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<script type="text/javascript"> function addDateSeparator(e, control, format){ this.Format = format; var keycode = (e.which) ? e.which : event.keyCode if (keycode > 31 && (keycode < 48 \|\| keycode > 57)){ return false; }else{ var DateFormatPattern = /^dd\/mm\/yyyy$\|^mm\/dd\/yyyy$\|^mm\/dd\/yyyy$\|^yyyy\/mm\/dd$/; if ( DateFormatPattern.test(this.Format) ){ var SplitFormat = this.Format.split("/"); if ( control.value.length >= this.Format.length ){ if ( keycode !=8){ return false; } } if ( control.value.length == SplitFormat[0].length ){ if ( keycode !=8){ control.value += '/'; } } if ( control.value.length == (SplitFormat[1].length + SplitFormat[0].length +1) ){ if ( keycode !=8){ control.value += '/'; } } }else{ alert("Supplied date format parameter is incorrect."); } } }</script> <?php $logged_user = $user_data['u_name']; $comCode = $user_data['company_assignment']; if(isset($_POST['updaterecord'])){ $pID=$_POST['pID']; echo "Patient ID:".$pID; //break; $pfType = $_POST['pfType']; $dialyzerID = $_POST['dialyzerID']; $HospitalName=$_POST['HospitalName']; $assigneddoctor=$_POST['assigneddoctor']; $myDoctor = explode("---",$assigneddoctor); $doctor=$myDoctor[1]; $extractHosID = explode("---",$HospitalName); $HosID=$extractHosID[1]; $AdmissionStatus= $_POST['AdmissionStatus']; $referral = $_POST['referral']; $fname=$_POST['fname']; $access=$_POST['access']; $frequency=$_POST['frequency']; $regCity=$_POST['regCity']; $region=$_POST['region']; $mname=$_POST['mname']; $lname=$_POST['lname']; $bday=$_POST['bday']; $age=$_POST['age']; $sex=$_POST['sex']; $status=$_POST['status']; $phicNumber=$_POST['phicNumber']; $admissionDate=$_POST['admissionDate']; //============================= $ptPackage = $_POST['package']; $ptDialyzer = $_POST['dialyzer']; $PatientEPO = $_POST['PatientEPO']; $myEPO = explode("---",$PatientEPO); $PatientEPOID = $myEPO[1]; //echo "EPO Selected: ".$PatientEPO; //echo "<br> EPO ID".$PatientEPOID; //break; $exPackage =explode("---",$ptPackage); $myPackageName = $exPackage[0]; $myPackageCode = $exPackage[1]; $exDialyzer =explode("---",$ptDialyzer); $myDialyzerCode = $exDialyzer[1]; $myDialyzerID = $exDialyzer[0]; //============================= $taddress=$_POST['taddress']; $occupation=$_POST['occupation']; $paddress=$_POST['paddress']; $landline=$_POST['landline']; $mobile=$_POST['mobile']; $emergencycontat=$_POST['emergencycontat']; $emergencyaddress=$_POST['emergencyaddress']; $emergencymobile=$_POST['emergencymobile']; $emergencylandline=$_POST['emergencylandline']; $hpActive=$_POST['hpActive']; $hpType=$_POST['hpType']; $datediagnosed=$_POST['datediagnosed']; $datefirstdialysis=$_POST['datefirstdialysis']; $placeofdialysis=$_POST['placeofdialysis']; $tmember = $_POST['tmember']; $onPD = $_POST['onPD']; $HDReasons=$_POST['HDReasons']; $renaldiagnosis=$_POST['renaldiagnosis']; $comordities1=$_POST['comordities1']; $comordities2=$_POST['comordities2']; $comordities3=$_POST['comordities3']; $comordities4=$_POST['comordities4']; $comordities5=$_POST['comordities5']; $comordities6=$_POST['comordities6']; //$attendingphysician=$_POST['attendingphysician']; mysql_query("UPDATE `patient_list` SET `pf_type`='$pfType',`patient_package_code`='$myPackageCode',`tx_package`='$myPackageName',`region`='$region',`reg_city`='$regCity',`admission_date`='$admissionDate',`phic_member`='$tmember',`admission_status`='$AdmissionStatus',`hospital_id`='$HosID',`tx_frequency`='$frequency',`access`='$access',`patient_fname`='$fname',`patient_mname`='$mname',`patient_lname`='$lname',`patient_bday`='$bday',`patient_age`='$age',`patient_sex`='$sex',`patient_status`='$status',`phic_number`='$phicNumber',`assigned_doctor`='$doctor',`patient_occupation`='$occupation',`patient_taddress`='$taddress',`patient_paddress`='$paddress',`patient_mobile`='$mobile',`patient_line`='$landline', `patient_ername`='$emergencycontat',`patient_eraddress`='$emergencyaddress',`patient_ermobile`='$emergencymobile',`patient_erline`='$emergencylandline',`patient_datefirstdiagnose`='$datediagnosed',`patient_datefirstdialysis`='$datefirstdialysis', `patient_placedialysis`='$placeofdialysis',`patient_pd`='$onPD',`patient_pdreason`='$HDReasons',`patient_renal`='$renaldiagnosis',`patient_como1`='$comordities1',`patient_como2`='$comordities2',`patient_como3`='$comordities3',`patient_como4`='$comordities4',`patient_como5`='$comordities5',`patient_como6`='$comordities6',`hepa_class`='$hpActive',`hepa_type`='$hpType',`entry_type`='$referral',`epo`='$PatientEPOID',`dialyzer`='$myDialyzerCode' WHERE `patient_id`='$pID'"); mysql_query("UPDATE `pindex_hdr` SET `index_hdr_fname`='$fname',`index_hdr_mname`='$mname',`index_hdr_lname`='$lname' WHERE `index_patient_id`='$pID'"); mysql_query("UPDATE `treatment_session` SET `session_fname`='$fname',`session_lname`='$lname' WHERE `session_patient_id`='$pID'"); mysql_query("UPDATE `sales_journal` SET `cust_fname`='$fname',`cust_lname`='$lname' WHERE `patient_id`='$pID'"); if($dialyzerID != $myDialyzerCode){ $sql="INSERT INTO `patient_dialyzer_issuance` (`trans_id`,`dialyzer_id`,`patient_id`,`date_issue`,`time_issue`,`issued_by`,`branch_code`) VALUES('','$myDialyzerCode','$pID','$toDate','$currentTime','$u_id ','$compCode')"; if(!mysql_query($sql)){ die('Error: ' . mysql_error()); }else{ echo "<div style='position:absolute;top:200px;left:250px;height:120px;width:300px;border:1px solid lightgray; border-radius:5px;background:white'> <table style='background:white;height:100%;width:100%'> <tr> <td align='center' width='500px'> <br> <font size = '3em' color='red'> Record Saved. Thank you!</font> <br> <br> <a href='laboratory_index.php?search=ABAGAO&view=plist'><input style='background-color:#E5E4E2;border:1px black solid;border-radius:1px;width:120px;height:20px;color:black;font-size:12px;font-weight:normal;'type ='button' name ='edit' value = 'Close'> </a> <br><br> </td> </tr> </table></div>"; } }else{ echo "<div style='position:absolute;top:200px;left:250px;height:120px;width:300px;border:1px solid lightgray; border-radius:5px;background:white'> <table style='background:white;height:100%;width:100%'> <tr> <td align='center' width='500px'> <br> <font size = '3em' color='red'> Record Saved. Thank you!</font> <br> <br> <a href='laboratory_index.php?search=".$_GET['search']."view=plist&id=".$_GET['id']."&subView=profile'><input style='background-color:#E5E4E2;border:1px black solid;border-radius:1px;width:120px;height:20px;color:black;font-size:12px;font-weight:normal;'type ='button' name ='edit' value = 'Close'> </a> <br><br> </td> </tr> </table></div>"; } } $pID=$_GET['pID']; $recordStatus =mysql_result(mysql_query("SELECT `nephro_status` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $docid = mysql_result(mysql_query("SELECT `assigned_doctor` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); // get name of doctor base on doctor it in the patient list $access = mysql_result(mysql_query("SELECT `access` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $region = mysql_result(mysql_query("SELECT `region` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $frequency = mysql_result(mysql_query("SELECT `tx_frequency` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $HospitalID = mysql_result(mysql_query("SELECT `hospital_id` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $HospitalName = mysql_result(mysql_query("SELECT `hos_name` FROM `hospitals` WHERE `hos_id` ='$HospitalID'"),0); $AdmissionStatus = mysql_result(mysql_query("SELECT `admission_status` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $ptINDialyzerID = mysql_result(mysql_query("SELECT `dialyzer` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $ptINDialyzer = mysql_result(mysql_query("SELECT `medicine_desc` FROM `medicines` WHERE `medicine_id` ='$ptINDialyzerID'"),0); $pfType = mysql_result(mysql_query("SELECT `pf_type` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $PackageCodeName = mysql_result(mysql_query("SELECT `tx_package` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $ptINPackageCode = mysql_result(mysql_query("SELECT `package_hdr_id` FROM `package_header` WHERE `package_code` ='$PackageCodeName'"),0); $getMyEPOID = mysql_result(mysql_query("SELECT `epo` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $getMyEPO = mysql_result(mysql_query("SELECT `medicine_desc` FROM `medicines` WHERE `medicine_id` ='$getMyEPOID'"),0); $lname = mysql_result(mysql_query("SELECT `patient_lname` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $fname = mysql_result(mysql_query("SELECT `patient_fname` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $mname = mysql_result(mysql_query("SELECT `patient_mname` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $sex = mysql_result(mysql_query("SELECT `patient_sex` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $age = mysql_result(mysql_query("SELECT `patient_age` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $status = mysql_result(mysql_query("SELECT `patient_status` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $occupation = mysql_result(mysql_query("SELECT `patient_occupation` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $bday = mysql_result(mysql_query("SELECT `patient_bday` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $renaldiagnosis = mysql_result(mysql_query("SELECT `patient_renal` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $fdoctor = mysql_result(mysql_query("SELECT `doc_fname` FROM `doctors_profile` WHERE `doc_id` ='$docid'"),0); $ldoctor = mysql_result(mysql_query("SELECT `doc_lname` FROM `doctors_profile` WHERE `doc_id` ='$docid'"),0); $regCity = mysql_result(mysql_query("SELECT `reg_city` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $phic_number = mysql_result(mysql_query("SELECT `phic_number` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $phic_member = mysql_result(mysql_query("SELECT `phic_member` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $taddress = mysql_result(mysql_query("SELECT `patient_taddress` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $paddress = mysql_result(mysql_query("SELECT `patient_paddress` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $mobile = mysql_result(mysql_query("SELECT `patient_mobile` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $eraddress = mysql_result(mysql_query("SELECT `patient_eraddress` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $line = mysql_result(mysql_query("SELECT `patient_line` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $ername = mysql_result(mysql_query("SELECT `patient_ername` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $ermobile = mysql_result(mysql_query("SELECT `patient_ermobile` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $erline = mysql_result(mysql_query("SELECT `patient_erline` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $admissionDate = mysql_result(mysql_query("SELECT `admission_date` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $datefirstdiagnose = mysql_result(mysql_query("SELECT `patient_datefirstdiagnose` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $hepaClass = mysql_result(mysql_query("SELECT `hepa_class` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $hepaType = mysql_result(mysql_query("SELECT `hepa_type` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $datefirstdialysis = mysql_result(mysql_query("SELECT `patient_datefirstdialysis` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $placedialysis= mysql_result(mysql_query("SELECT `patient_placedialysis` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $pd = mysql_result(mysql_query("SELECT `patient_pd` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $pdreason = mysql_result(mysql_query("SELECT `patient_pdreason` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $renal = mysql_result(mysql_query("SELECT `patient_renal` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities1= mysql_result(mysql_query("SELECT `patient_como1` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities2= mysql_result(mysql_query("SELECT `patient_como2` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities3= mysql_result(mysql_query("SELECT `patient_como3` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities4= mysql_result(mysql_query("SELECT `patient_como4` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities5= mysql_result(mysql_query("SELECT `patient_como5` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $comordities6= mysql_result(mysql_query("SELECT `patient_como6` FROM `patient_list` WHERE `patient_id` ='$pID'"),0); $checkAccess = $user_data['edit_patient_reocrd']; ?> <div STYLE='position:absolute;height:95%; width: 99.7%; font-size: 12px; overflow: auto;border:1px solid black;'> <table style="border-collapse:collapse;background:#fff:border:1px solid gray;height:100%;width:100%"> <tr> <td colspan="3" valign="TOP" style="border:1px solid white;font-size:14px;weight:bold;color:gray;height:400px;background:white"> <form action="" method="POST"> <input type='hidden' name='dialyzerID' value='<?php echo $ptINDialyzerID;?>'> <input type='hidden' name='pID' value='<?php echo $pID;?>'> <center><table style='width:100%;background:white;border:1px solid lightgray'> <tr> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Last Name:<br><input type="text" value="<?php echo $lname;?>" name="lname" style="font-size:12px;color:black;width:150px;border:1px solid lightgray;background:#fff;border-top:1px solid white;text-align:left"></td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>First Name:<br><input type="text" value="<?php echo $fname;?>" name="fname" style="font-size:12px;color:black;width:150px;border:1px solid lightgray;background:#fff;border-top:1px solid white;text-align:left"></td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Middle Name:<br><input type="text" value="<?php echo $mname;?>" name="mname" style="font-size:12px;color:black;width:100px;border:1px solid lightgray;background:#fff;border-top:1px solid white;text-align:left"></td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Age:<br> <?php //$dob=$bday; //$diff = (date('Y') - date('Y',strtotime($dob))); //echo $diff; $dateOfBirth = $bday; $today = date("m/d/Y"); $diff = date_diff(date_create($dateOfBirth), date_create($today)); $newAge = $diff->format('%y'); ?> <input type="text" value="<?php echo $newAge;?