You can not select more than 25 topics
Topics must start with a letter or number, can include dashes ('-') and can be up to 35 characters long.
75 lines
3.2 KiB
75 lines
3.2 KiB
<?php |
|
|
|
/** |
|
* Generated DocBlock |
|
* |
|
* @package OpenEMR |
|
* @link http://www.open-emr.org |
|
* @author andres_paglayan <andres_paglayan> |
|
* @author cornfeed <jdough823@gmail.com> |
|
* @author fndtn357 <fndtn357@gmail.com> |
|
* @author sunsetsystems <sunsetsystems> |
|
* @copyright Copyright (c) 2005 andres_paglayan <andres_paglayan> |
|
* @copyright Copyright (c) 2011 cornfeed <jdough823@gmail.com> |
|
* @copyright Copyright (c) 2012 fndtn357 <fndtn357@gmail.com> |
|
* @copyright Copyright (c) 2007 sunsetsystems <sunsetsystems> |
|
* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3 |
|
*/ |
|
|
|
?> |
|
<!-- Form generated from formsWiz --> |
|
<?php |
|
require_once("../../globals.php"); |
|
require_once("$srcdir/api.inc"); |
|
|
|
use OpenEMR\Core\Header; |
|
|
|
formHeader("Form: hearingtest"); |
|
?> |
|
<html><head> |
|
<?php Header::setupHeader(); ?> |
|
</head> |
|
<body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0> |
|
<form method=post action="<?php echo $rootdir;?>/forms/hearingtest/save.php?mode=new" name="my_form"> |
|
<span class="title">Hearing Test</span><br /><br /> |
|
<input type=checkbox name='with_hearing_aid' ><span class=text>With hearing Aid?</span><br /> |
|
<table> |
|
<tr> |
|
<td> |
|
<span class=text>Right Ear 250: </span><input type="text" name="right_ear_250" value="" ><br /> |
|
<span class=text>Right Ear 500: </span><input type="text" name="right_ear_500" value="" ><br /> |
|
<span class=text>Right Ear 1000: </span><input type="text" name="right_ear_1000" value="" ><br /> |
|
<span class=text>Right Ear 2000: </span><input type="text" name="right_ear_2000" value="" ><br /> |
|
<span class=text>Right Ear 3000: </span><input type="text" name="right_ear_3000" value="" ><br /> |
|
<span class=text>Right Ear 4000: </span><input type="text" name="right_ear_4000" value="" ><br /> |
|
<span class=text>Right Ear 5000: </span><input type="text" name="right_ear_5000" value="" ><br /> |
|
<span class=text>Right Ear 6000: </span><input type="text" name="right_ear_6000" value="" ><br /> |
|
</td> |
|
<td> |
|
<span class=text>Left Ear 250: </span><input type="text" name="left_ear_250" value="" ><br /> |
|
<span class=text>Left Ear 500: </span><input type="text" name="left_ear_500" value="" ><br /> |
|
<span class=text>Left Ear 1000: </span><input type="text" name="left_ear_1000" value="" ><br /> |
|
<span class=text>Left Ear 2000: </span><input type="text" name="left_ear_2000" value="" ><br /> |
|
<span class=text>Left Ear 3000: </span><input type="text" name="left_ear_3000" value="" ><br /> |
|
<span class=text>Left Ear 4000: </span><input type="text" name="left_ear_4000" value="" ><br /> |
|
<span class=text>Left Ear 5000: </span><input type="text" name="left_ear_5000" value="" ><br /> |
|
<span class=text>Left Ear 6000: </span><input type="text" name="left_ear_6000" value="" ><br /> |
|
</td> |
|
</tr> |
|
</table> |
|
<br /> |
|
<table> |
|
<tr> |
|
<td valign=top> |
|
<span class=text>Additional Notes: </span><br /><textarea cols=40 rows=8 name="additional_notes" ></textarea> |
|
</td> |
|
</tr> |
|
</table> |
|
<br /> |
|
<a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a> |
|
<br /> |
|
<a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link" onclick="top.restoreSession()">[Don't Save]</a> |
|
</form> |
|
<?php |
|
formFooter(); |
|
?>
|
|
|