Frequent urination
Incomplete emtying
Involuntary/Unintended urine loss
Urine loss when coughing or lifting
Abnormal bleeding
Painful periods
Premenstrual Syndrome (PMS)
Painful intercourse
Abnormal vaginal discharge
8. Musculoskeletal
Muscle weakness
Muscle or joint pain
9a. Skin
Rash
Sores
Dry skin
Moles (growth or changes)
9b. Breasts
Pain in breast
Nipple discharge
Lumps
10. Neurologic
Dizziness
Seizures
Numbness
Trouble walking
Memory problems
Frequent headaches
11. Psychiatric
Depression or frequent crying
Anxiety
12. Endocrine
Hair loss
Heat/cold intolerance
Abnormal thirst
Hot flashes
13. Hematologic/Lymphatic
Frequent bruises
Cuts do not stop bleeding
Enlarged Lymph nodes (glands)
14. Allergic/immunologic
Medication allergies
If any, please list allergy and type of reaction:
Latex allergy
Other allergies
Please list allergy and type of reaction:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Form completed by + + patient + + office nurse + + physician + + other: +
Signature of patient:
Date reviewed by physician with patient +	Physician signature:
Annual review of history
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/printable.php b/contrib/forms/patient_intake_history/printable.php new file mode 100644 index 000000000..6a435f308 --- /dev/null +++ b/contrib/forms/patient_intake_history/printable.php @@ -0,0 +1,1800 @@ + + + + + +Patient intake history + + + + + + + + + + + + + + + + + + + + + +

For office use only

':'

'); ?> + New patient

':'

'); ?> + Established patient

':'

'); ?> + Consultation

':'

'); ?> + Report sent:

Patient Intake history

+ + + + + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

Date:

+ + + + + + + + + + + + + + + + + + + +

Address:
City:	State/ZIP:
Home telephone:	Work telephone:
Employer:	Insurance:	Policy No:
Name you would like us to use:	Primary language:

+ + + + + + + + + + + + +

Name of spouse/partner:	Emergency contact:
	Relationship:
	Home telephone: +	Work telephone: +

+ + + + + + + + + + + + + + + +

Referred by: +

Why have you come to the office today? +

If you are here for the annual examination is this a + ':'

'); ?> + Primary care visit or + ':'

'); ?> + Gynecology only

Is this a new problem? + ':'

'); ?> + yes + ':'

'); ?> + no

Please, describe your problem, including, where it is, how severe it is, and how long it has lasted
+

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

Gynecologic history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	Physicians notes
Last normal menstrual period (first day) +
Age periods began: +
Length of periods (number of days of bleeding): +
Number of days between periods: +
Any recent changes in periods? + ':' '); ?> +Yes + ':' '); ?> +No
Are you currently sexually active? + ':' '); ?> +Yes + ':' '); ?> +No
have you ever had sex? + ':' '); ?> +Yes + ':' '); ?> +No
Number of sexual partners (Lifetime): +
Sexual partners are + ':' '); ?> + Men + ':' '); ?> + Women + ':' '); ?> + Both
Present method of birth control: +
Have you ever used an intrauterine device (IUD) or birth control pills ? + ':' '); ?> +Yes + ':' '); ?> +No
if yes, for how long? +
When was your last PAP test? +
Do you do breast self examinations? + ':' '); ?> + Yes + ':' '); ?> + No
Have you been exposed to diethylstilbestrol (DES)? + ':' '); ?> +Yes + ':' '); ?> +No

Obstetric history
+

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.	${oh_ch_date}	${oh_ch_width}	${oh_ch_sex}	${oh_ch_weeks}	${oh_ch_delivery}	${oh_ch_notes}

+ + + + +

Any pregnancy complications?

+ + + + + + + +

':' '); ?> + diabetes + ':' '); ?> + hypertension/high blood pressure + ':' '); ?> + preeclampsia/foxemia + ':' '); ?> + other
any history of depression before or after pregnancy? + ':' '); ?> + no + ':' '); ?> + yes, How treated

Current medications
+ (Including hormones, vitamins, herbs, nonprescription medications)
+

+ + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

Drug name	Dosage	Who prescribed	Drug name	Dosage	Who prescribed
${pres_dosage}	${pres_drug}	${pres_who}	${pres_drug1}	${pres_dosage1}	${pres_who1}

Family history
+

+ + + + + + + +

+ + + + + + + + + + + + +

Mother: + ':' '); ?> + living + ':' '); ?> + deceased - cause: + + Age: +	father: + ':' '); ?> +living + ':' '); ?> +deceased - cause: + +Age: +
Siblings: Num.living: + + , num.deceased: + + , cause(s)/age(s):
Children: Num.living: + +, num.deceased: + +, cause(s)/age(s):

Illness	yes	which relative(s) and age of onset	Physician's notes
diabetes	':' '); ?>
Stroke	':' '); ?>
Heart dIsease	':' '); ?>
Blood clots in lungs or legs	':' '); ?>
High blood pressure	':' '); ?>
High cholesterol	':' '); ?>
Osteoporosis (weak bones)	':' '); ?>
Hepatitis	':' '); ?>
HIV / AIDS	':' '); ?>
Tuberculosis	':' '); ?>
Birth defects	':' '); ?>
Alcohol or drug problems	':' '); ?>
Breast cancer	':' '); ?>
Colon cancer	':' '); ?>
Ovarian cancer	':' '); ?>
Uterine cancer	':' '); ?>
Mental illness/Depression	':' '); ?>
Alzheimer's disease	':' '); ?>
Other	':' '); ?>

Social history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	physician's notes
Ever smoked? Current smoking: packs/day: + + , years: +	':' '); ?>	':' '); ?>
alcohol: drinks/day: + + , + drinks/week: + + , + type of drink: +	':' '); ?>	':' '); ?>
Drug use	':' '); ?>	':' '); ?>
seat belt use	':' '); ?>	':' '); ?>
regular exercise: how long and how often? +	':' '); ?>	':' '); ?>
Dairy product intake and/or calcium supplements: daily intake: +	':' '); ?>	':' '); ?>
health hazards at home or work?	':' '); ?>	':' '); ?>
have you been sexually abused, threatened or hurt by anyone?	':' '); ?>	':' '); ?>
do you have an advance directive (living will)?	':' '); ?>	':' '); ?>
Are you an organ donor?	':' '); ?>	':' '); ?>

Personal profile
+

+ + + + + + + + + + + + + + + + + + + + + + +

Sexual orientation: + ':'

'); ?> + heterosexual + ':'

'); ?> + homosexual + ':'

'); ?> + bisexual

Marital status: + ':'

'); ?> + married + + ':'

'); ?> + living with partner ':'

'); ?> + single + + ':'

'); ?> + widowed ':'

'); ?> + divorced

Number of living children: +

Number of people in household: +

School completed: + ':'

'); ?> + high school + ':'

'); ?> + some college/AA degree + ':'

'); ?> + college + ':'

'); ?> + graduate degree + ':'

'); ?> + other

Current or most recent job: +

Travel outside the United States? + ':'

'); ?> + yes + ':'

'); ?> + no. Location(s): + +

Personal past history of illnesses
+

+ + + + +

major illnesses	yes (date)	no	Not sure	Physician's notes
Asthma	':' '); ?> +	':' '); ?>	':' '); ?>
Pneumonia/lungs disease	':' '); ?> +	':' '); ?>	':' '); ?>
Kidney infections/stones	':' '); ?> +	':' '); ?>	':' '); ?>
Tuberculosis	':' '); ?> +	':' '); ?>	':' '); ?>
Fibroids	':' '); ?> +	':' '); ?>	':' '); ?>
Sexually transmitted disease/chlamydia	':' '); ?> +	':' '); ?>	':' '); ?>
Infertility	':' '); ?> +	':' '); ?>	':' '); ?>
HIV / AIDS	':' '); ?> +	':' '); ?>	':' '); ?>
Heart attack / Disease	':' '); ?> +	':' '); ?>	':' '); ?>
Diabetes	':' '); ?> +	':' '); ?>	':' '); ?>
High blood pressure	':' '); ?> +	':' '); ?>	':' '); ?>
Stroke	':' '); ?> +	':' '); ?>	':' '); ?>
Rheumatic fever	':' '); ?> +	':' '); ?>	':' '); ?>
Blood clots in lungs or legs	':' '); ?> +	':' '); ?>	':' '); ?>
Eating disorders	':' '); ?> +	':' '); ?>	':' '); ?>
Autoimmune disease (Lupus)	':' '); ?> +	':' '); ?>	':' '); ?>
Chickenpox	':' '); ?> +	':' '); ?>	':' '); ?>
Cancer	':' '); ?> +	':' '); ?>	':' '); ?>
Reflux / Hiatal hernia / Ulcers	':' '); ?> +	':' '); ?>	':' '); ?>
Depression / Anxiety	':' '); ?> +	':' '); ?>	':' '); ?>
Anemia	':' '); ?> +	':' '); ?>	':' '); ?>
Blood transfusions	':' '); ?> +	':' '); ?>	':' '); ?>
Seizures / Convulsions /Epilepsy	':' '); ?> +	':' '); ?>	':' '); ?>
Bowel problems	':' '); ?> +	':' '); ?>	':' '); ?>
Glaucoma	':' '); ?> +	':' '); ?>	':' '); ?>
Cataracts	':' '); ?> +	':' '); ?>	':' '); ?>
Arthritis / Joint pain / Back problems	':' '); ?> +	':' '); ?>	':' '); ?>
Broken bones	':' '); ?> +	':' '); ?>	':' '); ?>
Hepatitis / Yellow jaundice / Liver disease	':' '); ?> +	':' '); ?>	':' '); ?>
Thyroid disease	':' '); ?> +	':' '); ?>	':' '); ?>
Gallbladder disease	':' '); ?> +	':' '); ?>	':' '); ?>
Headaches	':' '); ?> +	':' '); ?>	':' '); ?>
DES Exposure	':' '); ?> +	':' '); ?>	':' '); ?>
Bleeding disorders	':' '); ?> +	':' '); ?>	':' '); ?>
other	':' '); ?> +	':' '); ?>	':' '); ?>

Operations/Hospitalizations
+

+ + + + + + + + + + + +EOL; +$ii++; +} +?> +

Reason	Date	Hospital
${op_reason}	${op_date}	${op_hospital}

Injuries/Illnesses
+

+ + + + + + + + + + + + + +EOL; +$ii++; +} +?> +

Type	date	Type	date
${ii_type}	${ii_date}	${ii_type1}	${ii_date1}

Immunizations/Test
+

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Type	date	type	date
Tetanus-Diphteria booster	+	Influenza vaccine (Flu shot)	+
hepatitis a vaccine	+	Hepatitis B vaccine	+
varicella (Chickenpox) vaccine	+	pneumococcal (pneumonia) vaccine	+
Measles-Mumps-Rubella (MMR) Vaccine	+	Tuberculosis (TB) Skin test: + + , result: +	+

+ + + + +

Physician's notes:
+

Review of systems
+ Please check (x), if any of the following symptoms +apply to you now or since adulthood

	now	past	not sure	physician's notes
1. Constitutional
Weight loss	':' '); ?>	':' '); ?>	':' '); ?>
Weight gain	':' '); ?>	':' '); ?>	':' '); ?>
Fever	':' '); ?>	':' '); ?>	':' '); ?>
Fatigue	':' '); ?>	':' '); ?>	':' '); ?>
Change in height	':' '); ?>	':' '); ?>	':' '); ?>
2. Eyes
Double vision	':' '); ?>	':' '); ?>	':' '); ?>
Spots before eyes	':' '); ?>	':' '); ?>	':' '); ?>
Vision changes	':' '); ?>	':' '); ?>	':' '); ?>
Glasses/contacts	':' '); ?>	':' '); ?>	':' '); ?>
3. Ear, nose and throat
Earaches	':' '); ?>	':' '); ?>	':' '); ?>
Ringing in ears	':' '); ?>	':' '); ?>	':' '); ?>
Hearing problems	':' '); ?>	':' '); ?>	':' '); ?>
Sinus problems	':' '); ?>	':' '); ?>	':' '); ?>
Sore throat	':' '); ?>	':' '); ?>	':' '); ?>
Mouth sores	':' '); ?>	':' '); ?>	':' '); ?>
Dental problems	':' '); ?>	':' '); ?>	':' '); ?>
4. Cardiovascular
Chest pain on pressure	':' '); ?>	':' '); ?>	':' '); ?>
Difficulty breathing on exertion	':' '); ?>	':' '); ?>	':' '); ?>
Swelling on legs	':' '); ?>	':' '); ?>	':' '); ?>
Rapid or irregular heartbeat	':' '); ?>	':' '); ?>	':' '); ?>
5. Respiratory
Painful breathing	':' '); ?>	':' '); ?>	':' '); ?>
Wheezing	':' '); ?>	':' '); ?>	':' '); ?>
Spitting up blood	':' '); ?>	':' '); ?>	':' '); ?>
Shortness of breath	':' '); ?>	':' '); ?>	':' '); ?>
Chronic cough	':' '); ?>	':' '); ?>	':' '); ?>
6. Gastrointestinal
Frequent diarrhea	':' '); ?>	':' '); ?>	':' '); ?>
Bloody stool	':' '); ?>	':' '); ?>	':' '); ?>
Nausea / vomiting indigestion	':' '); ?>	':' '); ?>	':' '); ?>
Constipation	':' '); ?>	':' '); ?>	':' '); ?>
Involuntary loss of gas or stool	':' '); ?>	':' '); ?>	':' '); ?>
7. Genitourinary
Blood in urine	':' '); ?>	':' '); ?>	':' '); ?>
Pain with urination	':' '); ?>	':' '); ?>	':' '); ?>
Strong urgency to urinate	':' '); ?>	':' '); ?>	':' '); ?>
Frequent urination	':' '); ?>	':' '); ?>	':' '); ?>
Incomplete emtying	':' '); ?>	':' '); ?>	':' '); ?>
Involuntary/Unintended urine loss	':' '); ?>	':' '); ?>	':' '); ?>
Urine loss when coughing or lifting	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal bleeding	':' '); ?>	':' '); ?>	':' '); ?>
Painful periods	':' '); ?>	':' '); ?>	':' '); ?>
Premenstrual Syndrome (PMS)	':' '); ?>	':' '); ?>	':' '); ?>
Painful intercourse	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal vaginal discharge	':' '); ?>	':' '); ?>	':' '); ?>
8. Musculoskeletal
Muscle weakness	':' '); ?>	':' '); ?>	':' '); ?>
Muscle or joint pain	':' '); ?>	':' '); ?>	':' '); ?>
9a. Skin
Rash	':' '); ?>	':' '); ?>	':' '); ?>
Sores	':' '); ?>	':' '); ?>	':' '); ?>
Dry skin	':' '); ?>	':' '); ?>	':' '); ?>
Moles (growth or changes)	':' '); ?>	':' '); ?>	':' '); ?>
9b. Breasts
Pain in breast	':' '); ?>	':' '); ?>	':' '); ?>
Nipple discharge	':' '); ?>	':' '); ?>	':' '); ?>
Lumps	':' '); ?>	':' '); ?>	':' '); ?>
10. Neurologic
Dizziness	':' '); ?>	':' '); ?>	':' '); ?>
Seizures	':' '); ?>	':' '); ?>	':' '); ?>
Numbness	':' '); ?>	':' '); ?>	':' '); ?>
Trouble walking	':' '); ?>	':' '); ?>	':' '); ?>
Memory problems	':' '); ?>	':' '); ?>	':' '); ?>
Frequent headaches	':' '); ?>	':' '); ?>	':' '); ?>
11. Psychiatric
Depression or frequent crying	':' '); ?>	':' '); ?>	':' '); ?>
Anxiety	':' '); ?>	':' '); ?>	':' '); ?>
12. Endocrine
Hair loss	':' '); ?>	':' '); ?>	':' '); ?>
Heat/cold intolerance	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal thirst	':' '); ?>	':' '); ?>	':' '); ?>
Hot flashes	':' '); ?>	':' '); ?>	':' '); ?>
13. Hematologic/Lymphatic
Frequent bruises	':' '); ?>	':' '); ?>	':' '); ?>
Cuts do not stop bleeding	':' '); ?>	':' '); ?>	':' '); ?>
Enlarged Lymph nodes (glands)	':' '); ?>	':' '); ?>	':' '); ?>
14. Allergic/immunologic
Medication allergies	':' '); ?>	':' '); ?>	':' '); ?>
If any, please list allergy and type of reaction:
Latex allergy	':' '); ?>	':' '); ?>	':' '); ?>
Other allergies	':' '); ?>	':' '); ?>	':' '); ?>
Please list allergy and type of reaction:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Form completed by + ':' '); ?> + patient + ':' '); ?> + office nurse + ':' '); ?> + physician + ':' '); ?> + other: +
Signature of patient:
Date reviewed by physician with patient +	Physician signature:
Annual review of history
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:

+ + \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/report.php b/contrib/forms/patient_intake_history/report.php new file mode 100644 index 000000000..4f6736d4f --- /dev/null +++ b/contrib/forms/patient_intake_history/report.php @@ -0,0 +1,1788 @@ + + + + + + + + + + + + + + + + + +

For office use only

':'

'); ?> + New patient

':'

'); ?> + Established patient

':'

'); ?> + Consultation

':'

'); ?> + Report sent:

Patient Intake history

+ + + + + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

Date:

+ + + + + + + + + + + + + + + + + + + +

Address:
City:	State/ZIP:
Home telephone:	Work telephone:
Employer:	Insurance:	Policy No:
Name you would like us to use:	Primary language:

+ + + + + + + + + + + + +

Name of spouse/partner:	Emergency contact:
	Relationship:
	Home telephone: +	Work telephone: +

+ + + + + + + + + + + + + + + +

Referred by: +

Why have you come to the office today? +

If you are here for the annual examination is this a + ':'

'); ?> + Primary care visit or + ':'

'); ?> + Gynecology only

Is this a new problem? + ':'

'); ?> + yes + ':'

'); ?> + no

Please, describe your problem, including, where it is, how severe it is, and how long it has lasted
+

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

Gynecologic history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	Physicians notes
Last normal menstrual period (first day) +
Age periods began: +
Length of periods (number of days of bleeding): +
Number of days between periods: +
Any recent changes in periods? + ':' '); ?> +Yes + ':' '); ?> +No
Are you currently sexually active? + ':' '); ?> +Yes + ':' '); ?> +No
have you ever had sex? + ':' '); ?> +Yes + ':' '); ?> +No
Number of sexual partners (Lifetime): +
Sexual partners are + ':' '); ?> + Men + ':' '); ?> + Women + ':' '); ?> + Both
Present method of birth control: +
Have you ever used an intrauterine device (IUD) or birth control pills ? + ':' '); ?> +Yes + ':' '); ?> +No
if yes, for how long? +
When was your last PAP test? +
Do you do breast self examinations? + ':' '); ?> + Yes + ':' '); ?> + No
Have you been exposed to diethylstilbestrol (DES)? + ':' '); ?> +Yes + ':' '); ?> +No

Obstetric history
+

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.	${oh_ch_date}	${oh_ch_width}	${oh_ch_sex}	${oh_ch_weeks}	${oh_ch_delivery}	${oh_ch_notes}

+ + + + +

Any pregnancy complications?