>" name="age" style="font-size:12px;color:black;width:40px;border:1px solid lightgray;background:#fff;border-top:1px solid white;text-align:left"> </td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Sex:<br> <select name="sex" style="width:90%;height:25px;font-size:12px;color:black;border:1px solid lightgray;background:#fff;text-align:left" required> <option><?php echo $sex;?></option> <option>Male</option> <option>Female</option> </select> </td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Status:<br> <select name="status" style="width:90%;height:25px;font-size:12px;color:black;border:1px solid lightgray;background:#fff;text-align:left"> <option><?php echo $status;?></option> <option>Single</option> <option>Married</option> <option>Widow</option> <option>Separated</option> </select> </td> </tr> <tr> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Occupation:<br><input type="text" name="occupation" value="<?php echo $occupation;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Occupation"></td> <td colspan="1" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Landline No.:<br><input type="text" name="landline" value="<?php echo $line;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Landline No."></td> <td colspan="1" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Mobile No.:<br><input type="text" name="mobile" value="<?php echo $mobile;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Mobile No."></td> <td colspan="3" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Birthdate:          Access:                   TX Frequency/Week:<br> <input id="datepickerA" type="text" name="bday" value="<?php echo $bday;?>" style="font-size:12px;font-weight:normal;color:black;width:70px;height:25px;border:1px solid lightgray;text-align:center;background:white" onkeyup="addDateSeparator(event,this,'dd/mm/yyyy')" placeholder="mm/dd/yyyy"> <select name='access' style="font-size:12px;font-weight:normal;color:black;width:90px;height:25px;border:1px solid lightgray;text-align:center;background:white" placeholder="Frequency"> <option><?php echo $access;?></option> <option>AVF</option> <option>AVG</option> <option>FEMORAL</option> <option>INTRAJUGULAR</option> <option>SUBCLAVIAN</option> </select> <select name='frequency' style="font-size:12px;font-weight:normal;color:black;width:100px;height:25px;border:1px solid lightgray;text-align:center;background:white" placeholder="Frequency"> <option><?php echo $frequency;?></option> <option>1x</option> <option>2x</option> <option>3x</option> <option>4x</option> <option>2x\|3x</option> </select> </td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Present Address:<br><input type="text" value="<?php echo $taddress;?>"name="taddress" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Present Address"></td> <td style='background:#EFFBFB;border:none;font-size:10px;color:gray'>City: <input type='text' name = 'regCity' id='city' style='font-size:12px;color:black;width:100%;border:1px solid gray;background:white;border-top:1px solid white;text-align:left" required'> </td> <td colspan="3" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>PhilHealth No.:               PhilHealth Memeber:<br> <input type="text" value="<?php echo $phic_number;?>" name="phicNumber" style="font-size:12px;color:black;width:35%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Philhealth Number"> <input type="text" name="tmember" value="<?php echo $phic_member;?>" style="font-size:12px;color:black;width:60%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Name of PhilHealth Member" required></td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Provincial/Other Address:<br><input type="text" value="<?php echo $paddress;?>" name="paddress" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Permanent Address"></td> <td colspan="1" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Region:<br> <input type='text' name = 'region' id='region' style='font-size:12px;color:black;width:100%;border:1px solid gray;background:white;border-top:1px solid white;text-align:left" required'> </td> <td colspan="3" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Referral:                    Assigned Doctor:<br> <select name="referral" style="width:30%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:white" required> <?php $pID = $_GET['pID']; $getDeck = mysql_result(mysql_query("SELECT `entry_type` FROM `patient_list` WHERE `patient_id`= '$pID'"),0); echo " <option style='font-size:12px'>".$getDeck."</option>"; ?> <option id="0" style="font-size:12px">Referred</option> <option id="0" style="font-size:12px">Deck</option> </select> <select name="assigneddoctor" style="width:65%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:white"> <option><?php echo $ldoctor;?> <?php echo $fdoctor;?