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806 lines
52 KiB
806 lines
52 KiB
<?php |
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/** |
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* Review of Systems Checks form |
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* |
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* @package OpenEMR |
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* @link http://www.open-emr.org |
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* @author cfapress <cfapress> |
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* @author Brady Miller <brady.g.miller@gmail.com> |
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* @author Robert Down <robertdown@live.com> |
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* @copyright Copyright (c) 2008 cfapress <cfapress> |
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* @copyright Copyright (c) 2016-2019 Brady Miller <brady.g.miller@gmail.com> |
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* @copyright Copyright (c) 2017-2022 Robert Down <robertdown@live.com> |
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* @license https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3 |
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*/ |
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require_once(__DIR__ . "/../../globals.php"); |
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require_once("$srcdir/api.inc"); |
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use OpenEMR\Common\Csrf\CsrfUtils; |
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use OpenEMR\Core\Header; |
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$returnurl = 'encounter_top.php'; |
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?> |
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<html> |
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<head> |
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<title><?php echo xlt("Review of Systems Checks"); ?></title> |
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<?php Header::setupHeader();?> |
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</head> |
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<?php |
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$obj = formFetch("form_reviewofs", $_GET["id"]); |
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?> |
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<body class="body_top"> |
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<div class="container"> |
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<div class="row"> |
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<div class="col-12"> |
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<h2><?php echo xlt("Review of Systems Checks");?></h2> |
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</div> |
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</div> |
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<div class="row"> |
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<form method=post action="<?php echo $rootdir; ?>/forms/reviewofs/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form" onsubmit="return top.restoreSession()"> |
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<input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" /> |
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<fieldset> |
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<legend><?php echo xlt('General')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="fever" <?php echo ($obj["fever"] == "on") ? "checked" : ""; ?>><?php echo xlt('Fever');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="chills" <?php echo ($obj["chills"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chills');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="night_sweats" <?php echo ($obj["night_sweats"] == "on") ? "checked" : ""; ?>><?php echo xlt('Night Sweats');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="weight_loss" <?php echo ($obj["weight_loss"] == "on") ? "checked" : ""; ?>><?php echo xlt('Weight Loss');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="poor_appetite" <?php echo ($obj["poor_appetite"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Appetite');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="insomnia" <?php echo ($obj["insomnia"] == "on") ? "checked" : ""; ?>><?php echo xlt('Insomnia');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="fatigued" <?php echo ($obj["fatigued"] == "on") ? "checked" : ""; ?>><?php echo xlt('Fatigued');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="depressed" <?php echo ($obj["depressed"] == "on") ? "checked" : ""; ?>><?php echo xlt('Depressed');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="hyperactive" <?php echo ($obj["hyperactive"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hyperactive');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="exposure_to_foreign_countries" <?php echo ($obj["exposure_to_foreign_countries"] == "on") ? "checked" : ""; ?>><?php echo xlt('Exposure to Foreign Countries');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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</div> |
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</div> |
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</fieldset> |
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<fieldset> |
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<legend><?php echo xlt('Skin')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="rashes" <?php echo ($obj["rashes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Rashes');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="infections" <?php echo ($obj["infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Infections');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="ulcerations" <?php echo ($obj["ulcerations"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ulcerations');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="pemphigus" <?php echo ($obj["pemphigus"] == "on") ? "checked" : ""; ?>><?php echo xlt('Pemphigus');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="herpes" <?php echo ($obj["herpes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Herpes');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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</div> |
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</div> |
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</fieldset> |
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<fieldset> |
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<legend><?php echo xlt('HEENT')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="cataracts" <?php echo ($obj["cataracts"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cataracts');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="cataract_surgery" <?php echo ($obj["cataract_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cataract Surgery');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="glaucoma" <?php echo ($obj["glaucoma"] == "on") ? "checked" : ""; ?>><?php echo xlt('Glaucoma');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="double_vision" <?php echo ($obj["double_vision"] == "on") ? "checked" : ""; ?>><?php echo xlt('Double Vision');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="blurred_vision" <?php echo ($obj["blurred_vision"] == "on") ? "checked" : ""; ?>><?php echo xlt('Blurred Vision');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="poor_hearing" <?php echo ($obj["poor_hearing"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Hearing');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="headaches" <?php echo ($obj["headaches"] == "on") ? "checked" : ""; ?>><?php echo xlt('Headaches');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="ringing_in_ears" <?php echo ($obj["ringing_in_ears"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ringing in Ears');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="bloody_nose" <?php echo ($obj["bloody_nose"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bloody Nose');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="sinusitis" <?php echo ($obj["sinusitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sinusitis');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="sinus_surgery" <?php echo ($obj["sinus_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sinus Surgery');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="dry_mouth" <?php echo ($obj["dry_mouth"] == "on") ? "checked" : ""; ?>><?php echo xlt('Dry Mouth');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="strep_throat" <?php echo ($obj["strep_throat"] == "on") ? "checked" : ""; ?>><?php echo xlt('Strep Throat');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="tonsillectomy" <?php echo ($obj["tonsillectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Tonsillectomy');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="swollen_lymph_nodes" <?php echo ($obj["swollen_lymph_nodes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Swollen Lymph Nodes');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="throat_cancer" <?php echo ($obj["throat_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Throat Cancer');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="throat_cancer_surgery" <?php echo ($obj["throat_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Throat Cancer Surgery');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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</div> |