+ + + + + + + +

':' '); ?> + diabetes + ':' '); ?> + hypertension/high blood pressure + ':' '); ?> + preeclampsia/foxemia + ':' '); ?> + other
any history of depression before or after pregnancy? + ':' '); ?> + no + ':' '); ?> + yes, How treated

Current medications
+ (Including hormones, vitamins, herbs, nonprescription medications)
+

+ + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

Drug name	Dosage	Who prescribed	Drug name	Dosage	Who prescribed
${pres_dosage}	${pres_drug}	${pres_who}	${pres_drug1}	${pres_dosage1}	${pres_who1}

Family history
+

+ + + + + + + +

+ + + + + + + + + + + + +

Mother: + ':' '); ?> + living + ':' '); ?> + deceased - cause: + + Age: +	father: + ':' '); ?> +living + ':' '); ?> +deceased - cause: + +Age: +
Siblings: Num.living: + + , num.deceased: + + , cause(s)/age(s):
Children: Num.living: + +, num.deceased: + +, cause(s)/age(s):

Illness	yes	which relative(s) and age of onset	Physician's notes
diabetes	':' '); ?>
Stroke	':' '); ?>
Heart dIsease	':' '); ?>
Blood clots in lungs or legs	':' '); ?>
High blood pressure	':' '); ?>
High cholesterol	':' '); ?>
Osteoporosis (weak bones)	':' '); ?>
Hepatitis	':' '); ?>
HIV / AIDS	':' '); ?>
Tuberculosis	':' '); ?>
Birth defects	':' '); ?>
Alcohol or drug problems	':' '); ?>
Breast cancer	':' '); ?>
Colon cancer	':' '); ?>
Ovarian cancer	':' '); ?>
Uterine cancer	':' '); ?>
Mental illness/Depression	':' '); ?>
Alzheimer's disease	':' '); ?>
Other	':' '); ?>

Social history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	physician's notes
Ever smoked? Current smoking: packs/day: + + , years: +	':' '); ?>	':' '); ?>
alcohol: drinks/day: + + , + drinks/week: + + , + type of drink: +	':' '); ?>	':' '); ?>
Drug use	':' '); ?>	':' '); ?>
seat belt use	':' '); ?>	':' '); ?>
regular exercise: how long and how often? +	':' '); ?>	':' '); ?>
Dairy product intake and/or calcium supplements: daily intake: +	':' '); ?>	':' '); ?>
health hazards at home or work?	':' '); ?>	':' '); ?>
have you been sexually abused, threatened or hurt by anyone?	':' '); ?>	':' '); ?>
do you have an advance directive (living will)?	':' '); ?>	':' '); ?>
Are you an organ donor?	':' '); ?>	':' '); ?>

Personal profile
+

+ + + + + + + + + + + + + + + + + + + + + + +

Sexual orientation: + ':'

'); ?> + heterosexual + ':'

'); ?> + homosexual + ':'

'); ?> + bisexual

Marital status: + ':'

'); ?> + married + + ':'

'); ?> + living with partner ':'

'); ?> + single + + ':'

'); ?> + widowed ':'

'); ?> + divorced

Number of living children: +

Number of people in household: +

School completed: + ':'

'); ?> + high school + ':'

'); ?> + some college/AA degree + ':'

'); ?> + college + ':'

'); ?> + graduate degree + ':'

'); ?> + other

Current or most recent job: +

Travel outside the United States? + ':'

'); ?> + yes + ':'

'); ?> + no. Location(s): + +

Personal past history of illnesses
+

+ + + + +

major illnesses	yes (date)	no	Not sure	Physician's notes
Asthma	':' '); ?> +	':' '); ?>	':' '); ?>
Pneumonia/lungs disease	':' '); ?> +	':' '); ?>	':' '); ?>
Kidney infections/stones	':' '); ?> +	':' '); ?>	':' '); ?>
Tuberculosis	':' '); ?> +	':' '); ?>	':' '); ?>
Fibroids	':' '); ?> +	':' '); ?>	':' '); ?>
Sexually transmitted disease/chlamydia	':' '); ?> +	':' '); ?>	':' '); ?>
Infertility	':' '); ?> +	':' '); ?>	':' '); ?>
HIV / AIDS	':' '); ?> +	':' '); ?>	':' '); ?>
Heart attack / Disease	':' '); ?> +	':' '); ?>	':' '); ?>
Diabetes	':' '); ?> +	':' '); ?>	':' '); ?>
High blood pressure	':' '); ?> +	':' '); ?>	':' '); ?>
Stroke	':' '); ?> +	':' '); ?>	':' '); ?>
Rheumatic fever	':' '); ?> +	':' '); ?>	':' '); ?>
Blood clots in lungs or legs	':' '); ?> +	':' '); ?>	':' '); ?>
Eating disorders	':' '); ?> +	':' '); ?>	':' '); ?>
Autoimmune disease (Lupus)	':' '); ?> +	':' '); ?>	':' '); ?>
Chickenpox	':' '); ?> +	':' '); ?>	':' '); ?>
Cancer	':' '); ?> +	':' '); ?>	':' '); ?>
Reflux / Hiatal hernia / Ulcers	':' '); ?> +	':' '); ?>	':' '); ?>
Depression / Anxiety	':' '); ?> +	':' '); ?>	':' '); ?>
Anemia	':' '); ?> +	':' '); ?>	':' '); ?>
Blood transfusions	':' '); ?> +	':' '); ?>	':' '); ?>
Seizures / Convulsions /Epilepsy	':' '); ?> +	':' '); ?>	':' '); ?>
Bowel problems	':' '); ?> +	':' '); ?>	':' '); ?>
Glaucoma	':' '); ?> +	':' '); ?>	':' '); ?>
Cataracts	':' '); ?> +	':' '); ?>	':' '); ?>
Arthritis / Joint pain / Back problems	':' '); ?> +	':' '); ?>	':' '); ?>
Broken bones	':' '); ?> +	':' '); ?>	':' '); ?>
Hepatitis / Yellow jaundice / Liver disease	':' '); ?> +	':' '); ?>	':' '); ?>
Thyroid disease	':' '); ?> +	':' '); ?>	':' '); ?>
Gallbladder disease	':' '); ?> +	':' '); ?>	':' '); ?>
Headaches	':' '); ?> +	':' '); ?>	':' '); ?>
DES Exposure	':' '); ?> +	':' '); ?>	':' '); ?>
Bleeding disorders	':' '); ?> +	':' '); ?>	':' '); ?>
other	':' '); ?> +	':' '); ?>	':' '); ?>

Operations/Hospitalizations
+

+ + + + + + + + + + + +EOL; +$ii++; +} +?> +

Reason	Date	Hospital
${op_reason}	${op_date}	${op_hospital}

Injuries/Illnesses
+

+ + + + + + + + + + + + + +EOL; +$ii++; +} +?> +

Type	date	Type	date
${ii_type}	${ii_date}	${ii_type1}	${ii_date1}

Immunizations/Test
+

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Type	date	type	date
Tetanus-Diphteria booster	+	Influenza vaccine (Flu shot)	+
hepatitis a vaccine	+	Hepatitis B vaccine	+
varicella (Chickenpox) vaccine	+	pneumococcal (pneumonia) vaccine	+
Measles-Mumps-Rubella (MMR) Vaccine	+	Tuberculosis (TB) Skin test: + + , result: +	+

+ + + + +

Physician's notes:
+

Review of systems
+ Please check (x), if any of the following symptoms +apply to you now or since adulthood

	now	past	not sure	physician's notes
1. Constitutional
Weight loss	':' '); ?>	':' '); ?>	':' '); ?>
Weight gain	':' '); ?>	':' '); ?>	':' '); ?>
Fever	':' '); ?>	':' '); ?>	':' '); ?>
Fatigue	':' '); ?>	':' '); ?>	':' '); ?>
Change in height	':' '); ?>	':' '); ?>	':' '); ?>
2. Eyes
Double vision	':' '); ?>	':' '); ?>	':' '); ?>
Spots before eyes	':' '); ?>	':' '); ?>	':' '); ?>
Vision changes	':' '); ?>	':' '); ?>	':' '); ?>
Glasses/contacts	':' '); ?>	':' '); ?>	':' '); ?>
3. Ear, nose and throat
Earaches	':' '); ?>	':' '); ?>	':' '); ?>
Ringing in ears	':' '); ?>	':' '); ?>	':' '); ?>
Hearing problems	':' '); ?>	':' '); ?>	':' '); ?>
Sinus problems	':' '); ?>	':' '); ?>	':' '); ?>
Sore throat	':' '); ?>	':' '); ?>	':' '); ?>
Mouth sores	':' '); ?>	':' '); ?>	':' '); ?>
Dental problems	':' '); ?>	':' '); ?>	':' '); ?>
4. Cardiovascular
Chest pain on pressure	':' '); ?>	':' '); ?>	':' '); ?>
Difficulty breathing on exertion	':' '); ?>	':' '); ?>	':' '); ?>
Swelling on legs	':' '); ?>	':' '); ?>	':' '); ?>
Rapid or irregular heartbeat	':' '); ?>	':' '); ?>	':' '); ?>
5. Respiratory
Painful breathing	':' '); ?>	':' '); ?>	':' '); ?>
Wheezing	':' '); ?>	':' '); ?>	':' '); ?>
Spitting up blood	':' '); ?>	':' '); ?>	':' '); ?>
Shortness of breath	':' '); ?>	':' '); ?>	':' '); ?>
Chronic cough	':' '); ?>	':' '); ?>	':' '); ?>
6. Gastrointestinal
Frequent diarrhea	':' '); ?>	':' '); ?>	':' '); ?>
Bloody stool	':' '); ?>	':' '); ?>	':' '); ?>
Nausea / vomiting indigestion	':' '); ?>	':' '); ?>	':' '); ?>
Constipation	':' '); ?>	':' '); ?>	':' '); ?>
Involuntary loss of gas or stool	':' '); ?>	':' '); ?>	':' '); ?>
7. Genitourinary
Blood in urine	':' '); ?>	':' '); ?>	':' '); ?>
Pain with urination	':' '); ?>	':' '); ?>	':' '); ?>
Strong urgency to urinate	':' '); ?>	':' '); ?>	':' '); ?>
Frequent urination	':' '); ?>	':' '); ?>	':' '); ?>
Incomplete emtying	':' '); ?>	':' '); ?>	':' '); ?>
Involuntary/Unintended urine loss	':' '); ?>	':' '); ?>	':' '); ?>
Urine loss when coughing or lifting	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal bleeding	':' '); ?>	':' '); ?>	':' '); ?>
Painful periods	':' '); ?>	':' '); ?>	':' '); ?>
Premenstrual Syndrome (PMS)	':' '); ?>	':' '); ?>	':' '); ?>
Painful intercourse	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal vaginal discharge	':' '); ?>	':' '); ?>	':' '); ?>
8. Musculoskeletal
Muscle weakness	':' '); ?>	':' '); ?>	':' '); ?>
Muscle or joint pain	':' '); ?>	':' '); ?>	':' '); ?>
9a. Skin
Rash	':' '); ?>	':' '); ?>	':' '); ?>
Sores	':' '); ?>	':' '); ?>	':' '); ?>
Dry skin	':' '); ?>	':' '); ?>	':' '); ?>
Moles (growth or changes)	':' '); ?>	':' '); ?>	':' '); ?>
9b. Breasts
Pain in breast	':' '); ?>	':' '); ?>	':' '); ?>
Nipple discharge	':' '); ?>	':' '); ?>	':' '); ?>
Lumps	':' '); ?>	':' '); ?>	':' '); ?>
10. Neurologic
Dizziness	':' '); ?>	':' '); ?>	':' '); ?>
Seizures	':' '); ?>	':' '); ?>	':' '); ?>
Numbness	':' '); ?>	':' '); ?>	':' '); ?>
Trouble walking	':' '); ?>	':' '); ?>	':' '); ?>
Memory problems	':' '); ?>	':' '); ?>	':' '); ?>
Frequent headaches	':' '); ?>	':' '); ?>	':' '); ?>
11. Psychiatric
Depression or frequent crying	':' '); ?>	':' '); ?>	':' '); ?>
Anxiety	':' '); ?>	':' '); ?>	':' '); ?>
12. Endocrine
Hair loss	':' '); ?>	':' '); ?>	':' '); ?>
Heat/cold intolerance	':' '); ?>	':' '); ?>	':' '); ?>
Abnormal thirst	':' '); ?>	':' '); ?>	':' '); ?>
Hot flashes	':' '); ?>	':' '); ?>	':' '); ?>
13. Hematologic/Lymphatic
Frequent bruises	':' '); ?>	':' '); ?>	':' '); ?>
Cuts do not stop bleeding	':' '); ?>	':' '); ?>	':' '); ?>
Enlarged Lymph nodes (glands)	':' '); ?>	':' '); ?>	':' '); ?>
14. Allergic/immunologic
Medication allergies	':' '); ?>	':' '); ?>	':' '); ?>
If any, please list allergy and type of reaction:
Latex allergy	':' '); ?>	':' '); ?>	':' '); ?>
Other allergies	':' '); ?>	':' '); ?>	':' '); ?>
Please list allergy and type of reaction:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Form completed by + ':' '); ?> + patient + ':' '); ?> + office nurse + ':' '); ?> + physician + ':' '); ?> + other: +
Signature of patient:
Date reviewed by physician with patient +	Physician signature:
Annual review of history
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:

+ \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/save.php b/contrib/forms/patient_intake_history/save.php new file mode 100644 index 000000000..fea153a66 --- /dev/null +++ b/contrib/forms/patient_intake_history/save.php @@ -0,0 +1,98 @@ + $fld){ + if (substr($key, 0,4)!='ros_'){ $data[$fld] = ''; } +} +$flds = sqlListFields("form_patient_intake_history_ros"); +$flds = array_slice($flds,7); +foreach ($flds as $key => $fld){ + if (substr($key, 0,4)=='ros_'){ $ros[$fld] = ''; } +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + if (($k != 'pname')&&($k != 'pbdate')&&($k != 'pih_pid')&&($k != 'pih_date')){ + if ( + (substr($k, 0,4)!='ros_') && + (substr($k, 0,6)!='oh_ch_') && + (substr($k, 0,5)!='pres_') && + (substr($k, 0,3)!='op_') && + (substr($k, 0,3)!='ii_') + ) + { + $data[$k] = $_POST[$k]; + if ($data[$k] == "YYYY-MM-DD") { $data[$k] = ''; } + } else if (substr($k, 0,4)=='ros_') { + $ros[$k] = $_POST[$k]; + } + } + //echo "$var\n"; +} + $ii = 0; + while ($ii < 6){ + $data["oh_ch_rec_".$ii] = $_POST["oh_ch_date_".$ii] . '|~'. + $_POST["oh_ch_width_".$ii] . '|~'. + $_POST["oh_ch_sex_".$ii] . '|~'. + $_POST["oh_ch_weeks_".$ii] . '|~'. + $_POST["oh_ch_delivery_".$ii] . '|~'. + $_POST["oh_ch_notes_".$ii]; + $ii++; + } + $ii = 0; + while ($ii < 10){ + $data["pres_drug_rec_".$ii] = $_POST["pres_drug_".$ii] . '|~'. + $_POST["pres_dosage_".$ii] . '|~'. + $_POST["pres_who_".$ii]; + $ii++; + } + $ii = 0; + while ($ii < 6){ + $data["op_rec_".$ii] = $_POST["op_reason_".$ii] . '|~'. + $_POST["op_date_".$ii] . '|~'. + $_POST["op_hospital_".$ii]; + $ii++; + } + $ii=0; + while ($ii < 12){ + $data["ii_rec_".$ii] = $_POST["ii_type_".$ii] . '|~'. + $_POST["ii_date_".$ii]; + $ii++; + } + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_patient_intake_history_ros", $ros, $_GET["id"], $userauthorized); + $data['linked_ros_id'] = $newid; + $newid = formSubmit("form_patient_intake_history", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Patient intake history", $newid, "patient_intake_history", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_patient_intake_history set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); + $fres=sqlStatement("select linked_ros_id from form_patient_intake_history where id=$id"); + if ($fres){ $ids = sqlFetchArray($fres); } + + foreach ($ros as $key => $val){ + $q2 .= "$key='$val', "; + } + sqlInsert("update form_patient_intake_history_ros set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q2 date = NOW() where id=".$ids['linked_ros_id']); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/patient_intake_history/table.sql b/contrib/forms/patient_intake_history/table.sql new file mode 100644 index 000000000..c23979d14 --- /dev/null +++ b/contrib/forms/patient_intake_history/table.sql @@ -0,0 +1,641 @@ +CREATE TABLE IF NOT EXISTS `form_patient_intake_history` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +pih_patient tinyint(1), +pih_consultation tinyint(1), +pih_report_sent tinyint(1), +pih_report_sent_date varchar(255), +pname varchar(255), +pbdate varchar(255), +pih_pid varchar(255), +pih_date varchar(255), +address varchar(255), +city varchar(255), +state varchar(255), +home_phone varchar(255), +work_phone varchar(255), +employer varchar(255), +insurance varchar(255), +policy_no varchar(255), +name_to_use varchar(255), +primary_language varchar(255), +partner_emergency_contact varchar(255), +partner_name longtext, +relationship varchar(255), +partner_home_phone varchar(255), +partner_work_phone varchar(255), +referred_by varchar(255), +why_come_to_office varchar(255), +primary_care_visit tinyint(1), +new_problem tinyint(1), +problem_description longtext, +last_period_date varchar(255), +gh_notes_1 varchar(255), +periods_began varchar(255), +gh_notes_2 varchar(255), +period_lenght varchar(255), +gh_notes_3 varchar(255), +period_days_between varchar(255), +gh_notes_4 varchar(255), +period_changes tinyint(1), +pih_gh_recent_changes_periods tinyint(1), +gh_notes_5 varchar(255), +sexually_active tinyint(1), +gh_notes_6 varchar(255), +ever_had_sex tinyint(1), +gh_notes_7 varchar(255), +number_of_partners varchar(255), +gh_notes_8 varchar(255), +partners varchar(16), +gh_notes_9 varchar(255), +present_birth_control varchar(255), +gh_notes_10 varchar(255), +pills_iud tinyint(1), +gh_notes_11 varchar(255), +pills_how_long varchar(255), +gh_notes_12 varchar(255), +pap_test varchar(255), +gh_notes_13 varchar(255), +breast_self_exam tinyint(1), +gh_notes_14 varchar(255), +des tinyint(1), +gh_notes_15 varchar(255), +oh_pregnancies varchar(255), +oh_abortions varchar(255), +oh_miscarriages varchar(255), +oh_premature_births varchar(255), +oh_live_births varchar(255), +oh_living_children varchar(255), +oh_complications varchar(255), +oh_ch_rec_0 longtext, +oh_ch_rec_1 longtext, +oh_ch_rec_2 longtext, +oh_ch_rec_3 longtext, +oh_ch_rec_4 longtext, +oh_ch_rec_5 longtext, +oh_diabetes tinyint(1), +oh_hipertension tinyint(1), +oh_preemclampsia tinyint(1), +oh_complic_other tinyint(1), +oh_depression tinyint(1), +oh_depression_treated varchar(255), +pres_drug_rec_0 longtext, +pres_drug_rec_1 longtext, +pres_drug_rec_2 longtext, +pres_drug_rec_3 longtext, +pres_drug_rec_4 longtext, +pres_drug_rec_5 longtext, +pres_drug_rec_6 longtext, +pres_drug_rec_7 longtext, +pres_drug_rec_8 longtext, +pres_drug_rec_9 longtext, +fh_mother tinyint(1), +fh_mother_dec_cause varchar(255), +fh_mother_dec_age varchar(255), +fh_father tinyint(1), +fh_father_dec_cause varchar(255), +fh_father_dec_age varchar(255), +fh_sibl_living varchar(255), +fh_sib_deceased varchar(255), +fh_sib_dec_cause varchar(255), +fh_children_living varchar(255), +fh_children_deceased varchar(255), +fh_children_dec_cause varchar(255), +fh_diabetes tinyint(1), +fh_diabetes_info varchar(255), +fh_notes_1 varchar(255), +fh_stroke tinyint(1), +fh_stroke_info varchar(255), +fh_notes_2 varchar(255), +fh_heart_disease tinyint(1), +fh_heart_disease_info varchar(255), +fh_notes_3 varchar(255), +fhbllod_clots tinyint(1), +fhbllod_clots_info varchar(255), +fh_notes_4 varchar(255), +fh_high_pressure tinyint(1), +fh_high_pressure_info varchar(255), +fh_notes_5 varchar(255), +fh_high_cholesterol tinyint(1), +fh_high_cholesterol_info varchar(255), +fh_notes_6 varchar(255), +fh_osteoporosis tinyint(1), +fh_osteoporosis_info varchar(255), +fh_notes_7 varchar(255), +fh_hepatitis tinyint(1), +fh_hepatitis_info varchar(255), +fh_notes_8 varchar(255), +fh_hiv tinyint(1), +fh_hiv_info varchar(255), +fh_notes_9 varchar(255), +fh_tuberculosis tinyint(1), +fh_tuberculosis_info varchar(255), +fh_notes_10 varchar(255), +dh_birth_defects tinyint(1), +dh_birth_defects_info varchar(255), +fh_notes_11 varchar(255), +fh_alcohol_drugs tinyint(1), +fh_alcohol_drugs_info varchar(255), +fh_notes_12 varchar(255), +fh_breast_cancer tinyint(1), +fh_breast_cancer_info varchar(255), +fh_notes_13 varchar(255), +fh_colon_cancer tinyint(1), +fh_colon_cancer_info varchar(255), +fh_notes_14 varchar(255), +fh_ovarian_cancer varchar(255), +fh_notes_15 varchar(255), +fh_uterine_cancer tinyint(1), +fh_uterine_cancer_info varchar(255), +fh_notes_16 varchar(255), +fh_mental_illness tinyint(1), +fh_mental_illness_info varchar(255), +fh_notes_17 varchar(255), +fh_alzheimer tinyint(1), +fh_alzheimer_info varchar(255), +fh_notes_18 varchar(255), +fh_other_illness tinyint(1), +fh_other_illness_info varchar(255), +fh_notes_19 varchar(255), +sh_smoked_packs varchar(255), +sh_smoked_years varchar(255), +pih_smoked tinyint(1), +sh_notes_1 varchar(255), +sh_alcohol_drinks_day varchar(255), +sh_alcohol_drinks_week varchar(255), +sh_alcohol_drinks_type varchar(255), +pih_alcohol tinyint(1), +sh_notes_2 varchar(255), +pih_drug tinyint(1), +sh_notes_3 varchar(255), +pih_seat_belt tinyint(1), +sh_notes_4 varchar(255), +sh_exercise_info varchar(255), +pih_exercise tinyint(1), +sh_notes_5 varchar(255), +sh_dairy_daily varchar(255), +pih_dairy tinyint(1), +sh_notes_6 varchar(255), +pih_hazards tinyint(1), +sh_notes_7 varchar(255), +pih_abuse tinyint(1), +sh_notes_8 varchar(255), +pih_living_will tinyint(1), +sh_notes_9 varchar(255), +pih_donor tinyint(1), +sh_notes_10 varchar(255), +pih_pp_orientation varchar(16), +pih_pp_status varchar(16), +pp_living_children varchar(255), +pp_number_household varchar(255), +pih_pp_education varchar(32), +pp_current_job varchar(255), +pp_travel_outside_us tinyint(1), +pp_travel_outside_locations varchar(255), +pih_ih_asthma tinyint(1), +pih_ih_asthma_date varchar(255), +ih_notes_1 varchar(255), +pih_ih_pneumonia tinyint(1), +pih_ih_pneumonia_date varchar(255), +ih_notes_2 varchar(255), +pih_ih_kidney tinyint(1), +pih_ih_kidney_date varchar(255), +ih_notes_3 varchar(255), +pih_ih_tuber tinyint(1), +pih_ih_tuber_date varchar(255), +ih_notes_4 varchar(255), +pih_ih_fibroids tinyint(1), +pih_ih_fibroids_date varchar(255), +ih_notes_5 varchar(255), +pih_ih_sexually tinyint(1), +pih_ih_sexually_date varchar(255), +ih_notes_6 varchar(255), +pih_ih_infertil tinyint(1), +pih_ih_infertil_date varchar(255), +ih_notes_7 varchar(255), +pih_ih_hiv tinyint(1), +pih_ih_hiv_date varchar(255), +ih_notes_8 varchar(255), +pih_ih_heart tinyint(1), +pih_ih_heart_date varchar(255), +ih_notes_9 varchar(255), +pih_ih_diabetes tinyint(1), +pih_ih_diabetes_date varchar(255), +ih_notes_10 varchar(255), +pih_ih_high_pressure tinyint(1), +pih_ih_high_pressure_date varchar(255), +ih_notes_11 varchar(255), +pih_ih_stroke tinyint(1), +pih_ih_stroke_date varchar(255), +ih_notes_12 varchar(255), +pih_ih_rheumatic tinyint(1), +pih_ih_rheumatic_date varchar(255), +ih_notes_13 varchar(255), +pih_ih_blood_clots tinyint(1), +pih_ih_blood_clots_date varchar(255), +ih_notes_14 varchar(255), +pih_ih_eating_disorder tinyint(1), +pih_ih_eating_disorder_date varchar(255), +ih_notes_15 varchar(255), +pih_ih_autoimmune tinyint(1), +pih_ih_autoimmune_date varchar(255), +ih_notes_16 varchar(255), +pih_ih_chickenpox tinyint(1), +pih_ih_chickenpox_date varchar(255), +ih_notes_17 varchar(255), +pih_ih_cancer tinyint(1), +pih_ih_cancer_date varchar(255), +ih_notes_18 varchar(255), +pih_ih_reflux tinyint(1), +pih_ih_reflux_date varchar(255), +ih_notes_19 varchar(255), +pih_ih_depression tinyint(1), +pih_ih_depression_date varchar(255), +ih_notes_20 varchar(255), +pih_ih_anemia tinyint(1), +pih_ih_anemia_date varchar(255), +ih_notes_21 varchar(255), +pih_ih_blood_transf tinyint(1), +pih_ih_blood_transf_date varchar(255), +ih_notes_22 varchar(255), +pih_ih_seizures tinyint(1), +pih_ih_seizures_date varchar(255), +ih_notes_23 varchar(255), +pih_ih_bowel_problems tinyint(1), +pih_ih_bowel_problems_date varchar(255), +ih_notes_24 varchar(255), +pih_ih_glaucoma tinyint(1), +pih_ih_glaucoma_date varchar(255), +ih_notes_25 varchar(255), +pih_ih_cataracts tinyint(1), +pih_ih_cataracts_date varchar(255), +ih_notes_26 varchar(255), +pih_ih_joint_pain tinyint(1), +pih_ih_joint_pain_date varchar(255), +ih_notes_27 varchar(255), +pih_ih_broken_bones tinyint(1), +pih_ih_broken_bones_date varchar(255), +ih_notes_28 varchar(255), +pih_ih_hepatitis tinyint(1), +pih_ih_hepatitis_date varchar(255), +ih_notes_29 varchar(255), +pih_ih_thyroid tinyint(1), +pih_ih_thyroid_date varchar(255), +ih_notes_30 varchar(255), +pih_ih_galibladder tinyint(1), +pih_ih_galibladder_date varchar(255), +ih_notes_31 varchar(255), +pih_ih_headaches tinyint(1), +pih_ih_headaches_date varchar(255), +ih_notes_32 varchar(255), +pih_ih_des tinyint(1), +pih_ih_des_date varchar(255), +ih_notes_33 varchar(255), +pih_ih_bleeding_disorders tinyint(1), +pih_ih_bleeding_disorders_date varchar(255), +ih_notes_34 varchar(255), +pih_ih_other tinyint(1), +pih_ih_other_date varchar(255), +ih_notes_35 varchar(255), +pih_ih_extended_info longtext, +op_rec_0 longtext, +op_rec_1 longtext, +op_rec_2 longtext, +op_rec_3 longtext, +op_rec_4 longtext, +op_rec_5 longtext, +ii_rec_0 varchar(255), +ii_rec_1 varchar(255), +ii_rec_2 varchar(255), +ii_rec_3 varchar(255), +ii_rec_4 varchar(255), +ii_rec_5 varchar(255), +ii_rec_6 varchar(255), +ii_rec_7 varchar(255), +ii_rec_8 varchar(255), +ii_rec_9 varchar(255), +ii_rec_10 varchar(255), +ii_rec_11 varchar(255), +imm_influenza varchar(255), +imm_hepatitis_a varchar(255), +imm_hepatitis_b varchar(255), +imm_varicella varchar(255), +imm_pneumococcal varchar(255), +imm_mmr varchar(255), +imm_tetanus varchar(255), +imm_tuberculosis_skin varchar(255), +imm_tuberculosis_result varchar(255), +imm_tuberculosis varchar(255), +imm_extended_info longtext, + +pih_completed_by varchar(32), +pih_completed_by_other varchar(255), +pih_date_reviewed_1 varchar(255), +pih_date_reviewed_2 varchar(255), +pih_date_reviewed_3 varchar(255), +pih_date_reviewed_4 varchar(255), +pih_date_reviewed_5 varchar(255), +pih_date_reviewed_6 varchar(255), + +linked_ros_id bigint(20) NOT NULL, + +PRIMARY KEY (id) +) TYPE=MyISAM; + + +CREATE TABLE IF NOT EXISTS `form_patient_intake_history_ros` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +ros_weight_loss_now tinyint(1), +ros_weight_loss_past tinyint(1), +ros_weight_loss_notsure tinyint(1), +ros_notes_1 varchar(255), +ros_weight_gain_now tinyint(1), +ros_weight_gain_past tinyint(1), +ros_weight_gain_notsure tinyint(1), +ros_notes_2 varchar(255), +ros_fever_now tinyint(1), +ros_fever_past tinyint(1), +ros_fever_notsure tinyint(1), +ros_notes_3 varchar(255), +ros_fatigue_now tinyint(1), +ros_fatigue_past tinyint(1), +ros_fatigue_notsure tinyint(1), +ros_notes_4 varchar(255), +ros_height_change_now tinyint(1), +ros_height_change_past tinyint(1), +ros_height_change_notsure tinyint(1), +ros_notes_5 varchar(255), +ros_dvision_now tinyint(1), +ros_dvision_past tinyint(1), +ros_dvision_notsure tinyint(1), +ros_notes_6 varchar(255), +ros_spots_eyes_now tinyint(1), +ros_spots_eyes_past tinyint(1), +ros_spots_eyes_notsure tinyint(1), +ros_notes_7 varchar(255), +ros_vis_changes_now tinyint(1), +ros_vis_changes_past tinyint(1), +ros_vis_changes_notsure tinyint(1), +ros_notes_8 varchar(255), +ros_glasses_now tinyint(1), +ros_glasses_past tinyint(1), +ros_glasses_notsure tinyint(1), +ros_notes_9 varchar(255), +ros_earaches_now tinyint(1), +ros_earaches_past tinyint(1), +ros_earaches_notsure tinyint(1), +ros_notes_10 varchar(255), +ros_ringing_now tinyint(1), +ros_ringing_past tinyint(1), +ros_ringing_notsure tinyint(1), +ros_notes_11 varchar(255), +ros_hearing_problems_now tinyint(1), +ros_hearing_problems_past tinyint(1), +ros_hearing_problems_notsure tinyint(1), +ros_notes_12 varchar(255), +ros_sinus_problems_now tinyint(1), +ros_sinus_problems_past tinyint(1), +ros_sinus_problems_notsure tinyint(1), +ros_notes_13 varchar(255), +ros_sore_throat_now tinyint(1), +ros_sore_throat_past tinyint(1), +ros_sore_throat_notsure tinyint(1), +ros_notes_14 varchar(255), +ros_mouth_sores_now tinyint(1), +ros_mouth_sores_past tinyint(1), +ros_mouth_sores_notsure tinyint(1), +ros_notes_15 varchar(255), +ros_dental_problems_now tinyint(1), +ros_dental_problems_past tinyint(1), +ros_dental_problems_notsure tinyint(1), +ros_notes_16 varchar(255), +ros_chest_pain_now tinyint(1), +ros_chest_pain_past tinyint(1), +ros_chest_pain_notsure tinyint(1), +ros_notes_17 varchar(255), +ros_difficulty_breathing_now tinyint(1), +ros_difficulty_breathing_past tinyint(1), +ros_difficulty_breathing_notsure tinyint(1), +ros_notes_18 varchar(255), +ros_swelling_legs_now tinyint(1), +ros_swelling_legs_past tinyint(1), +ros_swelling_legs_notsure tinyint(1), +ros_notes_19 varchar(255), +ros_rapid_heartbeat_now tinyint(1), +ros_rapid_heartbeat_past tinyint(1), +ros_rapid_heartbeat_notsure tinyint(1), +ros_notes_20 varchar(255), +ros_painful_breathing_now tinyint(1), +ros_painful_breathing_past tinyint(1), +ros_painful_breathing_notsure tinyint(1), +ros_notes_21 varchar(255), +ros_wheezing_now tinyint(1), +ros_wheezing_past tinyint(1), +ros_wheezing_notsure tinyint(1), +ros_notes_22 varchar(255), +ros_spitting_blood_now tinyint(1), +ros_spitting_blood_past tinyint(1), +ros_spitting_blood_notsure tinyint(1), +ros_notes_23 varchar(255), +ros_breath_shortness_now tinyint(1), +ros_breath_shortness_past tinyint(1), +ros_breath_shortness_notsure tinyint(1), +ros_notes_24 varchar(255), +ros_chronic_cough_now tinyint(1), +ros_chronic_cough_past tinyint(1), +ros_chronic_cough_notsure tinyint(1), +ros_notes_25 varchar(255), +ros_diarrhea_now tinyint(1), +ros_diarrhea_past tinyint(1), +ros_diarrhea_notsure tinyint(1), +ros_notes_26 varchar(255), +ros_bloody_stool_now tinyint(1), +ros_bloody_stool_past tinyint(1), +ros_bloody_stool_notsure tinyint(1), +ros_notes_27 varchar(255), +ros_nausea_now tinyint(1), +ros_nausea_past tinyint(1), +ros_nausea_notsure tinyint(1), +ros_notes_28 varchar(255), +ros_constipation_now tinyint(1), +ros_constipation_past tinyint(1), +ros_constipation_notsure tinyint(1), +ros_notes_29 varchar(255), +ros_gas_loss_now tinyint(1), +ros_gas_loss_past tinyint(1), +ros_gas_loss_notsure tinyint(1), +ros_notes_30 varchar(255), +ros_blood_urine_now tinyint(1), +ros_blood_urine_past tinyint(1), +ros_blood_urine_notsure tinyint(1), +ros_notes_31 varchar(255), +ros_pain_urination_now tinyint(1), +ros_pain_urination_past tinyint(1), +ros_pain_urination_notsure tinyint(1), +ros_notes_32 varchar(255), +ros_urgency_urinate_now tinyint(1), +ros_urgency_urinate_past tinyint(1), +ros_urgency_urinate_notsure tinyint(1), +ros_notes_33 varchar(255), +ros_frequent_urination_now tinyint(1), +ros_frequent_urination_past tinyint(1), +ros_frequent_urination_notsure tinyint(1), +ros_notes_34 varchar(255), +ros_incomplete_emptying_now tinyint(1), +ros_incomplete_emptying_past tinyint(1), +ros_incomplete_emptying_notsure tinyint(1), +ros_notes_35 varchar(255), +ros_unint_urine_loss_now tinyint(1), +ros_unint_urine_loss_past tinyint(1), +ros_unint_urine_loss_notsure tinyint(1), +ros_notes_36 varchar(255), +ros_lifting_urine_loss_now tinyint(1), +ros_lifting_urine_loss_past tinyint(1), +ros_lifting_urine_loss_notsure tinyint(1), +ros_notes_37 varchar(255), +ros_abnormal_bleeding_now tinyint(1), +ros_abnormal_bleeding_past tinyint(1), +ros_abnormal_bleeding_notsure tinyint(1), +ros_notes_38 varchar(255), +ros_painful_periods_now tinyint(1), +ros_painful_periods_past tinyint(1), +ros_painful_periods_notsure tinyint(1), +ros_notes_39 varchar(255), +ros_pms_now tinyint(1), +ros_pms_past tinyint(1), +ros_pms_notsure tinyint(1), +ros_notes_40 varchar(255), +ros_painful_intercourse_now tinyint(1), +ros_painful_intercourse_past tinyint(1), +ros_painful_intercourse_notsure tinyint(1), +ros_notes_41 varchar(255), +ros_vaginal_discharge_now tinyint(1), +ros_vaginal_discharge_past tinyint(1), +ros_vaginal_discharge_notsure tinyint(1), +ros_notes_42 varchar(255), +ros_muscle_weakness_now tinyint(1), +ros_muscle_weakness_past tinyint(1), +ros_muscle_weakness_notsure tinyint(1), +ros_notes_43 varchar(255), +ros_muscle_pain_now tinyint(1), +ros_muscle_pain_past tinyint(1), +ros_muscle_pain_notsure tinyint(1), +ros_notes_44 varchar(255), +ros_rash_now tinyint(1), +ros_rash_past tinyint(1), +ros_rash_notsure tinyint(1), +ros_notes_45 varchar(255), +ros_sores_now tinyint(1), +ros_sores_past tinyint(1), +ros_sores_notsure tinyint(1), +ros_notes_46 varchar(255), +ros_dry_skin_now tinyint(1), +ros_dry_skin_past tinyint(1), +ros_dry_skin_notsure tinyint(1), +ros_notes_47 varchar(255), +ros_moles_now tinyint(1), +ros_moles_past tinyint(1), +ros_moles_notsure tinyint(1), +ros_notes_48 varchar(255), +ros_pain_breast_now tinyint(1), +ros_pain_breast_past tinyint(1), +ros_pain_breast_notsure tinyint(1), +ros_notes_49 varchar(255), +ros_nipple_discharge_now tinyint(1), +ros_nipple_discharge_past tinyint(1), +ros_nipple_discharge_notsure tinyint(1), +ros_notes_50 varchar(255), +ros_lumps_now tinyint(1), +ros_lumps_past tinyint(1), +ros_lumps_notsure tinyint(1), +ros_notes_51 varchar(255), +ros_dizziness_now tinyint(1), +ros_dizziness_past tinyint(1), +ros_dizziness_notsure tinyint(1), +ros_notes_52 varchar(255), +ros_seizures_now tinyint(1), +ros_seizures_past tinyint(1), +ros_seizures_notsure tinyint(1), +ros_notes_53 varchar(255), +ros_numbness_now tinyint(1), +ros_numbness_past tinyint(1), +ros_numbness_notsure tinyint(1), +ros_notes_54 varchar(255), +ros_trouble_walking_now tinyint(1), +ros_trouble_walking_past tinyint(1), +ros_trouble_walking_notsure tinyint(1), +ros_notes_55 varchar(255), +ros_memory_problems_now tinyint(1), +ros_memory_problems_past tinyint(1), +ros_memory_problems_notsure tinyint(1), +ros_notes_56 varchar(255), +ros_freq_headaches_now tinyint(1), +ros_freq_headaches_past tinyint(1), +ros_freq_headaches_notsure tinyint(1), +ros_notes_57 varchar(255), +ros_depression_now tinyint(1), +ros_depression_past tinyint(1), +ros_depression_notsure tinyint(1), +ros_notes_58 varchar(255), +ros_anxiety_now tinyint(1), +ros_anxiety_past tinyint(1), +ros_anxiety_notsure tinyint(1), +ros_notes_59 varchar(255), +ros_hair_loss_now tinyint(1), +ros_hair_loss_past tinyint(1), +ros_hair_loss_notsure tinyint(1), +ros_notes_60 varchar(255), +ros_heat_cold_intolerance_now tinyint(1), +ros_heat_cold_intolerance_past tinyint(1), +ros_heat_cold_intolerance_notsure tinyint(1), +ros_notes_61 varchar(255), +ros_abnormal_thirst_now tinyint(1), +ros_abnormal_thirst_past tinyint(1), +ros_abnormal_thirst_notsure tinyint(1), +ros_notes_62 varchar(255), +ros_hot_flashes_now tinyint(1), +ros_hot_flashes_past tinyint(1), +ros_hot_flashes_notsure tinyint(1), +ros_notes_63 varchar(255), +ros_frequent_bruises_now tinyint(1), +ros_frequent_bruises_past tinyint(1), +ros_frequent_bruises_notsure tinyint(1), +ros_notes_64 varchar(255), +ros_cuts_bleeding_now tinyint(1), +ros_cuts_bleeding_past tinyint(1), +ros_cuts_bleeding_notsure tinyint(1), +ros_notes_65 varchar(255), +ros_enlarged_nodes_now tinyint(1), +ros_enlarged_nodes_past tinyint(1), +ros_enlarged_nodes_notsure tinyint(1), +ros_notes_66 varchar(255), +ros_med_allergy_now tinyint(1), +ros_med_allergy_past tinyint(1), +ros_med_allergy_notsure tinyint(1), +ros_notes_68 varchar(255), +ros_med_allergy_reaction varchar(255), +ros_latex_allergy_now tinyint(1), +ros_latex_allergy_past tinyint(1), +ros_latex_allergy_notsure tinyint(1), +ros_notes_69 varchar(255), +ros_other_allergy_now tinyint(1), +ros_other_allergy_past tinyint(1), +ros_other_allergy_notsure tinyint(1), +ros_notes_70 varchar(255), +ros_other_allergy_reaction_ varchar(255), + +PRIMARY KEY (id) +) TYPE=MyISAM; \ No newline at end of file diff --git a/contrib/forms/patient_intake_history/view.php b/contrib/forms/patient_intake_history/view.php new file mode 100644 index 000000000..005d029a9 --- /dev/null +++ b/contrib/forms/patient_intake_history/view.php @@ -0,0 +1,1872 @@ + + + + + + + + + + + +> + + +