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</div> |
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</fieldset> |
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<fieldset> |
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<legend><?php echo xlt('Pulmonary')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="emphysema" <?php echo ($obj["emphysema"] == "on") ? "checked" : ""; ?>><?php echo xlt('Emphysema');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="chronic_bronchitis" <?php echo ($obj["chronic_bronchitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chronic Bronchitis');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="interstitial_lung_disease" <?php echo ($obj["interstitial_lung_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Interstitial Lung Disease');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="shortness_of_breath_2" <?php echo ($obj["shortness_of_breath_2"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shortness of Breath');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="lung_cancer" <?php echo ($obj["lung_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lung Cancer');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="lung_cancer_surgery" <?php echo ($obj["lung_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lung Cancer Surgery');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="pheumothorax" <?php echo ($obj["pheumothorax"] == "on") ? "checked" : ""; ?>><?php echo xlt('Pheumothorax');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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</div> |
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</div> |
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</fieldset> |
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<fieldset> |
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<legend><?php echo xlt('Cardiovascular')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="heart_attack" <?php echo ($obj["heart_attack"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Attack');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="irregular_heart_beat" <?php echo ($obj["irregular_heart_beat"] == "on") ? "checked" : ""; ?>><?php echo xlt('Irregular Heart Beat');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="chest_pains" <?php echo ($obj["chest_pains"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chest Pains');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="shortness_of_breath" <?php echo ($obj["shortness_of_breath"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shortness of Breath');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="high_blood_pressure" <?php echo ($obj["high_blood_pressure"] == "on") ? "checked" : ""; ?>><?php echo xlt('High Blood Pressure');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="heart_failure" <?php echo ($obj["heart_failure"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Failure');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="poor_circulation" <?php echo ($obj["poor_circulation"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Circulation');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="vascular_surgery" <?php echo ($obj["vascular_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Vascular Surgery');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="cardiac_catheterization" <?php echo ($obj["cardiac_catheterization"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cardiac Catheterization');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="heart_transplant" <?php echo ($obj["heart_transplant"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Transplant');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="stress_test" <?php echo ($obj["stress_test"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stress Test');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="stress_test" <?php echo ($obj["stress_test"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stress Test');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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</div> |
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</div> |
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</fieldset> |
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<fieldset> |
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<legend><?php echo xlt('Gastrointestinal')?></legend> |
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<div class="row"> |
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<div class="col-12"> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="stomach_pains" <?php echo ($obj["stomach_pains"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stomach Pains');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="peptic_ulcer_disease" <?php echo ($obj["peptic_ulcer_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Peptic Ulcer Disease');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="gastritis" <?php echo ($obj["gastritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Gastritis');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="endoscopy" <?php echo ($obj["endoscopy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Endoscopy');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="polyps" <?php echo ($obj["polyps"] == "on") ? "checked" : ""; ?>><?php echo xlt('Polyps');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="colonoscopy" <?php echo ($obj["colonoscopy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colonoscopy');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="colon_cancer" <?php echo ($obj["colon_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colon Cancer');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="colon_cancer_surgery" <?php echo ($obj["colon_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colon Cancer Surgery');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="ulcerative_colitis" <?php echo ($obj["ulcerative_colitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ulcerative Colitis');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="crohns_disease" <?php echo ($obj["crohns_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Crohn\'s Disease');?> |
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</label> |
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</div> |
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</div> |
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</div> |
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<div class="col-sm-3"> |
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<div class="form-group"> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="appendectomy" <?php echo ($obj["appendectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Appendectomy');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
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<input type="checkbox" name="divirticulitis" <?php echo ($obj["divirticulitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Divirticulitis');?> |
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</label> |
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</div> |
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<div class="checkbox"> |
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<label> |
|