For office use only

> + New patient

> + Established patient

> + Consultation

> + Report sent +

Patient Intake history

+ + + + + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

+ + + + + + + + + + + + + + + + + + + + +

Address: +
City: +	State/ZIP: +
Home telephone: + + +	Work telephone: +
Employer: +	Insurance +	Policy No: +
Name you would like us to use:	Primary language: +

+ + + + + + + + + + + + +

Name of spouse/partner:	Emergency contact: +
<? echo $fdata{'partner_name'}; ?>	Relationship: +
	Home telephone: +	Work telephone: +

+ + + + + + + + + + + + + + + +

Referred by: +

Why have you come to the office today? +

If you are here for the annual examination is this a + > + Primary care visit or + > + Gynecology only

Is this a new problem? + > + yes + > + no

Please, describe your problem, including, where it is, how severe it is, and how long it has lasted
+

If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.

Gynecologic history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	Physicians notes
Last normal menstrual period (first day) +
Age periods began: +
Length of periods (number of days of bleeding): +
Number of days between periods: +
Any recent changes in periods? + > +Yes +> +No
Are you currently sexually active? + > +Yes +> +No
have you ever had sex? + > +Yes +> +No
Number of sexual partners (Lifetime): +
Sexual partners are + > + Men + > + Women + > + Both
Present method of birth control: +
Have you ever used an intrauterine device (IUD) or birth control pills ? + > +Yes +> +No
if yes, for how long? +
When was your last PAP test? +
Do you do breast self examinations? + > + Yes + > + No
Have you been exposed to diethylstilbestrol (DES)? + > +Yes +> +No

Obstetric history
+

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.

+ + + + +

Any pregnancy complications?

+ + + + + + + +

> + diabetes + > + hypertension/high blood pressure + > + preeclampsia/foxemia + > + other
any history of depression before or after pregnancy? + > + no + > + yes, How treated

Current medications
+ (Including hormones, vitamins, herbs, nonprescription medications)
+

+ + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

Drug name	Dosage	Who prescribed	Drug name	Dosage	Who prescribed

Family history
+

+ + + + + + + +

+ + + + + + + + + + + + +

Mother: + > + living + > + deceased - cause: + + Age: +	father: + > +living +> +deceased - cause: + +Age: +
Siblings: Num.living: + + , num.deceased: + + , cause(s)/age(s):
Children: Num.living: + +, num.deceased: + +, cause(s)/age(s):

Illness	yes	which relative(s) and age of onset	Physician's notes
diabetes	>
Stroke	>
Heart dIsease	>
Blood clots in lungs or legs	>
High blood pressure	>
High cholesterol	>
Osteoporosis (weak bones)	>
Hepatitis	>
HIV / AIDS	>
Tuberculosis	>
Birth defects	>
Alcohol or drug problems	>
Breast cancer	>
Colon cancer	>
Ovarian cancer	>
Uterine cancer	>
Mental illness/Depression	>
Alzheimer's disease	>
Other	>

Social history
+

+ + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	physician's notes
Ever smoked? current smoking: packs/day: + + , years: +	>	>
alcohol: drinks/day: + + , + drinks/week: + + , + type of drink: +	>	>
Drug use	>	>
seat belt use	>	>
regular exercise: how long and how often? +	>	>
Dairy product intake and/or calcium supplements: daily intake: +	>	>
health hazards at home or work?	>	>
have you been sexually abused, threatened or hurt by anyone?	>	>
do you have an advance directive (living will)?	>	>
Are you an organ donor?	>	>

Personal profile
+

+ + + + + + + + + + + + + + + + + + + + + + +

Sexual orientation: + > + heterosexual + > + homosexual + > + bisexual

Marital status: + > + married + + > + living with partner > + single + + > + widowed > + divorced

Number of living children: +

Number of people in household: +

School completed: + > + high school + > + some college/AA degree + > + college + > + graduate degree + > + other

Current or most recent job: +

Travel outside the United States? + > + yes + > + no. Location(s): + +

Personal past history of illnesses
+

+ + + + +

major illnesses	yes (date)	no	Not sure	Physician's notes
Asthma	> +	>	>
Pneumonia/lungs disease	> +	>	>
Kidney infections/stones	> +	>	>
Tuberculosis	> +	>	>
Fibroids	> +	>	>
Sexually transmitted disease/chlamydia	> +	>	>
Infertility	> +	>	>
HIV / AIDS	> +	>	>
Heart attack / Disease	> +	>	>
Diabetes	> +	>	>
High blood pressure	> +	>	>
Stroke	> +	>	>
Rheumatic fever	> +	>	>
Blood clots in lungs or legs	> +	>	>
Eating disorders	> +	>	>
Autoimmune disease (Lupus)	> +	>	>
Chickenpox	> +	>	>
Cancer	> +	>	>
Reflux / Hiatal hernia / Ulcers	> +	>	>
Depression / Anxiety	> +	>	>
Anemia	> +	>	>
Blood transfusions	> +	>	>
Seizures / Convulsions /Epilepsy	> +	>	>
Bowel problems	> +	>	>
Glaucoma	> +	>	>
Cataracts	> +	>	>
Arthritis / Joint pain / Back problems	> +	>	>
Broken bones	> +	>	>
Hepatitis / Yellow jaundice / Liver disease	> +	>	>
Thyroid disease	> +	>	>
Gallbladder disease	> +	>	>
Headaches	> +	>	>
DES Exposure	> +	>	>
Bleeding disorders	> +	>	>
other	> +	>	>
<? echo $fdata{'pih_ih_extended_info'}; ?>

Operations/Hospitalizations
+

+ + + + + + + + + + + +EOL; +$ii++; +} +?> +

Reason	Date	Hospital

Injuries/Illnesses
+

+ + + + + + + + + + + + + +EOL; +$ii++; +} +?> +

Type	date	Type	date

Immunizations/Test
+

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Type	date	type	date
Tetanus-Diphteria booster	+ +	Influenza vaccine (Flu shot)	+ +
hepatitis a vaccine	+ +	Hepatitis B vaccine	+ +
varicella (Chickenpox) vaccine	+ +	pneumococcal (pneumonia) vaccine	+ +
Measles-Mumps-Rubella (MMR) Vaccine	+ +	Tuberculosis (TB) Skin test: + + , result: +	+ +

+ + + + +

Physician's notes:
+

+ +

Review of systems
+ Please check (x), if any of the following symptoms +apply to you now or since adulthood

	now	past	not sure	physician's notes
1. Constitutional
Weight loss	>	>	>
Weight gain	>	>	>
Fever	>	>	>
Fatigue	>	>	>
Change in height	>	>	>
2. Eyes
Double vision	>	>	>
Spots before eyes	>	>	>
Vision changes	>	>	>
Glasses/contacts	>	>	>
3. Ear, nose and throat
Earaches	>	>	>
Ringing in ears	>	>	>
Hearing problems	>	>	>
Sinus problems	>	>	>
Sore throat	>	>	>
Mouth sores	>	>	>
Dental problems	>	>	>
4. Cardiovascular
Chest pain on pressure	>	>	>
Difficulty breathing on exertion	>	>	>
Swelling on legs	>	>	>
Rapid or irregular heartbeat	>	>	>
5. Respiratory
Painful breathing	>	>	>
Wheezing	>	>	>
Spitting up blood	>	>	>
Shortness of breath	>	>	>
Chronic cough	>	>	>
6. Gastrointestinal
Frequent diarrhea	>	>	>
Bloody stool	>	>	>
Nausea / vomiting indigestion	>	>	>
Constipation	>	>	>
Involuntary loss of gas or stool	>	>	>
7. Genitourinary
Blood in urine	>	>	>
Pain with urination	>	>	>
Strong urgency to urinate	>	>	>
Frequent urination	>	>	>
Incomplete emtying	>	>	>
Involuntary/Unintended urine loss	>	>	>
Urine loss when coughing or lifting	>	>	>
Abnormal bleeding	>	>	>
Painful periods	>	>	>
Premenstrual Syndrome (PMS)	>	>	>
Painful intercourse	>	>	>
Abnormal vaginal discharge	>	>	>
8. Musculoskeletal
Muscle weakness	>	>	>
Muscle or joint pain	>	>	>
9a. Skin
Rash	>	>	>
Sores	>	>	>
Dry skin	>	>	>
Moles (growth or changes)	>	>	>
9b. Breasts
Pain in breast	>	>	>
Nipple discharge	>	>	>
Lumps	>	>	>
10. Neurologic
Dizziness	>	>	>
Seizures	>	>	>
Numbness	>	>	>
Trouble walking	>	>	>
Memory problems	>	>	>
Frequent headaches	>	>	>
11. Psychiatric
Depression or frequent crying	>	>	>
Anxiety	>	>	>
12. Endocrine
Hair loss	>	>	>
Heat/cold intolerance	>	>	>
Abnormal thirst	>	>	>
Hot flashes	>	>	>
13. Hematologic/Lymphatic
Frequent bruises	>	>	>
Cuts do not stop bleeding	>	>	>
Enlarged Lymph nodes (glands)	>	>	>
14. Allergic/immunologic
Medication allergies	>	>	>
If any, please list allergy and type of reaction:
Latex allergy	>	>	>
Other allergies	>	>	>
Please list allergy and type of reaction:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Form completed by + > + patient + > + office nurse + > + physician + > + other: +
Signature of patient:
Date reviewed by physician with patient +	Physician signature:
Annual review of history
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:
Date reviewed: + +	Physician signature:

+ + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/physical_examination/genit01.gif b/contrib/forms/physical_examination/genit01.gif new file mode 100644 index 0000000000000000000000000000000000000000..2faa5208e58ae064a98bb5d36bf38cac47ea536f GIT binary patch literal 2530 zcwPbG2_5!FNk%w1Vdnte0HOx~0000hC@4ZeK@bcLR#jDhe}8FcXaE2JA^8LW000L7 zEC2ui0OtVS000C3c)HyFFv>}*y*TU5yZ>M)j$~<`OJShwMYM1%Kg2NK1#s{DnfI(3 za7gq33Pq8?mTWpF1HqFMom#JofD~H+thnH&U>klM%V^@@m0k?K?f7kga)UQI7BzZ)fD;CYdIXCV226yNEk6;H00NO7j%*W#mZK;_4LM#g1pxqb5Tc~9 zC4vfhpf?73a0jlkz9egTojkd8Yrn`N1C&mi$CyA&pxF zAi%H`ta^p4p!9$MhYx(pB2ZL=t$Q+=n%q)S>L{vEFXRe)P2~iYI+$>h1kG6psz>|j zSfzl8S7`N0REubXk}I3P_RhLX>f|yq2i%n`fOym~7W1Cn&CzLD%UDfOME(VH!nRG- zXobSeQ#0W~cSSWcxxfzvp_W9;AYc}m$N+FCbxvHNww!-GIwq3}TtRWx#=QcbvixDP z)e?Xz$ZEiB#psoA525>uEb>}x^wb3;*g@kq&4JmL0Q*1yvrpYH&}bko7o!`9_OUPF zbQz8Rw_Mc7NE3L6MRQc0cNIRr05~6e1WMpr8M}Gp9aR}H<_my;IQZQwax8ZS1tVS- z%SWJi$QyQX0OleF{(*sFgcQ*TVjIvgRaykcQBa{JACaMvCA9F5rz^9Q@s9BS7Y@ovBiXX*T#GZB>`r#;V)&l8tby6BA zm~C2hC7BU`!UR=>ikc*qe_}AEEIz>oWve7fuokSnSsAM(8b-j?NQ6S?6Qf7MsHCR< zSv1JvfQb>x#F7ti7l)Tn>2{c$4A9n$3DS(9vLkf3?)Xn-si)lFba z9jhou3bh#Mm&m^9LX+78teAACYlRizZp8)8E6>bRXr~RuzU+f=7tR8)F&fu_urjbX zcOYChM`s|LEKkEgn>ri&JRHg%pv%o>{tV4U(Bs)M9*oyyMolZMNZu#Z^m}jo} z=A2v3=jL_8vuhX)weq?L6SbZUOdI75O{!UR_-F~juG%6 zOwCIxbr2s2-!3U{1RygVex&p+X`KY}pfV56?eSQjL@}YO!o59kGk5w7Vq;!@Gurcz ze&(}Z>U@6l#}mIcd00`uJ$WB#Z4>*uNB?**m-C?@fczL>A^6n;1ootTEa=Sm$k90s zC=dp!fgtWGxPc3@fEf<_2?seK0P2|l9ddJD2r;t0O8_K<;TWMe5V)E5jes381c6(E za1k5o(11A%m*12@y~LFOhe5pI5V655VUU0o;Y%VT$aRM*{=pyfs#_la8kZ_7-XSMk zl%fn8;fSJCkrj{l0Au#>6o|3$ieikT9Op>KI@3}b;RorlYypIgD5dJbcv+^Qbzz;wMJlt8ZoQ~JX@$&_l4!sUuxnE-24Rg&_(2aCojiM!)x}O%ydYK-23e&O z8c+@*a&iC~OKb+py~R0!Ai5e1{>njqz41-XKe3jnl(3>k4ZX zeQiw=BC&17HB}uxa&K9-i9597UK`#sUj6G1KSS65xAyeFa2Zrz4aixs!9(;>XX~{^ zgTT@kj< zlYf}HA$a8#Rz79exje_%CSk;_vh!%%JlSfe>p9O`^z&B~{cZF{}ZAm=%ZR z({BLnV>_u>EGFUegM2 zRe8$=}OB=+S~s2S4aQ=J3EMcEC2ui literal 0 HcwPel00001 diff --git a/contrib/forms/physical_examination/info.txt b/contrib/forms/physical_examination/info.txt new file mode 100644 index 000000000..ee5d2003f --- /dev/null +++ b/contrib/forms/physical_examination/info.txt @@ -0,0 +1 @@ +ACOG / Physical Examination \ No newline at end of file diff --git a/contrib/forms/physical_examination/new.php b/contrib/forms/physical_examination/new.php new file mode 100644 index 000000000..35c878fce --- /dev/null +++ b/contrib/forms/physical_examination/new.php @@ -0,0 +1,504 @@ + + + + + +Physical examination + + + + + + +> + +Physical Examination section +should be completed by the physician each time a +physical examination is provided. The form offers prompts to +aid in documenting the services that are provided. This form +is based on the 1997 CMS (formerly, HCFA) guidelines for +the female genitourinary system examination and can be +used to document any level of examination.

+ +The female genitourinary examination template includes 9 organ systems/body areas with 3 shaded boxes and 6 unshaded boxes. The shading only becomes important when a comprehensive +examination is performed. For all other levels of examination, the total number of bulleted elements documented in the medical record will determine the level that can be +reported.

+ + + + + + +

LEVEL OF EXAMINATION	PERFORM AND DOCUMENT
PROBLEM FOCUSED	1–5 ELEMENTS IDENTIFIED BY A BULLET
EXPANDED PROBLEM FOCUSED	6–11 ELEMENTS IDENTIFIED BY A BULLET
DETAILED	12 OR MORE ELEMENTS IDENTIFIED BY A BULLET
COMPREHENSIVE	ALL ELEMENTS IDENTIFIED BY A BULLET IN CONSTITUTIONAL AND GASTROINTESTINAL, +ANY 7 BULLETS IN GYNECOLOGIC, AT LEAST 1 BULLET IN ALL OTHER SYSTEMS

+EOL; +$tip1 = strtr($tip1, "\n\r", " "); +?> +

Physical examination

+ +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

Constitutional

Vital signs (record > 3 vital signs)

+ + + + + + + + + + +

Height
+

Weight
+

BMI
+

Blood pressure (sitting)
+

Temperature
+

Pulse
+

Respiration
+

General appearance (Note all that apply):

+ + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ Well-developed +	+ Other +		+ No deformities +	+ Other +
+ Well-nourished +	+ Other +		+ Well-groomed +	+ Other +
+ Normal habitus	+ Obese	+ Other

Neck

+ + + + + + + + + + + + + +

Neck	+ Normal	+ ABNormal
Thyroid	+ + Normal	+ABNormal

Respiratory

+ + + + + + + + + + + + + +

Respiratory effort	+ + Normal	+ ABNormal
Auscultated lungs	+Normal	+ABNormal

Cardiovascular

+ + + + + + + + + + + + + + + + + + + + + + + + + +

Auscultated heart
Sounds	+Normal	+ABNormal
Murmurs	+Normal	+ABNormal
Perirheral vascular	+Normal	+ABNormal

Gastrointestinal

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Abdomen	+Normal	+ABNormal
Hernia	+ none	+ present
Liver/Spleen
Liver	+ Normal	+ ABNormal
Spleen	+ Normal	+ ABNormal
Stool guaIac, if indic.	+ positive	+ negative

Lymphatic

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Palpation of nodes (Choose all, that are applicable)
Neck	+ Normal	+ ABNormal
Axilla	+ Normal	+ ABNormal
Groin	+ Normal	+ ABNormal
Other site	+ Normal	+ ABNormal

Skin

+ + + + + + + +

inspected/palpated

+ Normal

+ ABNormal

Neurologic/psychiatric

+ + + + + + + + + + + + + + + + + +

Orientation	+ Time	+ Place	+ Person +	+ Comments +
Mood and affect	+ Normal	+ Depressed	+ Anxious +	+ Agitated +	+ Other +

Gynecologic (at least 7)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Breasts	+ Normal	+ ABNormal	+ genit01.gif" width="231" height="222">
External genitalia	+ Normal	+ ABNormal
Urethral meatus	+ Normal	+ ABNormal
Urethra	+ Normal	+ ABNormal
Bladder	+ Normal	+ ABNormal
Vagina/Pelvic support	+ Normal	+ ABNormal
Cervix	+ Normal	+ ABNormal
Uterus	+ Normal	+ ABNormal
Adnexa/Parametria	+ Normal	+ ABNormal
Anus/Perineum	+ Normal	+ ABNormal
Rectal	+ Normal	+ ABNormal
+ (See also "Stool guaiac" above )

Total number of bulleted elements examined +

+
+ +

+[Save Data] +

+" class="link_submit">[Don't Save] +

+ + + \ No newline at end of file diff --git a/contrib/forms/physical_examination/printable.php b/contrib/forms/physical_examination/printable.php new file mode 100644 index 000000000..a6f2d52d9 --- /dev/null +++ b/contrib/forms/physical_examination/printable.php @@ -0,0 +1,432 @@ + + + + + +Physical examination + + + + +

Physical examination

+ +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

Date:

Constitutional

Vital signs (record > 3 vital signs)

+ + + + + + + + + + +

Height
+

Weight
+

BMI
+

Blood pressure (sitting)
+

Temperature
+

Pulse
+

Respiration
+

General appearance (Note all that apply):

+ + + + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> + Well-developed +	':' '); ?> + Other +		':' '); ?> + No deformities +	':' '); ?> + Other +
':' '); ?> + Well-nourished +	':' '); ?> + Other +		':' '); ?> + Well-groomed +	':' '); ?> + Other +
':' '); ?> + Normal habitus	':' '); ?> + Obese	':' '); ?> + Other

Neck

+ + + + + + + + + + + + + +

Neck	':' '); ?> + Normal	':' '); ?> + ABNormal
Thyroid	+ ':' '); ?> + Normal	':' '); ?> +ABNormal

Respiratory

+ + + + + + + + + + + + + +

Respiratory effort	+ ':' '); ?> + Normal	':' '); ?> + ABNormal
Auscultated lungs	':' '); ?> +Normal	':' '); ?> +ABNormal

Cardiovascular

+ + + + + + + + + + + + + + + + + + + + + + + + + +

Auscultated heart
Sounds	':' '); ?> +Normal	':' '); ?> +ABNormal
Murmurs	':' '); ?> +Normal	':' '); ?> +ABNormal
Perirheral vascular	':' '); ?> +Normal	':' '); ?> +ABNormal

Gastrointestinal

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Abdomen	':' '); ?> +Normal	':' '); ?> +ABNormal
Hernia	':' '); ?> + none	':' '); ?> + present
Liver/Spleen
Liver	':' '); ?> + Normal	':' '); ?> + ABNormal
Spleen	':' '); ?> + Normal	':' '); ?> + ABNormal
Stool guaIac, if indic.	':' '); ?> + positive	':' '); ?> + negative

Lymphatic

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Palpation of nodes (Choose all, that are applicable)
Neck	':' '); ?> + Normal	':' '); ?> + ABNormal
Axilla	':' '); ?> + Normal	':' '); ?> + ABNormal
Groin	':' '); ?> + Normal	':' '); ?> + ABNormal
Other site	':' '); ?> + Normal	':' '); ?> + ABNormal

Skin

+ + + + + + + +

inspected/palpated

':'

'); ?> + Normal

':'

'); ?> + ABNormal

Neurologic/psychiatric

+ + + + + + + + + + + + + + + + + +

Orientation	':' '); ?> + Time	':' '); ?> + Place	':' '); ?> + Person +	':' '); ?> + Comments +
Mood and affect	':' '); ?> + Normal	':' '); ?> + Depressed	':' '); ?> + Anxious +	':' '); ?> + Agitated +	':' '); ?> + Other +

Gynecologic (at least 7)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Breasts	':' '); ?> + Normal	':' '); ?> + ABNormal	+ genit01.gif" width="231" height="222">
External genitalia	':' '); ?> + Normal	':' '); ?> + ABNormal
Urethral meatus	':' '); ?> + Normal	':' '); ?> + ABNormal
Urethra	':' '); ?> + Normal	':' '); ?> + ABNormal
Bladder	':' '); ?> + Normal	':' '); ?> + ABNormal
Vagina/Pelvic support	':' '); ?> + Normal	':' '); ?> + ABNormal
Cervix	':' '); ?> + Normal	':' '); ?> + ABNormal
Uterus	':' '); ?> + Normal	':' '); ?> + ABNormal
Adnexa/Parametria	':' '); ?> + Normal	':' '); ?> + ABNormal
Anus/Perineum	':' '); ?> + Normal	':' '); ?> + ABNormal
Rectal	':' '); ?> + Normal	':' '); ?> + ABNormal
+ (See also "Stool guaiac" above )

Total number of bulleted elements examined +

+ + \ No newline at end of file diff --git a/contrib/forms/physical_examination/report.php b/contrib/forms/physical_examination/report.php new file mode 100644 index 000000000..79f6ba8f2 --- /dev/null +++ b/contrib/forms/physical_examination/report.php @@ -0,0 +1,419 @@ + +

Physical examination

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + +

Patient name:

Birth date:

ID No:

Date:

Constitutional

Vital signs (record > 3 vital signs)

+ + + + + + + + + + +

Height
+

Weight
+

BMI
+

Blood pressure (sitting)
+

Temperature
+

Pulse
+

Respiration
+

General appearance (Note all that apply):

+ + + + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> + Well-developed +	':' '); ?> + Other +		':' '); ?> + No deformities +	':' '); ?> + Other +
':' '); ?> + Well-nourished +	':' '); ?> + Other +		':' '); ?> + Well-groomed +	':' '); ?> + Other +
':' '); ?> + Normal habitus	':' '); ?> + Obese	':' '); ?> + Other

Neck

+ + + + + + + + + + + + + +

Neck	':' '); ?> + Normal	':' '); ?> + ABNormal
Thyroid	+ ':' '); ?> + Normal	':' '); ?> +ABNormal

Respiratory

+ + + + + + + + + + + + + +

Respiratory effort	+ ':' '); ?> + Normal	':' '); ?> + ABNormal
Auscultated lungs	':' '); ?> +Normal	':' '); ?> +ABNormal

Cardiovascular

+ + + + + + + + + + + + + + + + + + + + + + + + + +

Auscultated heart
Sounds	':' '); ?> +Normal	':' '); ?> +ABNormal
Murmurs	':' '); ?> +Normal	':' '); ?> +ABNormal
Perirheral vascular	':' '); ?> +Normal	':' '); ?> +ABNormal

Gastrointestinal

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Abdomen	':' '); ?> +Normal	':' '); ?> +ABNormal
Hernia	':' '); ?> + none	':' '); ?> + present
Liver/Spleen
Liver	':' '); ?> + Normal	':' '); ?> + ABNormal
Spleen	':' '); ?> + Normal	':' '); ?> + ABNormal
Stool guaIac, if indic.	':' '); ?> + positive	':' '); ?> + negative

Lymphatic

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Palpation of nodes (Choose all, that are applicable)
Neck	':' '); ?> + Normal	':' '); ?> + ABNormal
Axilla	':' '); ?> + Normal	':' '); ?> + ABNormal
Groin	':' '); ?> + Normal	':' '); ?> + ABNormal
Other site	':' '); ?> + Normal	':' '); ?> + ABNormal

Skin

+ + + + + + + +

inspected/palpated

':'

'); ?> + Normal

':'

'); ?> + ABNormal

Neurologic/psychiatric

+ + + + + + + + + + + + + + + + + +

Orientation	':' '); ?> + Time	':' '); ?> + Place	':' '); ?> + Person +	':' '); ?> + Comments +
Mood and affect	':' '); ?> + Normal	':' '); ?> + Depressed	':' '); ?> + Anxious +	':' '); ?> + Agitated +	':' '); ?> + Other +

Gynecologic (at least 7)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Breasts	':' '); ?> + Normal	':' '); ?> + ABNormal	+ genit01.gif" width="231" height="222">
External genitalia	':' '); ?> + Normal	':' '); ?> + ABNormal
Urethral meatus	':' '); ?> + Normal	':' '); ?> + ABNormal
Urethra	':' '); ?> + Normal	':' '); ?> + ABNormal
Bladder	':' '); ?> + Normal	':' '); ?> + ABNormal
Vagina/Pelvic support	':' '); ?> + Normal	':' '); ?> + ABNormal
Cervix	':' '); ?> + Normal	':' '); ?> + ABNormal
Uterus	':' '); ?> + Normal	':' '); ?> + ABNormal
Adnexa/Parametria	':' '); ?> + Normal	':' '); ?> + ABNormal
Anus/Perineum	':' '); ?> + Normal	':' '); ?> + ABNormal
Rectal	':' '); ?> + Normal	':' '); ?> + ABNormal
+ (See also "Stool guaiac" above )

Total number of bulleted elements examined +

+ \ No newline at end of file diff --git a/contrib/forms/physical_examination/save.php b/contrib/forms/physical_examination/save.php new file mode 100644 index 000000000..210a97b8b --- /dev/null +++ b/contrib/forms/physical_examination/save.php @@ -0,0 +1,45 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + if (($k != 'pname')&&($k != 'pbdate')&&($k != 'pe_id')&&($k != 'pe_date') + && (substr($k, 0,5)!='oh_ch')){ + $data[$k] = $_POST[$k]; + if ($data[$k] == "YYYY-MM-DD") { + $data[$k] = ''; + } + } + //echo "$var\n"; +} +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_physical_examination", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Physical examination", $newid, "physical_examination", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_physical_examination set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/physical_examination/table.sql b/contrib/forms/physical_examination/table.sql new file mode 100644 index 000000000..2daf7b164 --- /dev/null +++ b/contrib/forms/physical_examination/table.sql @@ -0,0 +1,94 @@ +CREATE TABLE IF NOT EXISTS `form_physical_examination` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +pname varchar(255), +pbdate varchar(255), +pe_id varchar(255), +pe_date varchar(255), +height varchar(255), +weight varchar(255), +bmi varchar(255), +blood_pressure varchar(255), +temperature varchar(255), +pulse varchar(255), +respiration varchar(255), +general_well_developed tinyint(1) default NULL, +general_no_deformities tinyint(1) default NULL, +general_well_nourished tinyint(1) default NULL, +general_well_groomed tinyint(1) default NULL, +general_normal_habitus tinyint(1) default NULL, +neck_neck tinyint(1) default NULL, +neck_neck_data varchar(255), +neck_thyroid tinyint(1) default NULL, +neck_thyroid_data varchar(255), +respiratory_effort tinyint(1) default NULL, +respiratory_effort_data varchar(255), +auscultated_lungs tinyint(1) default NULL, +auscultated_lungs_data varchar(255), +auscultated_heart_sounds tinyint(1) default NULL, +auscultated_heart_sounds_data varchar(255), +auscultated_heart_murmurs tinyint(1) default NULL, +auscultated_heart_murmurs_data varchar(255), +peripheral_vascular tinyint(1) default NULL, +peripheral_vascular_data varchar(255), +gastr_abdomen tinyint(1) default NULL, +gastr_abdomen_data varchar(255), +gastr_hernia tinyint(1) default NULL, +gastr_hernia_data varchar(255), +gastr_liver tinyint(1) default NULL, +gastr_liver_data varchar(255), +gastr_spleen tinyint(1) default NULL, +gastr_spleen_data varchar(255), +gastr_stool_guaiac tinyint(1) default NULL, +gastr_stool_guaiac_data varchar(255), +lymph_neck tinyint(1) default NULL, +lymph_neck_data varchar(255), +lymph_axilla tinyint(1) default NULL, +lymph_axilla_data varchar(255), +lymph_groin tinyint(1) default NULL, +lymph_groin_data varchar(255), +lymph_other tinyint(1) default NULL, +lymph_other_data varchar(255), +skin_inspected tinyint(1) default NULL, +skin_inspected_data varchar(255), +neur_orient_time tinyint(1) default NULL, +neur_orient_place tinyint(1) default NULL, +neur_orient_person tinyint(1) default NULL, +neur_orient_comments tinyint(1) default NULL, +neur_mood_normal tinyint(1) default NULL, +neur_mood_depressed tinyint(1) default NULL, +neur_mood_anxious tinyint(1) default NULL, +neur_mood_agitated tinyint(1) default NULL, +neur_mood_other tinyint(1) default NULL, +gynec_breasts tinyint(1) default NULL, +gynec_breasts_data varchar(255), +gynec_ext_genitalia tinyint(1) default NULL, +gynec_ext_genitalia_data varchar(255), +gynec_urethral_meatus tinyint(1) default NULL, +gynec_urethral_meatus_data varchar(255), +gynec_urethra tinyint(1) default NULL, +gynec_urethra_data varchar(255), +gynec_bladder tinyint(1) default NULL, +gynec_bladder_data varchar(255), +gynec_vagina_support tinyint(1) default NULL, +gynec_vagina_support_data varchar(255), +gynec_cervix tinyint(1) default NULL, +gynec_cervix_data varchar(255), +gynec_uterus tinyint(1) default NULL, +gynec_uterus_data varchar(255), +gynec_adnexa tinyint(1) default NULL, +gynec_adnexa_data varchar(255), +gynec_anus tinyint(1) default NULL, +gynec_anus_data varchar(255), +gynec_rectal tinyint(1) default NULL, +gynec_rectal_data varchar(255), +tot_num_examined varchar(255), + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/physical_examination/view.php b/contrib/forms/physical_examination/view.php new file mode 100644 index 000000000..6de9d7424 --- /dev/null +++ b/contrib/forms/physical_examination/view.php @@ -0,0 +1,491 @@ + + + + + +Physical examination + + + + + + +> + +Physical Examination section +should be completed by the physician each time a +physical examination is provided. The form offers prompts to +aid in documenting the services that are provided. This form +is based on the 1997 CMS (formerly, HCFA) guidelines for +the female genitourinary system examination and can be +used to document any level of examination.

+ +The female genitourinary examination template includes 9 organ systems/body areas with 3 shaded boxes and 6 unshaded boxes. The shading only becomes important when a comprehensive +examination is performed. For all other levels of examination, the total number of bulleted elements documented in the medical record will determine the level that can be +reported.