<input type="checkbox" name="divirticulitis_surgery" <?php echo ($obj["divirticulitis_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Diverticulitis Surgery');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="gall_stones" <?php echo ($obj["gall_stones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Gall Stones');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="cholecystectomy" <?php echo ($obj["cholecystectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cholecystectomy');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="hepatitis" <?php echo ($obj["hepatitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hepatitis');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="cirrhosis_of_the_liver" <?php echo ($obj["cirrhosis_of_the_liver"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cirrhosis of the Liver');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="splenectomy" <?php echo ($obj["splenectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Splenectomy');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</fieldset> |
|
<fieldset> |
|
<legend><?php echo xlt('Genitourinary')?></legend> |
|
<div class="row"> |
|
<div class="col-12"> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="kidney_failure" <?php echo ($obj["kidney_failure"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Failure');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="kidney_stones" <?php echo ($obj["kidney_stones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Stones');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="kidney_cancer" <?php echo ($obj["kidney_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Cancer');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="kidney_infections" <?php echo ($obj["kidney_infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Infections');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="bladder_infections" <?php echo ($obj["bladder_infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bladder Infections');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="bladder_cancer" <?php echo ($obj["bladder_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bladder Cancer');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="prostate_problems" <?php echo ($obj["prostate_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Prostate Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="prostate_cancer" <?php echo ($obj["prostate_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Prostate Cancer');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="kidney_transplant" <?php echo ($obj["kidney_transplant"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Transplant');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="sexually_transmitted_disease" <?php echo ($obj["sexually_transmitted_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sexually Transmitted Disease');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="burning_with_urination" <?php echo ($obj["burning_with_urination"] == "on") ? "checked" : ""; ?>><?php echo xlt('Burning with Urination');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="discharge_from_urethra" <?php echo ($obj["discharge_from_urethra"] == "on") ? "checked" : ""; ?>><?php echo xlt('Discharge From Urethra');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</fieldset> |
|
<fieldset> |
|
<legend><?php echo xlt('Musculoskeletal')?></legend> |
|
<div class="row"> |
|
<div class="col-12"> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="osetoarthritis" <?php echo ($obj["osetoarthritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Osetoarthritis');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="rheumotoid_arthritis" <?php echo ($obj["rheumotoid_arthritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Rheumatoid Arthritis');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="lupus" <?php echo ($obj["lupus"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lupus');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="ankylosing_sondlilitis" <?php echo ($obj["ankylosing_sondlilitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ankylosing Sondlilitis');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="swollen_joints" <?php echo ($obj["swollen_joints"] == "on") ? "checked" : ""; ?>><?php echo xlt('Swollen Joints');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="stiff_joints" <?php echo ($obj["stiff_joints"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stiff Joints');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="broken_bones" <?php echo ($obj["broken_bones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Broken Bones');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="neck_problems" <?php echo ($obj["neck_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Neck Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="back_problems" <?php echo ($obj["back_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Back Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="back_surgery" <?php echo ($obj["back_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Back Surgery');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="scoliosis" <?php echo ($obj["scoliosis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Scoliosis');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="herniated_disc" <?php echo ($obj["herniated_disc"] == "on") ? "checked" : ""; ?>><?php echo xlt('Herniated Disc');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="shoulder_problems" <?php echo ($obj["shoulder_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shoulder Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="elbow_problems" <?php echo ($obj["elbow_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Elbow Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="wrist_problems" <?php echo ($obj["wrist_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Wrist Problems');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="hand_problems" <?php echo ($obj["hand_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hand Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="hip_problems" <?php echo ($obj["hip_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hip Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="knee_problems" <?php echo ($obj["knee_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Knee Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="ankle_problems" <?php echo ($obj["ankle_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ankle Problems');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="foot_problems" <?php echo ($obj["foot_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Foot Problems');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</fieldset> |
|
<fieldset> |
|
<legend><?php echo xlt('Endocrine')?></legend> |
|
<div class="row"> |
|
<div class="col-12"> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="insulin_dependent_diabetes" <?php echo ($obj["insulin_dependent_diabetes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Insulin Dependent Diabetes');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="noninsulin_dependent_diabetes" <?php echo ($obj["noninsulin_dependent_diabetes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Non-Insulin Dependent Diabetes');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="hypothyroidism" <?php echo ($obj["hypothyroidism"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hypothyroidism');?> |
|
</label> |
|
</div> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="hyperthyroidism" <?php echo ($obj["hyperthyroidism"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hyperthyroidism');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="cushing_syndrom" <?php echo ($obj["cushing_syndrom"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cushing Syndrome');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
<div class="col-sm-3"> |
|
<div class="form-group"> |
|
<div class="checkbox"> |
|
<label> |
|
<input type="checkbox" name="addison_syndrom" <?php echo ($obj["addison_syndrom"] == "on") ? "checked" : ""; ?>><?php echo xlt('Addison Syndrome');?> |
|
</label> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</div> |
|
</fieldset> |
|
<fieldset> |
|
<legend class=""><?php echo xlt('Additional Notes');?></legend> |
|
<div class="form-group"> |
|
<div class="col-sm-10 offset-sm-1"> |
|
<textarea name="additional_notes" class="form-control" cols="80" rows="5" ><?php echo text($obj["additional_notes"]); ?></textarea> |
|
</div> |
|
</div> |
|
</fieldset> |
|
<div class="form-group clearfix"> |
|
<div class="col-sm-12 offset-sm-1 position-override"> |
|
<div class="btn-group" role="group"> |
|
<button type="submit" onclick="top.restoreSession()" class="btn btn-secondary btn-save"><?php echo xlt('Save'); ?></button> |
|
<button type="button" class="btn btn-link btn-cancel" onclick="top.restoreSession(); parent.closeTab(window.name, false);"><?php echo xlt('Cancel');?></button> |
|
</div> |
|
</div> |
|
</div> |
|
</form> |
|
</div> |
|
</div> |
|
</body> |
|
</html>
|
|
|