+ + + + + + +

LEVEL OF EXAMINATION	PERFORM AND DOCUMENT
PROBLEM FOCUSED	1–5 ELEMENTS IDENTIFIED BY A BULLET
EXPANDED PROBLEM FOCUSED	6–11 ELEMENTS IDENTIFIED BY A BULLET
DETAILED	12 OR MORE ELEMENTS IDENTIFIED BY A BULLET
COMPREHENSIVE	ALL ELEMENTS IDENTIFIED BY A BULLET IN CONSTITUTIONAL AND GASTROINTESTINAL, +ANY 7 BULLETS IN GYNECOLOGIC, AT LEAST 1 BULLET IN ALL OTHER SYSTEMS

+EOL; +$tip1 = strtr($tip1, "\n\r", " "); +?> +

Physical examination

+ +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + +

Patient name
+

birth date +
+

ID No
+

date
+

Constitutional

Vital signs (record > 3 vital signs)

+ + + + + + + + + + +

Height
+

Weight
+

BMI
+

Blood pressure (sitting)
+

Temperature
+

Pulse
+

Respiration
+

General appearance (Note all that apply):

+ + + + + + + + + + + + + + + + + + + + + + + + + + + +

> + Well-developed +	> + Other +		> + No deformities +	> + Other +
> + Well-nourished +	> + Other +		> + Well-groomed +	> + Other +
> + Normal habitus	> + Obese	> + Other

Neck

+ + + + + + + + + + + + + +

Neck	> + Normal	> + ABNormal
Thyroid	+ > + Normal	> +ABNormal

Respiratory

+ + + + + + + + + + + + + +

Respiratory effort	+ > + Normal	> + ABNormal
Auscultated lungs	> +Normal	> +ABNormal

Cardiovascular

+ + + + + + + + + + + + + + + + + + + + + + + + + +

Auscultated heart
Sounds	> +Normal	> +ABNormal
Murmurs	> +Normal	> +ABNormal
Perirheral vascular	> +Normal	> +ABNormal

Gastrointestinal

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Abdomen	> +Normal	> +ABNormal
Hernia	> + none	> + present
Liver/Spleen
Liver	> + Normal	> + ABNormal
Spleen	> + Normal	> + ABNormal
Stool guaIac, if indic.	> + positive	> + negative

Lymphatic

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Palpation of nodes (Choose all, that are applicable)
Neck	> + Normal	> + ABNormal
Axilla	> + Normal	> + ABNormal
Groin	> + Normal	> + ABNormal
Other site	> + Normal	> + ABNormal

Skin

+ + + + + + + +

inspected/palpated

> + Normal

> + ABNormal

Neurologic/psychiatric

+ + + + + + + + + + + + + + + + + +

Orientation	> + Time	> + Place	> + Person +	> + Comments +
Mood and affect	> + Normal	> + Depressed	> + Anxious +	> + Agitated +	> + Other +

Gynecologic (at least 7)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Breasts	> + Normal	> + ABNormal	+ genit01.gif" width="231" height="222">
External genitalia	> + Normal	> + ABNormal
Urethral meatus	> + Normal	> + ABNormal
Urethra	> + Normal	> + ABNormal
Bladder	> + Normal	> + ABNormal
Vagina/Pelvic support	> + Normal	> + ABNormal
Cervix	> + Normal	> + ABNormal
Uterus	> + Normal	> + ABNormal
Adnexa/Parametria	> + Normal	> + ABNormal
Anus/Perineum	> + Normal	> + ABNormal
Rectal	> + Normal	> + ABNormal
+ (See also "Stool guaiac" above )

Total number of bulleted elements examined +

+
+

+ + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/physician_history/info.txt b/contrib/forms/physician_history/info.txt new file mode 100644 index 000000000..00eb643f6 --- /dev/null +++ b/contrib/forms/physician_history/info.txt @@ -0,0 +1 @@ +ACOG / Physician history \ No newline at end of file diff --git a/contrib/forms/physician_history/new.php b/contrib/forms/physician_history/new.php new file mode 100644 index 000000000..4349e9dec --- /dev/null +++ b/contrib/forms/physician_history/new.php @@ -0,0 +1,1026 @@ + + + + + +Physician history + + + + + + + + +> +

Patient name:
Birth date:
ID No:
Date

+Physician History can be used record the history for every type of outpatient encounter, including consultations. A new Physician History should be completed by the physician at each visit when clinically indicated. +EOL; +?> +

Physician history

+ + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + + + +

+ New patient

+ Established patient

+ Consultation

+ + + + +

+ Report sent

Primary care physician:
+

Who sent patient:
+

Other physician(s):
+ +

+ + + + + + + + + + + + + + + + +

Chief complaint (CC) (Required for all visits except preventive):	Current prescription medications:
<? echo $edata['reason']; ?> +	<? +if ($result = getListByType($pid, "medication", "id,title,comments,activity,date", 1, "all", 0)){ + foreach ($result as $iter) { + $tmp_med[] = $iter{"title"}.' ('.$iter{"comments"}.') '; + } +echo join(', ', $tmp_med); +} +?> +
History of present ilness (HPI): +	Current nonpresription, complementary, and alternative medications:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Changes since last visit	yes	no	Notes
Illnesses
Surgery
New medications
Change in family history
New allergies
Change in gynecologic history
Change in obstetric history

+ + + + + +

Allergies (describe reaction): + > + None

+ + + + + + + + + + + + +

Last cervical cancer screening: + + Cytology + + + HPV test +
last mammogram: +
Last colorectal screening: +

Gynecologic history (PH)

+ + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + +

Imp

Age at menarche

Length of flow

Interval between periods

Recent changes

Sexually active: + + Yes + + No Ever had sex: + +Yes + +No Number of partners (Lifetime) +

Partners are: + + men + + women + + both

Current method of contraception:

past contraceptive history:

Obstetric history (PH)

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.

+ + + + +

Any pregnancy complications?

+ + + + + + + +

+ diabetes + + hypertension/high blood pressure + + preeclampsia/foxemia + + other
any history of depression before or after pregnancy? + + no + + yes, How treated

Past history (PH)

+ + + + + + + + + + + + + + + + +

+ Noncontributory + + no interval change since +

SUrgeries:
+

Illnesses (Physical and mental):
+

Injuries:
+

Immunizations/Tuberculosis test:
+

Family history (FH)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+Noncontributory + +no interval change since +
Mother: + + living + + deceased - cause: + + age: + + Father: + +living + +deceased - cause: + +age: +
Siblings: number living: + + Number deceased: + + cause(s) / Age(s) : +
Children: number living: + +Number deceased: + +cause(s) / Age(s) : +
(IF YES, indicate whom, and age of diagnosis)
+ diabetes +	+ heart disease +	+ hyperlipidemia +
+ cancer +	+ Hypertension +	+ deep venous tromboembolIsm / Pulmonary embolism +
+ osteoporosis +	+ other illnesses +

Social history (SH)

+ + + + + + + +

+Noncontributory + +no interval change since +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	notes		yes	no	notes
Tobacco use				diet discussed			+
Alcohol use + specify amount and type + 12 OZ beer = 5 oz wine = 1 1/2 oz liquor				folic acid intake
				calcium intake
Illegal/Street drug use				regular exercise
misuse of prescription drugs				caffeine intake
intimate partner violence				advance directive (living will)
sexual abuse				organ donation
health hazards at home/work				other
seat belt use				+ no changes since

Review of systems (ROS)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/physician_history/printable.php b/contrib/forms/physician_history/printable.php new file mode 100644 index 000000000..401c29be7 --- /dev/null +++ b/contrib/forms/physician_history/printable.php @@ -0,0 +1,921 @@ + + + + + +Physician history + + + + + + + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Physician history

+ + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + + + +

':' '); ?> + New patient	':' '); ?> + Established patient	':' '); ?> + Consultation	':' '); ?> Report sent
Primary care physician: +		Who sent patient: +
Other physician(s):

+ + + + + + + + + + + + + + + + +

Chief complaint (CC) (Required for all visits except preventive):	Current prescription medications:

History of present ilness (HPI):	Current nonpresription, complementary, and alternative medications:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Changes since last visit	yes	no	Notes
Illnesses	':' '); ?>	':' '); ?>
Surgery	':' '); ?>	':' '); ?>
New medications	':' '); ?>	':' '); ?>
Change in family history	':' '); ?>	':' '); ?>
New allergies	':' '); ?>	':' '); ?>
Change in gynecologic history	':' '); ?>	':' '); ?>
Change in obstetric history	':' '); ?>	':' '); ?>

+ + + + +

Allergies (describe reaction): + ':'

'); ?> +none

+ + + + + + + + + + + + +

Last cervical cancer screening: + ':' '); ?> + Cytology + + ':' '); ?> + HPV test +
last mammogram: +
Last colorectal screening: +

Gynecologic history (PH)

+ + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + +

Imp

Age at menarche

Length of flow

Interval between periods

Recent changes

Sexually active: + ':'

'); ?> + Yes + ':'

'); ?> + No Ever had sex: + ':'

'); ?> +Yes + ':'

'); ?> +No Number of partners (Lifetime) +

Partners are: + ':'

'); ?> + men + ':'

'); ?> + women + ':'

'); ?> + both

Current method of contraception:

Past contraceptive history:

Obstetric history (PH)

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.	${oh_ch_date}	${oh_ch_width}	${oh_ch_sex}	${oh_ch_weeks}	${oh_ch_delivery}	${oh_ch_notes}

+ + + + +

Any pregnancy complications?

+ + + + + + + +

':' '); ?> + diabetes + ':' '); ?> + hypertension/high blood pressure + ':' '); ?> + preeclampsia/foxemia + ':' '); ?> + other
any history of depression before or after pregnancy? + ':' '); ?> + no + ':' '); ?> + yes, How treated

Past history (PH)

+ + + + + + + + + + + + + + + + +

':'

'); ?> + Noncontributory + ':'

'); ?> + no interval change since +

Surgeries: +

Illnesses (Physical and mental): +

Injuries: +

Immunizations/Tuberculosis test: +

Family history (FH)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> +Noncontributory + ':' '); ?> +no interval change since +
Mother: + living':' deceased'); ?> + ':' '); ?> + cause: + + , age: + + Father: + Living':' Deceased'); ?> + +deceased — cause: + +, age: +
Siblings: number living: + + Number deceased: + + Cause(s) / Age(s) : +
Children: number living: + + Number deceased: + + Cause(s) / Age(s) : +
(IF YES, indicate whom, and age of diagnosis)
':' '); ?> + diabetes +	':' '); ?> + heart disease +	':' '); ?> + hyperlipidemia +
':' '); ?> + cancer +	':' '); ?> + Hypertension +	':' '); ?> + deep venous tromboembolIsm / Pulmonary embolism +
':' '); ?> + osteoporosis +	':' '); ?> + other illnesses +

Social history (SH)

+ + + + + + + +

':'

'); ?> +Noncontributory + ':'

'); ?> +no interval change since +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	notes		yes	no	notes
Tobacco use	':' '); ?>	':' '); ?>		diet discussed	':' '); ?>	':' '); ?>	+
Alcohol use + specify amount and type + 12 OZ beer = 5 oz wine = 1 1/2 oz liquor	':' '); ?>	':' '); ?>		folic acid intake	':' '); ?>	':' '); ?>
	':' '); ?>	':' '); ?>		calcium intake	':' '); ?>	':' '); ?>
Illegal/Street drug use	':' '); ?>	':' '); ?>		regular exercise	':' '); ?>	':' '); ?>
misuse of prescription drugs	':' '); ?>	':' '); ?>		caffeine intake	':' '); ?>	':' '); ?>
intimate partner violence	':' '); ?>	':' '); ?>		advance directive (living will)	':' '); ?>	':' '); ?>
sexual abuse	':' '); ?>	':' '); ?>		organ donation	':' '); ?>	':' '); ?>
health hazards at home/work	':' '); ?>	':' '); ?>		other	':' '); ?>	':' '); ?>
seat belt use	':' '); ?>	':' '); ?>		':' '); ?> + no changes since

Review of systems (ROS)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

1. Constitutional

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + weight loss	':' '); ?> + weight gain +
':' '); ?> + fever	':' '); ?> + fatigue	':' '); ?> + other	tallest height

2. Eyes

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Vision change		':' '); ?> +Glasses/contacts
':' '); ?> + Other

3. Ear, nose and throat

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Ulcers	':' '); ?> + sinusitis
':' '); ?> + Headache	':' '); ?> + Hearing loss	':' '); ?> + other

4. Cardiovascular

+ + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Orthopnea	':' '); ?> + Chest pain	':' '); ?> + Difficulty breathing on exertion +
':' '); ?> + Edema	':' '); ?> + Palpitation	':' '); ?> + other	':' '); ?> + Difficulty breathing on exertion +

5. Respiratory

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Wheezing	':' '); ?> + Hemoptysis
':' '); ?> + Shortness of breath		':' '); ?> + Cough	':' '); ?> + Other +

6. Gastrointestinal

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Diarrhea	':' '); ?> + Bloody stool	':' '); ?> + Nausea/Vomiting/Indigestion +
':' '); ?> + Constipation	':' '); ?> + Flatulence	':' '); ?> + pain	':' '); ?> + Fecal incontinence	':' '); ?> + Other

7. Genitourinary

+ + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Hematuria	':' '); ?> + Dysuria	':' '); ?> + Urgency
':' '); ?> + Frequency	':' '); ?> + Incomplete emptying		':' '); ?> + Incontinence
':' '); ?> + Dyspareunia	':' '); ?> + Abnormal or painful periods		':' '); ?> + PMS
':' '); ?> + Abnormal vaginal bleeding		':' '); ?> + Abnormal vaginal discharge	':' '); ?> + other

8. Musculoskeletal

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Muscle weakness
':' '); ?> + Muscle or joint pain	':' '); ?> +other

9a. Skin

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Rash	':' '); ?> + Ulcers
':' '); ?> + Dry skin	':' '); ?> + Pigmented lesions		':' '); ?> +other

9b. Breast

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Mastalgia
':' '); ?> + Discharge	':' '); ?> + Masses	':' '); ?> + other

10. Neurologic

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Syncope	':' '); ?> + Seizures	':' '); ?> + Numbness
':' '); ?> + Trouble walking		':' '); ?> +Severe memory problems		':' '); ?> +other

11. Psychiatric

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Depression	':' '); ?> + Crying
':' '); ?> + Severe anxiety		':' '); ?> +Other

12. Endocrine

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Diabetes	':' '); ?> + Hypothyroid	':' '); ?> +Hyperthyroid
':' '); ?> + Hot flashes	':' '); ?> + Hair loss	':' '); ?> + Heat/cold intolerance	':' '); ?> + Other +

13. Hematologic/Lymphatic

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Bruises
':' '); ?> + Bleeding	':' '); ?> + Adenopathy	':' '); ?> + other

14. Allergic/Immunologic

See above (Page 1 of PH)

+ + \ No newline at end of file diff --git a/contrib/forms/physician_history/report.php b/contrib/forms/physician_history/report.php new file mode 100644 index 000000000..94837feb7 --- /dev/null +++ b/contrib/forms/physician_history/report.php @@ -0,0 +1,908 @@ + + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Physician history

+ + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + + + +

':' '); ?> + New patient	':' '); ?> + Established patient	':' '); ?> + Consultation	':' '); ?> Report sent
Primary care physician: +		Who sent patient: +
Other physician(s):

+ + + + + + + + + + + + + + + + +

Chief complaint (CC) (Required for all visits except preventive):	Current prescription medications:

History of present ilness (HPI):	Current nonpresription, complementary, and alternative medications:

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Changes since last visit	yes	no	Notes
Illnesses	':' '); ?>	':' '); ?>
Surgery	':' '); ?>	':' '); ?>
New medications	':' '); ?>	':' '); ?>
Change in family history	':' '); ?>	':' '); ?>
New allergies	':' '); ?>	':' '); ?>
Change in gynecologic history	':' '); ?>	':' '); ?>
Change in obstetric history	':' '); ?>	':' '); ?>

+ + + + +

Allergies (describe reaction): + ':'

'); ?> +none

+ + + + + + + + + + + + +

Last cervical cancer screening: + ':' '); ?> + Cytology + + ':' '); ?> + HPV test +
last mammogram: +
Last colorectal screening: +

Gynecologic history (PH)

+ + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + +

Imp

Age at menarche

Length of flow

Interval between periods

Recent changes

Sexually active: + ':'

'); ?> + Yes + ':'

'); ?> + No Ever had sex: + ':'

'); ?> +Yes + ':'

'); ?> +No Number of partners (Lifetime) +

Partners are: + ':'

'); ?> + men + ':'

'); ?> + women + ':'

'); ?> + both

Current method of contraception:

Past contraceptive history:

Obstetric history (PH)

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.	${oh_ch_date}	${oh_ch_width}	${oh_ch_sex}	${oh_ch_weeks}	${oh_ch_delivery}	${oh_ch_notes}

+ + + + +

Any pregnancy complications?

+ + + + + + + +

':' '); ?> + diabetes + ':' '); ?> + hypertension/high blood pressure + ':' '); ?> + preeclampsia/foxemia + ':' '); ?> + other
any history of depression before or after pregnancy? + ':' '); ?> + no + ':' '); ?> + yes, How treated

Past history (PH)

+ + + + + + + + + + + + + + + + +

':'

'); ?> + Noncontributory + ':'

'); ?> + no interval change since +

Surgeries: +

Illnesses (Physical and mental): +

Injuries: +

Immunizations/Tuberculosis test: +

Family history (FH)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> +Noncontributory + ':' '); ?> +no interval change since +
Mother: + living':' deceased'); ?> + ':' '); ?> + cause: + + , age: + + Father: + Living':' Deceased'); ?> + +deceased — cause: + +, age: +
Siblings: number living: + + Number deceased: + + Cause(s) / Age(s) : +
Children: number living: + + Number deceased: + + Cause(s) / Age(s) : +
(IF YES, indicate whom, and age of diagnosis)
':' '); ?> + diabetes +	':' '); ?> + heart disease +	':' '); ?> + hyperlipidemia +
':' '); ?> + cancer +	':' '); ?> + Hypertension +	':' '); ?> + deep venous tromboembolIsm / Pulmonary embolism +
':' '); ?> + osteoporosis +	':' '); ?> + other illnesses +

Social history (SH)

+ + + + + + + +

':'

'); ?> +Noncontributory + ':'

'); ?> +no interval change since +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	notes		yes	no	notes
Tobacco use	':' '); ?>	':' '); ?>		diet discussed	':' '); ?>	':' '); ?>	+
Alcohol use + specify amount and type + 12 OZ beer = 5 oz wine = 1 1/2 oz liquor	':' '); ?>	':' '); ?>		folic acid intake	':' '); ?>	':' '); ?>
	':' '); ?>	':' '); ?>		calcium intake	':' '); ?>	':' '); ?>
Illegal/Street drug use	':' '); ?>	':' '); ?>		regular exercise	':' '); ?>	':' '); ?>
misuse of prescription drugs	':' '); ?>	':' '); ?>		caffeine intake	':' '); ?>	':' '); ?>
intimate partner violence	':' '); ?>	':' '); ?>		advance directive (living will)	':' '); ?>	':' '); ?>
sexual abuse	':' '); ?>	':' '); ?>		organ donation	':' '); ?>	':' '); ?>
health hazards at home/work	':' '); ?>	':' '); ?>		other	':' '); ?>	':' '); ?>
seat belt use	':' '); ?>	':' '); ?>		':' '); ?> + no changes since

Review of systems (ROS)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

1. Constitutional

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + weight loss	':' '); ?> + weight gain +
':' '); ?> + fever	':' '); ?> + fatigue	':' '); ?> + other	tallest height

2. Eyes

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Vision change		':' '); ?> +Glasses/contacts
':' '); ?> + Other

3. Ear, nose and throat

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Ulcers	':' '); ?> + sinusitis
':' '); ?> + Headache	':' '); ?> + Hearing loss	':' '); ?> + other

4. Cardiovascular

+ + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Orthopnea	':' '); ?> + Chest pain	':' '); ?> + Difficulty breathing on exertion +
':' '); ?> + Edema	':' '); ?> + Palpitation	':' '); ?> + other	':' '); ?> + Difficulty breathing on exertion +

5. Respiratory

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Wheezing	':' '); ?> + Hemoptysis
':' '); ?> + Shortness of breath		':' '); ?> + Cough	':' '); ?> + Other +

6. Gastrointestinal

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Diarrhea	':' '); ?> + Bloody stool	':' '); ?> + Nausea/Vomiting/Indigestion +
':' '); ?> + Constipation	':' '); ?> + Flatulence	':' '); ?> + pain	':' '); ?> + Fecal incontinence	':' '); ?> + Other

7. Genitourinary

+ + + + + + + + + + + + + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Hematuria	':' '); ?> + Dysuria	':' '); ?> + Urgency
':' '); ?> + Frequency	':' '); ?> + Incomplete emptying		':' '); ?> + Incontinence
':' '); ?> + Dyspareunia	':' '); ?> + Abnormal or painful periods		':' '); ?> + PMS
':' '); ?> + Abnormal vaginal bleeding		':' '); ?> + Abnormal vaginal discharge	':' '); ?> + other

8. Musculoskeletal

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Muscle weakness
':' '); ?> + Muscle or joint pain	':' '); ?> +other

9a. Skin

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Rash	':' '); ?> + Ulcers
':' '); ?> + Dry skin	':' '); ?> + Pigmented lesions		':' '); ?> +other

9b. Breast

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Mastalgia
':' '); ?> + Discharge	':' '); ?> + Masses	':' '); ?> + other

10. Neurologic

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Syncope	':' '); ?> + Seizures	':' '); ?> + Numbness
':' '); ?> + Trouble walking		':' '); ?> +Severe memory problems		':' '); ?> +other

11. Psychiatric

+ + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Depression	':' '); ?> + Crying
':' '); ?> + Severe anxiety		':' '); ?> +Other

12. Endocrine

+ + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Diabetes	':' '); ?> + Hypothyroid	':' '); ?> +Hyperthyroid
':' '); ?> + Hot flashes	':' '); ?> + Hair loss	':' '); ?> + Heat/cold intolerance	':' '); ?> + Other +

13. Hematologic/Lymphatic

+ + + + + + + + + + + + + + +

':' '); ?> + Negative	':' '); ?> + Bruises
':' '); ?> + Bleeding	':' '); ?> + Adenopathy	':' '); ?> + other

14. Allergic/Immunologic

See above (Page 1 of PH)

+ diff --git a/contrib/forms/physician_history/save.php b/contrib/forms/physician_history/save.php new file mode 100644 index 000000000..5a870b3cc --- /dev/null +++ b/contrib/forms/physician_history/save.php @@ -0,0 +1,58 @@ + $fld){ + $data[$fld] = ''; +} + + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + if (($k != 'pname')&&($k != 'pbdate')&&($k != 'ph_pid')&&($k != 'ph_date') + && (substr($k, 0,5)!='oh_ch')){ + $data[$k] = $_POST[$k]; + if ($data[$k] == "YYYY-MM-DD") { + $data[$k] = ''; + } + } + //echo "$var\n"; +} + $ii = 0; + while ($ii < 4){ + $data["oh_ch_rec_".$ii] = $_POST["oh_ch_date_".$ii] . "|~". + $_POST["oh_ch_width_".$ii] . "|~". + $_POST["oh_ch_sex_".$ii] . "|~". + $_POST["oh_ch_weeks_".$ii] . "|~". + $_POST["oh_ch_delivery_".$ii] . "|~". + $_POST["oh_ch_notes_".$ii]; + $ii++; + } + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_physician_history", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Physician history", $newid, "physician_history", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + //print $q1; exit; + sqlInsert("update form_physician_history set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/physician_history/table.sql b/contrib/forms/physician_history/table.sql new file mode 100644 index 000000000..ce8b591ae --- /dev/null +++ b/contrib/forms/physician_history/table.sql @@ -0,0 +1,262 @@ +CREATE TABLE IF NOT EXISTS `form_physician_history` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +/* Physician History */ + +established tinyint(1), +consultation tinyint(1), +report_sent tinyint(1), +report_sent_date varchar(32), +primary_care varchar(255), +other_physician varchar(255), +who_sent varchar(255), +chief_complaint longtext, +hpi longtext, +current_prescription longtext, +current_nonprescription longtext, + +/* Changes since last visit */ +ph_lvch_ill tinyint(1), +ph_lvch_surg tinyint(1), +ph_lvch_newmed tinyint(1), +ph_lvch_famhist tinyint(1), +ph_lvch_newallerg tinyint(1), +ph_lvch_gynhist tinyint(1), +ph_lvch_obsthist tinyint(1), +ph_lvch_notes longtext, + +ph_allergies_none tinyint(1), +ph_allergies_data longtext, + +cancer_scr_cytology tinyint(1), +cancer_scr_cytology_date varchar(32), +cancer_scr_hpv tinyint(1), +cancer_scr_hpv_date varchar(32), +cancer_scr_notes longtext, + +last_mammogram varchar(32), +last_mammogram_notes longtext, + +last_colorectal varchar(32), +last_colorectal_notes longtext, + +/* Gynecologic history */ +gh_imp varchar(32), +gh_age_at_menarche varchar(255), +gh_length_of_flow varchar(255), +gh_interval_periods varchar(255), +gh_recent_changes varchar(255), +gh_sexually_active tinyint(1), +gh_had_sex tinyint(1), +gh_partners tinyint, +gh_partners_are varchar(6), +gh_method_contraception varchar(255), +gh_contraceptive_history varchar(255), + +/* Obstetric history */ +oh_pregnancies tinyint, +oh_abortions tinyint, +oh_miscarriages tinyint, +oh_premature_births tinyint, +oh_live_births tinyint, +oh_living_children tinyint, +oh_ch_rec_0 longtext, /* compound record: date, width, sex, weeks, delivery, notes : separated by |~ */ +oh_ch_rec_1 longtext, /* compound record: date, width, sex, weeks, delivery, notes : separated by |~ */ +oh_ch_rec_2 longtext, /* compound record: date, width, sex, weeks, delivery, notes : separated by |~ */ +oh_ch_rec_3 longtext, /* compound record: date, width, sex, weeks, delivery, notes : separated by |~ */ +oh_complications longtext, +oh_diabetes tinyint(1), +oh_hipertension tinyint(1), +oh_preemclampsia tinyint(1), +oh_depression tinyint(1), +oh_depression_treated longtext, + +/* Past history */ +ph_noncontrib tinyint(1), +ph_nochange_since tinyint(1), +ph_nochange_since_date varchar(32), +ph_surgeries longtext, +ph_illnesses longtext, +ph_injuries longtext, +ph_immunizations_tuberculosis longtext, + +/* Family history */ +fh_noncontrib tinyint(1), +fh_nochange_since tinyint(1), +fh_nochange_since_date varchar(32), +fh_mother tinyint(1), +fh_mother_dec_cause varchar(255), +fh_mother_dec_age tinyint, +fh_father tinyint(1), +fh_father_dec_cause varchar(255), +fh_father_dec_age tinyint, +fh_sibl_living tinyint, +fh_sibl_deceased tinyint, +fh_sibl_cause varchar(255), +fh_children_living tinyint, +fh_children_deceased tinyint, +fh_children_cause varchar(255), +fhd_diabetes tinyint(1), +fhd_cancer tinyint(1), +fhd_osteoporosis tinyint(1), +fhd_heart tinyint(1), +fhd_hipertension tinyint(1), +fhd_other tinyint(1), +fhd_hyperlipidemia tinyint(1), +fhd_deepvenous tinyint(1), +fhd_diabetes_who varchar(255), +fhd_cancer_who varchar(255), +fhd_osteoporosis_who varchar(255), +fhd_heart_who varchar(255), +fhd_hipertension_who varchar(255), +fhd_other_who varchar(255), +fhd_hyperlipidemia_who varchar(255), +fhd_deepvenous_who varchar(255), + +/* Social history */ +sh_noncontrib tinyint(1), +sh_nochange_since tinyint(1), +sh_nochange_since_date varchar(32), +sh_tobacco tinyint(1), +sh_alcohol tinyint(1), +sh_drugs tinyint(1), +sh_misuse tinyint(1), +sh_partner_violence tinyint(1), +sh_sexual_abuse tinyint(1), +sh_health_hazards tinyint(1), +sh_seat_belt tinyint(1), +sh_diet tinyint(1), +sh_folic_acid tinyint(1), +sh_calcium tinyint(1), +sh_reg_exercise tinyint(1), +sh_caffeine tinyint(1), +sh_advance tinyint(1), +sh_organ_donation tinyint(1), +sh_other tinyint(1), +sh_nochanges_since2 tinyint(1), +sh_nochanges_since2_date varchar(32), +sh_notes_1 varchar(255), +sh_notes_2 varchar(255), +sh_notes_3 varchar(255), +sh_notes_4 varchar(255), +sh_notes_5 varchar(255), +sh_notes_6 varchar(255), +sh_notes_7 varchar(255), +sh_notes_8 varchar(255), +sh_notes_9 varchar(255), +sh_notes_10 varchar(255), +sh_notes_11 varchar(255), +sh_notes_12 varchar(255), +sh_notes_13 varchar(255), +sh_notes_14 varchar(255), +sh_notes_15 varchar(255), +sh_notes_16 varchar(255), +ros_const_negative tinyint(1) DEFAULT 0, +ros_const_weight_loss tinyint(1) DEFAULT 0, +ros_const_weight_gain tinyint(1) DEFAULT 0, +ros_const_fever tinyint(1) DEFAULT 0, +ros_const_fatigue tinyint(1) DEFAULT 0, +ros_const_other tinyint(1) DEFAULT 0, +ros_const_tallest_height varchar(32), +ros_eyes_negative tinyint(1) DEFAULT 0, +ros_eyes_vision_change tinyint(1) DEFAULT 0, +ros_eyes_glasses tinyint(1) DEFAULT 0, +ros_eyes_other tinyint(1) DEFAULT 0, +ros_ear_negative tinyint(1) DEFAULT 0, +ros_ear_ulcers tinyint(1) DEFAULT 0, +ros_ear_sinusitis tinyint(1) DEFAULT 0, +ros_ear_headache tinyint(1) DEFAULT 0, +ros_ear_hearing_loss tinyint(1) DEFAULT 0, +ros_ear_other tinyint(1) DEFAULT 0, +ros_cv_negative tinyint(1) DEFAULT 0, +ros_cv_orthopnea tinyint(1) DEFAULT 0, +ros_cv_chest_pain tinyint(1) DEFAULT 0, +ros_cv_difficulty_breathing tinyint(1) DEFAULT 0, +ros_cv_edema tinyint(1) DEFAULT 0, +ros_cv_palpitation tinyint(1) DEFAULT 0, +ros_cv_other tinyint(1) DEFAULT 0, +ros_resp_negative tinyint(1) DEFAULT 0, +ros_resp_wheezing tinyint(1) DEFAULT 0, +ros_hemoptysis tinyint(1) DEFAULT 0, +ros_resp_shortness tinyint(1) DEFAULT 0, +ros_resp_cough tinyint(1) DEFAULT 0, +ros_resp_other tinyint(1) DEFAULT 0, +ros_gastr_negative tinyint(1) DEFAULT 0, +ros_gastr_diarrhea tinyint(1) DEFAULT 0, +ros_gastr_bloody_stool tinyint(1) DEFAULT 0, +ros_gastr_nausea tinyint(1) DEFAULT 0, +ros_gastr_constipation tinyint(1) DEFAULT 0, +ros_gastr_flatulence tinyint(1) DEFAULT 0, +ros_gastr_pain tinyint(1) DEFAULT 0, +ros_gastr_fecal tinyint(1) DEFAULT 0, +ros_gastr_other tinyint(1) DEFAULT 0, +ros_genit_negative tinyint(1) DEFAULT 0, +ros_genit_hematuria tinyint(1) DEFAULT 0, +ros_genit_dysuria tinyint(1) DEFAULT 0, +ros_genit_urgency tinyint(1) DEFAULT 0, +ros_genit_frequency tinyint(1) DEFAULT 0, +ros_genit_incomplete_emptying tinyint(1) DEFAULT 0, +ros_genit_incontinence tinyint(1) DEFAULT 0, +ros_genit_dyspareunia tinyint(1) DEFAULT 0, +ros_genit_abnormal_periods tinyint(1) DEFAULT 0, +ros_genit_pms tinyint(1) DEFAULT 0, +ros_genit_abnormal_bleeding tinyint(1) DEFAULT 0, +ros_genit_abnormal_discharge tinyint(1) DEFAULT 0, +ros_genit_other tinyint(1) DEFAULT 0, +ros_muscul_negative tinyint(1) DEFAULT 0, +ros_muscul_weakness tinyint(1) DEFAULT 0, +ros_muscul_pain tinyint(1) DEFAULT 0, +ros_muscul_other tinyint(1) DEFAULT 0, +ros_skin_negative tinyint(1) DEFAULT 0, +ros_skin_rash tinyint(1) DEFAULT 0, +ros_skin_ulcers tinyint(1) DEFAULT 0, +ros_skin_dry tinyint(1) DEFAULT 0, +ros_skin_pigmented tinyint(1) DEFAULT 0, +ros_skin_other tinyint(1) DEFAULT 0, +ros_breast_negative tinyint(1) DEFAULT 0, +ros_breast_mastalgia tinyint(1) DEFAULT 0, +ros_breast_discharge tinyint(1) DEFAULT 0, +ros_breast_masses tinyint(1) DEFAULT 0, +ros_breast_other tinyint(1) DEFAULT 0, +ros_neuro_negative tinyint(1) DEFAULT 0, +ros_neuro_syncope tinyint(1) DEFAULT 0, +ros_neuro_seizures tinyint(1) DEFAULT 0, +ros_neuro_numbness tinyint(1) DEFAULT 0, +ros_neuro_trouble_walking tinyint(1) DEFAULT 0, +ros_neuro_memory tinyint(1) DEFAULT 0, +ros_neuro_other tinyint(1) DEFAULT 0, +ros_psych_negative tinyint(1) DEFAULT 0, +ros_psych_depression tinyint(1) DEFAULT 0, +ros_psych_crying tinyint(1) DEFAULT 0, +ros_psych_anxiety tinyint(1) DEFAULT 0, +ros_psych_other tinyint(1) DEFAULT 0, +ros_endo_negative tinyint(1) DEFAULT 0, +ros_endo_diabetes tinyint(1) DEFAULT 0, +ros_endo_hipothyroid tinyint(1) DEFAULT 0, +ros_endo_hiperthyroid tinyint(1) DEFAULT 0, +ros_endo_flashes tinyint(1) DEFAULT 0, +ros_endo_hair_loss tinyint(1) DEFAULT 0, +ros_endo_intolerance tinyint(1) DEFAULT 0, +ros_endo_other tinyint(1) DEFAULT 0, +ros_hemato_negative tinyint(1) DEFAULT 0, +ros_hemato_bruises tinyint(1) DEFAULT 0, +ros_hemato_bleeding tinyint(1) DEFAULT 0, +ros_hemato_adenopathy tinyint(1) DEFAULT 0, +ros_hemato_other tinyint(1) DEFAULT 0, + +/* Review of systems */ + + + + + + + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/physician_history/view.php b/contrib/forms/physician_history/view.php new file mode 100644 index 000000000..41e870774 --- /dev/null +++ b/contrib/forms/physician_history/view.php @@ -0,0 +1,972 @@ + + + + + +Physician history + + + + + + + + +> + +

Patient name:
Birth date:
ID No:
Date

Physician history

+ + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + + + +

> + New patient

> + Established patient

> + Consultation

+ + + + +

> +Report sent

Primary care physician:
+

Who sent patient:
+

Other physician(s):

+ + + + + + + + + + + + + + + + +

Chief complaint (CC) (Required for all visits except preventive):	Current prescription medications:
<? echo $fdata{'chief_complaint'}; ?>	<? echo $fdata{'current_prescription'}; ?>
History of present ilness (HPI):	Current nonpresription, complem., and alt. medications:
<? echo $fdata{'hpi'}; ?>	<? echo $fdata{'current_nonprescription'}; ?>

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

Changes since last visit	yes	no	Notes
Illnesses	>	>	<? echo $fdata{'ph_lvch_notes'}; ?>
Surgery	>	>
New medications	>	>
Change in family history	>	>
New allergies	>	>
Change in gynecologic history	>	>
Change in obstetric history	>	>

+ + + + +

Allergies (describe reaction): + > +none

+ + + + + + + + + + + + +

Last cervical cancer screening: + > + Cytology + + > + HPV test +
last mammogram: +
Last colorectal screening: +

Gynecologic history (PH)

+ + + + + + + + + + + + + + + + +

+ + + + + + + + + + + + +

Imp

Age at menarche

Length of flow

Interval between periods

Recent changes

Sexually active: + > + Yes + > + No Ever had sex: + > +Yes +> +No Number of partners (Lifetime) +

Partners are: + > + men + > + women + > + both

Current method of contraception:

past contraceptive history:

Obstetric history (PH)

+ + + + + + + + + + + + + +

+ + + + + + + + + + + + + + + + + + + + + + + + +

	Number		Number		Number
Pregnancies		abortions		miscarriages
premature births(<37 weeks)		live births		living children

+ + + + + + + + + + + + + + + + + + +EOL; + $bi++; + } +?> +

No	birth date	weight at birth	baby's sex	weeks pregnant	type of delivery (vaginal, cesarian etc.)	physician's notes
$n.

+ + + + +

Any pregnancy complications?

+ + + + + + + +

> + diabetes + > + hypertension/high blood pressure + > + preeclampsia/foxemia + > + other
any history of depression before or after pregnancy? + > + no + > + yes, How treated

Past history (PH)

+ + + + + + + + + + + + + + + + +

> + Noncontributory + > + no interval change since +

SUrgeries:
+

Illnesses (Physical and mental):
+

Injuries:
+

Immunizations/Tuberculosis test:
+

Family history (FH)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

> +Noncontributory + > +no interval change since +
Mother: + > + living + > + deceased - cause: + + age: + + Father: + > +living +> +deceased - cause: + +age: +
Siblings: number living: + + Number deceased: + + cause(s) / Age(s) : +
Children: number living: + +Number deceased: + +cause(s) / Age(s) : +
(IF YES, indicate whom, and age of diagnosis)
> + diabetes +	> + heart disease +	> + hyperlipidemia +
> + cancer +	> + Hypertension +	> + deep venous tromboembolIsm / Pulmonary embolism +
> + osteoporosis +	> + other illnesses +

Social history (SH)

+ + + + + + + +

> +Noncontributory +> +no interval change since +

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

	yes	no	notes		yes	no	notes
Tobacco use	>	>		diet discussed	>	>	+
Alcohol use + specify amount and type + 12 OZ beer = 5 oz wine = 1 1/2 oz liquor	>	>		folic acid intake	>	>
	>	>		calcium intake	>	>
Illegal/Street drug use	>	>		regular exercise	>	>
misuse of prescription drugs	>	>		caffeine intake	>	>
intimate partner violence	>	>		advance directive (living will)	>	>
sexual abuse	>	>		organ donation	>	>
health hazards at home/work	>	>		other	>	>
seat belt use	>	>		> + no changes since

Review of systems (ROS)

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +

+ + + + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/plist/info.txt b/contrib/forms/plist/info.txt new file mode 100644 index 000000000..aa33942c5 --- /dev/null +++ b/contrib/forms/plist/info.txt @@ -0,0 +1 @@ +ACOG / Problem list \ No newline at end of file diff --git a/contrib/forms/plist/new.php b/contrib/forms/plist/new.php new file mode 100644 index 000000000..ee7d1f192 --- /dev/null +++ b/contrib/forms/plist/new.php @@ -0,0 +1,152 @@ + + + + + + + + + + + + > + +

+ + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Problem list

+ + + + + + + + + + + + + + + + + +

High risk:	Family history:
<? echo $obj{'pl_high_risk'} ?>	<? + ($history['history_mother'] != '')?$tmp[] = "Mother: ".$history['history_mother']:''; + ($history['history_father'] != '')?$tmp[] = "Father: ".$history['history_father']:''; + ($history['history_siblings'] != '')?$tmp[] = "Siblings: ".$history['history_siblings']:''; + ($history['history_spouse'] != '')?$tmp[] = "Spouse: ".$history['history_spouse']:''; + ($history['history_offspring'] != '')?$tmp[] = "Offspring: ".$history['history_offspring']:''; + echo join(', ', $tmp); + ?>
Drug/Latex/Transfusion/Allergic reactions:	Current medications:
<? +$allergies = ''; $checked = 'checked'; +if ($result = getListByType($pid, "allergy", "id,title,comments,activity,date", 1, "all", 0)){ + foreach ($result as $iter) { + $al_tmp[] = $iter{"title"}.' ('.$iter{"comments"}.') '; + $checked = ''; + } + $allergies = join(',', $al_tmp); +} +echo $allergies; +?>	<? +if ($result = getListByType($pid, "medication", "id,title,comments,activity,date", 1, "all", 0)){ + foreach ($result as $iter) { + $tmp_med[] = $iter{"title"}.' ('.$iter{"comments"}.') '; + } +echo join(', ', $tmp_med); +} +?>

+ + + + + + + + + + + + + + + +EOL; +$pli++; +} +?> +

No	Entry date	Problem/Resolution	Onset age and date	Resolution date
${pli}.

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/plist/printable.php b/contrib/forms/plist/printable.php new file mode 100644 index 000000000..b2c3a2b89 --- /dev/null +++ b/contrib/forms/plist/printable.php @@ -0,0 +1,92 @@ + + + + + + + + + +> + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Problem list

+ + + + + + + + + + + + + + + + + +

High risk:	Family history:

Drug/Latex/Transfusion/Allergic reactions:	Current medications:

+ + + + + + + + + + + + + + + +EOL; +$pli++; +} +?> +

No	Entry date	Problem/Resolution	Onset age and date	Resolution date
${pli}.	${pl_ed}	${pl_problem}	${pl_onset}	${pl_rd}

+ + \ No newline at end of file diff --git a/contrib/forms/plist/report.php b/contrib/forms/plist/report.php new file mode 100644 index 000000000..eb86ccf16 --- /dev/null +++ b/contrib/forms/plist/report.php @@ -0,0 +1,81 @@ + + + + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Problem list

+ + + + + + + + + + + + + + + + + +

High risk:	Family history:

Drug/Latex/Transfusion/Allergic reactions:	Current medications:

+ + + + + + + + + + + + + + + +EOL; +$pli++; +} +?> +

No	Entry date	Problem/Resolution	Onset age and date	Resolution date
${pli}.	${pl_ed}	${pl_problem}	${pl_onset}	${pl_rd}

+ \ No newline at end of file diff --git a/contrib/forms/plist/save.php b/contrib/forms/plist/save.php new file mode 100644 index 000000000..128915618 --- /dev/null +++ b/contrib/forms/plist/save.php @@ -0,0 +1,58 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + //echo "$var\n"; +} + $data['pl_high_risk'] = $_POST['pl_high_risk']; + $data['pl_family_history'] = $_POST['pl_family_history']; + $data['pl_reactions'] = $_POST['pl_reactions']; + $data['pl_medications'] = $_POST['pl_medications']; + + $si = 1; + while ($si < 26){ + if ($_POST["pl_ed_${si}"] != ''){ + $data["pl_problem_${si}"] = $_POST["pl_ed_${si}"].'|~'. + $_POST["pl_problem_${si}"].'|~'. + $_POST["pl_onset_${si}"].'|~'. + $_POST["pl_rd_${si}"]; + } else { + $data["pl_problem_${si}"] = ''; + } + $si++; + } + +//if ($pid == "") { $pid = $_SESSION["pid"]; } + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_plist", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Problem list", $newid, "plist", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +}elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_plist set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/plist/table.sql b/contrib/forms/plist/table.sql new file mode 100644 index 000000000..bd8e87e87 --- /dev/null +++ b/contrib/forms/plist/table.sql @@ -0,0 +1,39 @@ +CREATE TABLE IF NOT EXISTS `form_plist` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, +pl_high_risk longtext, +pl_family_history longtext, +pl_reactions longtext, +pl_medications longtext, +pl_problem_1 longtext, +pl_problem_2 longtext, +pl_problem_3 longtext, +pl_problem_4 longtext, +pl_problem_5 longtext, +pl_problem_6 longtext, +pl_problem_7 longtext, +pl_problem_8 longtext, +pl_problem_9 longtext, +pl_problem_10 longtext, +pl_problem_11 longtext, +pl_problem_12 longtext, +pl_problem_13 longtext, +pl_problem_14 longtext, +pl_problem_15 longtext, +pl_problem_16 longtext, +pl_problem_17 longtext, +pl_problem_18 longtext, +pl_problem_19 longtext, +pl_problem_20 longtext, +pl_problem_21 longtext, +pl_problem_22 longtext, +pl_problem_23 longtext, +pl_problem_24 longtext, +pl_problem_25 longtext, +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/plist/view.php b/contrib/forms/plist/view.php new file mode 100644 index 000000000..f3b516686 --- /dev/null +++ b/contrib/forms/plist/view.php @@ -0,0 +1,116 @@ + + + + + + + + + + + +> + +

" method="post" enctype="multipart/form-data" name="my_form"> + + + + + + + + + + + + + + + + + + +

Patient name:
Birth date:
ID No:
Date

Problem list

+ + + + + + + + + + + + + + + + + +

High risk:	Family history:
<? echo $obj{'pl_high_risk'} ?>	<? echo $obj{'pl_family_history'} ?>
Drug/Latex/Transfusion/Allergic reactions:	Current medications:
<? echo $obj{'pl_reactions'} ?>	<? echo $obj{'pl_medications'} ?>

+ + + + + + + + + + + + + + + +EOL; +$pli++; +} +?> +

No	Entry date	Problem/Resolution	Onset age and date	Resolution date
${pli}.

+ + + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/routine_screening_record/info.txt b/contrib/forms/routine_screening_record/info.txt new file mode 100644 index 000000000..850b10f2e --- /dev/null +++ b/contrib/forms/routine_screening_record/info.txt @@ -0,0 +1 @@ +ACOG / Routine screening record \ No newline at end of file diff --git a/contrib/forms/routine_screening_record/new.php b/contrib/forms/routine_screening_record/new.php new file mode 100644 index 000000000..fd9cc6fbb --- /dev/null +++ b/contrib/forms/routine_screening_record/new.php @@ -0,0 +1,231 @@ + + + + + +Form: Routine screening record + + + + + + + +> + +

+ +

Routine screening record

+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +EOL; +$rsi++; +} +?> +

patient name: +				Birth date: +				ID No: +
age	Cervical cytology	Lipid profile assessment	Mammo- + graphy	Colorectal cancer screening	Bone density screening	Chlamydia screening	Gonor- + rhea screening	Urinalysis	Fasting glucose test	Thyroid stimulating hormone screening
13-18	ANNUALLY BEGINNING + APPROXIMATELY 3 YEARS + AFTER INITIATION OF + SEXUAL INTERCOURSE					SEXUALLY ACTIVE WOMEN + UNDER AGE 25	SEXUALLY ACTIVE + ADOLES- + CENTS
19-39	ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS					SEXUALLY ACTIVE WOMEN +UNDER AGE 25
40-64	EVERY 2–3 YEARS AFTER 3 + CONSECuTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS + BEGINNING + AT AGE 45	EVERY 1–2 YEARS UNTIL + AGE 50; YEARLY + BEGINNING AT AGE 50	BEGINNING AT AGE 50 + YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY 5 + YEARS OR DCBE EVERY 5 + YEARS OR COLONOSCOPY + EVERY 10 YEARS					EVERY 3 YEARS + AFTER AGE 45	EVERY 5 YEARS + BEGINNING AT AGE 50
65 and older	EVERY 2–3 YEARS AFTER 3 + CONSECUTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS	YEARLY OR AS + APPROPRIATE	YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY + YEARS OR DCBE EVERY + YEARS OR COLONOSCOPY + EVERY 10 YEARS	IN THE ABSENCE OF + NEW RISK FACTORS, + SUBSEQUENT SCREENING + NOT MORE FREQUENTLY + THAN EVERY 2 YEARS			YEARLY OR AS + APPROPRIATE	EVERY 3 YEARS	EVERY 5 YEARS

Date
result

+ + + + + +

+ + + \ No newline at end of file diff --git a/contrib/forms/routine_screening_record/printable.php b/contrib/forms/routine_screening_record/printable.php new file mode 100644 index 000000000..d6138da3e --- /dev/null +++ b/contrib/forms/routine_screening_record/printable.php @@ -0,0 +1,206 @@ + + + + + +Form: Routine screening record + + + + +> +

Routine screening record

Patient name:				Birth date:				ID No:
age	Cervical cytology	Lipid profile assessment^*	Mammo- + graphy^*	Colorectal cancer screening ^*	Bone density screening^*	Chlamydia screening^*	Gonor- + rhea screening ^*	Urinalysis	Fasting glucose test^*	Thyroid stimulating hormone screening
13-18	ANNUALLY BEGINNING + APPROXIMATELY 3 YEARS + AFTER INITIATION OF + SEXUAL INTERCOURSE					SEXUALLY ACTIVE WOMEN + UNDER AGE 25	SEXUALLY ACTIVE + ADOLES- + CENTS
19-39	ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS					SEXUALLY ACTIVE WOMEN +UNDER AGE 25
40-64	EVERY 2–3 YEARS AFTER 3 + CONSECuTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS + BEGINNING + AT AGE 45	EVERY 1–2 YEARS UNTIL + AGE 50; YEARLY + BEGINNING AT AGE 50	BEGINNING AT AGE 50 + YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY 5 + YEARS OR DCBE EVERY 5 + YEARS OR COLONOSCOPY + EVERY 10 YEARS					EVERY 3 YEARS + AFTER AGE 45	EVERY 5 YEARS + BEGINNING AT AGE 50
65 and older	EVERY 2–3 YEARS AFTER 3 + CONSECUTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS	YEARLY OR AS + APPROPRIATE	YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY + YEARS OR DCBE EVERY + YEARS OR COLONOSCOPY + EVERY 10 YEARS	IN THE ABSENCE OF + NEW RISK FACTORS, + SUBSEQUENT SCREENING + NOT MORE FREQUENTLY + THAN EVERY 2 YEARS			YEARLY OR AS + APPROPRIATE	EVERY 3 YEARS	EVERY 5 YEARS

Date	${cervical_date}	${lipid_date}	${mammo_date}	${colorectal_date}	${bone_date}	${chlamyd_date}	${gonor_date}	${urinal_date}	${glucose_date}	${thyroid_date}
result	${cervical_res}	${lipid_res}	${mammo_res}	${colorectal_res}	${bone_res}	${chlamyd_res}	${gonor_res}	${urinal_res}	${glucose_res}	${thyroid_res}

^*This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)

+ + \ No newline at end of file diff --git a/contrib/forms/routine_screening_record/report.php b/contrib/forms/routine_screening_record/report.php new file mode 100644 index 000000000..8d5757c76 --- /dev/null +++ b/contrib/forms/routine_screening_record/report.php @@ -0,0 +1,193 @@ + +

Routine screening record

Patient name:				Birth date:				ID No:
age	Cervical cytology	Lipid profile assessment^*	Mammo- + graphy^*	Colorectal cancer screening ^*	Bone density screening^*	Chlamydia screening^*	Gonor- + rhea screening^*	Urinalysis	Fasting glucose test^*	Thyroid stimulating hormone screening
13-18	ANNUALLY BEGINNING + APPROXIMATELY 3 YEARS + AFTER INITIATION OF + SEXUAL INTERCOURSE					SEXUALLY ACTIVE WOMEN + UNDER AGE 25	SEXUALLY ACTIVE + ADOLES- + CENTS
19-39	ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS					SEXUALLY ACTIVE WOMEN +UNDER AGE 25
40-64	EVERY 2–3 YEARS AFTER 3 + CONSECuTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS + BEGINNING + AT AGE 45	EVERY 1–2 YEARS UNTIL + AGE 50; YEARLY + BEGINNING AT AGE 50	BEGINNING AT AGE 50 + YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY 5 + YEARS OR DCBE EVERY 5 + YEARS OR COLONOSCOPY + EVERY 10 YEARS					EVERY 3 YEARS + AFTER AGE 45	EVERY 5 YEARS + BEGINNING AT AGE 50
65 and older	EVERY 2–3 YEARS AFTER 3 + CONSECUTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS	YEARLY OR AS + APPROPRIATE	YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY + YEARS OR DCBE EVERY + YEARS OR COLONOSCOPY + EVERY 10 YEARS	IN THE ABSENCE OF + NEW RISK FACTORS, + SUBSEQUENT SCREENING + NOT MORE FREQUENTLY + THAN EVERY 2 YEARS			YEARLY OR AS + APPROPRIATE	EVERY 3 YEARS	EVERY 5 YEARS

Date	${cervical_date}	${lipid_date}	${mammo_date}	${colorectal_date}	${bone_date}	${chlamyd_date}	${gonor_date}	${urinal_date}	${glucose_date}	${thyroid_date}
result	${cervical_res}	${lipid_res}	${mammo_res}	${colorectal_res}	${bone_res}	${chlamyd_res}	${gonor_res}	${urinal_res}	${glucose_res}	${thyroid_res}

^*This test may be appropriate for other patients based on risk (see High-Risk Laboratory Record and Table of High-Risk Factors)

+ \ No newline at end of file diff --git a/contrib/forms/routine_screening_record/save.php b/contrib/forms/routine_screening_record/save.php new file mode 100644 index 000000000..f24b47fe4 --- /dev/null +++ b/contrib/forms/routine_screening_record/save.php @@ -0,0 +1,53 @@ + $fld){ + $data[$fld] = ''; +} + +foreach ($_POST as $k => $var) { + $_POST[$k] = mysql_escape_string($var); + //echo "$var\n"; +} +$factors = array("cervical", "lipid", "mammo", "colorectal", +"bone", "chlamyd", "gonor", "urinal", "glucose", "thyroid"); + + +$ii = 1; +while ($ii<9){ + $record = ''; + foreach($factors as $k=>$v){ + $record .= $_POST[$v."_date_".$ii] .'|'. $_POST[$v."_res_".$ii]; + if ($v != "thyroid") { $record .= '|~'; } + } + $data["record_".$ii] = $record; + $ii++; +} + +if ($_GET["mode"] == "new"){ + if ($encounter == "") { $encounter = date("Ymd"); } + $newid = formSubmit("form_routine_screening_record", $data, $_GET["id"], $userauthorized); + addForm($encounter, "Routine screening record", $newid, "routine_screening_record", $pid, $userauthorized); + $_SESSION["encounter"] = $encounter; +} elseif ($_GET["mode"] == "update") { + $q1 = ''; + foreach ($data as $key => $val){ + $q1 .= "$key='$val', "; + } + sqlInsert("update form_routine_screening_record set pid = {$_SESSION["pid"]},groupname='".$_SESSION["authProvider"]."',user='".$_SESSION["authUser"]."',authorized=$userauthorized,activity=1, $q1 date = NOW() where id=$id"); +} +sqlInsert("update patient_data set DOB='".$_POST['pbdate']."' where id=$pid"); + +//$_SESSION["pid"] = $pid; +formHeader("Redirecting...."); +formJump(); +formFooter(); +?> diff --git a/contrib/forms/routine_screening_record/table.sql b/contrib/forms/routine_screening_record/table.sql new file mode 100644 index 000000000..40beb42d1 --- /dev/null +++ b/contrib/forms/routine_screening_record/table.sql @@ -0,0 +1,20 @@ +CREATE TABLE IF NOT EXISTS `form_routine_screening_record` ( +id bigint(20) NOT NULL auto_increment, +date datetime default NULL, +pid bigint(20) default NULL, +user varchar(255) default NULL, +groupname varchar(255) default NULL, +authorized tinyint(4) default NULL, +activity tinyint(4) default NULL, + +record_1 longtext, +record_2 longtext, +record_3 longtext, +record_4 longtext, +record_5 longtext, +record_6 longtext, +record_7 longtext, +record_8 longtext, + +PRIMARY KEY (id) +) TYPE=MyISAM; diff --git a/contrib/forms/routine_screening_record/view.php b/contrib/forms/routine_screening_record/view.php new file mode 100644 index 000000000..0328b2ded --- /dev/null +++ b/contrib/forms/routine_screening_record/view.php @@ -0,0 +1,232 @@ + + + + + +Form: Routine screening record + + + + + + + +> + +

+ +

Routine screening record

patient name: +				Birth date: +				ID No: +
age	Cervical cytology	Lipid profile assessment	Mammo- + graphy	Colorectal cancer screening	Bone density screening	Chlamydia screening	Gonor- + rhea screening	Urinalysis	Fasting glucose test	Thyroid stimulating hormone screening
13-18	ANNUALLY BEGINNING + APPROXIMATELY 3 YEARS + AFTER INITIATION OF + SEXUAL INTERCOURSE					SEXUALLY ACTIVE WOMEN + UNDER AGE 25	SEXUALLY ACTIVE + ADOLES- + CENTS
19-39	ANNUALLY BEGINNING NO LATER THAN AGE 21 YEARS					SEXUALLY ACTIVE WOMEN +UNDER AGE 25
40-64	EVERY 2–3 YEARS AFTER 3 + CONSECuTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS + BEGINNING + AT AGE 45	EVERY 1–2 YEARS UNTIL + AGE 50; YEARLY + BEGINNING AT AGE 50	BEGINNING AT AGE 50 + YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY 5 + YEARS OR DCBE EVERY 5 + YEARS OR COLONOSCOPY + EVERY 10 YEARS					EVERY 3 YEARS + AFTER AGE 45	EVERY 5 YEARS + BEGINNING AT AGE 50
65 and older	EVERY 2–3 YEARS AFTER 3 + CONSECUTIVE NEGATIVE TEST + RESULTS IF NO HISTORY OF + CIN 2 OR 3, + IMMUNOSUP- + PRESSION, + HIV INFECTION, OR DES + EXPOSURE IN UTERO	EVERY 5 YEARS	YEARLY OR AS + APPROPRIATE	YEARLY FOBT OR FLEXIBLE + SIGMOIDOSCOPY EVERY + 5 YEARS OR YEARLY FOBT + PLUS FLEXIBLE + SIGMOIDOSCOPY EVERY + YEARS OR DCBE EVERY + YEARS OR COLONOSCOPY + EVERY 10 YEARS	IN THE ABSENCE OF + NEW RISK FACTORS, + SUBSEQUENT SCREENING + NOT MORE FREQUENTLY + THAN EVERY 2 YEARS			YEARLY OR AS + APPROPRIATE	EVERY 3 YEARS	EVERY 5 YEARS

Date
result

+ + + + +