>---<?php echo $docid;?></option> <?php $getdoctor = mysql_query("SELECT * FROM `doctors_profile` WHERE `doc_status`= '1'"); while($myMT = mysql_fetch_array($getdoctor)){ ?> <option id = "<?php echo $myMT['doc_id'];?>" style="font-size:12px;color:gray;"> <?php echo $myMT['doc_lname'];?>, <?php echo $myMT['doc_fname'];?>---<?php echo $myMT['doc_id'];?></option> <?php } ?> </select> </td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:bold;color:gray'><br>Nearest Relative (to notify in case of emergency):</td> <td colspan="1" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Admission Date<br> <input id="datepicker" type="text" name="admissionDate" value ="<?php echo $admissionDate;?>" style="font-size:12px;color:black;width:70%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Admission Date"></td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>HD Unit / Hospital<br> <select name="HospitalName" style="width:100%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:white"> <option><?php echo $HospitalName;?>---<?php echo $HospitalID;?></option> <?php $getHos = mysql_query("SELECT * FROM `hospitals` WHERE `status`= '1'"); while($myHos = mysql_fetch_array($getHos)){ ?> <option style="font-size:12px;color:gray;"> <?php echo $myHos['hos_name'];?>---<?php echo $myHos['hos_id'];?></option> <?php } ?> </select> </td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Admission Status:<br> <select name="AdmissionStatus" style="width:100%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:white"> <option><?php echo $AdmissionStatus;?></option> <option>Walk-in</option> <option>Referral</option> </select> </td> </tr> <tr> <td colspan="4" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Relative Full Name:<br><input type="text" name="emergencycontat" value ="<?php echo $ername;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Name"></td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Contact Details:<br><input type="text" name="emergencylandline" value ="<?php echo $erline;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Landline"></td> </tr> <tr> <td colspan="4" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Complete Address:<br><input type="text" name="emergencyaddress" value ="<?php echo $eraddress;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" placeholder="Address"></td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:10px;color:gray'>Mobile Number:<br><input type="text" name="emergencymobile" value ="<?php echo $ermobile;?>" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Mobile"></td> </tr> <tr> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:normal;color:gray'> <br>Date first diagnosed with kidney disease (mm-dd-yyyy)</td> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:normal;color:gray'> <br>Date of first dialysis (mm-dd-yyyy)</td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:normal;color:gray'> <br>Place where first dialysis done</td> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:normal;color:gray'>Hepatitis (HP)</td> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:normal;color:gray'>Hepatitis (Type)</td> </tr> <tr> <td style='background:#EFFBFB;border:none;font-size:12px'><br><input type="text" name="datediagnosed" value="<?php echo $datefirstdiagnose; ?>" style="font-size:12px;font-weight:normal;color:black;width:150px;height:25px;border:1px solid lightgray;text-align:center;background:white" onkeyup="addDateSeparator(event,this,'dd/mm/yyyy')" placeholder="mm/dd/yyyy" maxlength="10"></td> <td style='background:#EFFBFB;border:none;font-size:12px'><br><input type="text" name="datefirstdialysis" value="<?php echo $datefirstdialysis; ?>" style="font-size:12px;font-weight:normal;color:black;width:150px;height:25px;border:1px solid lightgray;text-align:center;background:white" onkeyup="addDateSeparator(event,this,'dd/mm/yyyy')" placeholder="mm/dd/yyyy" maxlength="10"></td> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px'><br><input type="text" name="placeofdialysis" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:center" placeholder="Place done"></td> <td style='background:#EFFBFB;border:none;font-size:12px'><br> <select name="hpActive" style="font-size:12px;color:black;width:120px;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"> <option style='font-size:12px'><?php echo $hepaClass;?></option> <option style='font-size:12px'>None</option> <option style='font-size:12px'>Non-Reactive</option> <option style='font-size:12px'>Reactive</option> </select> </td> <td style='background:#EFFBFB;border:none;font-size:12px;width:150px'><br> <select name="hpType" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"> <option style='font-size:12px'><?php echo $hepaType;?></option> <option style='font-size:12px'>None</option> <option style='font-size:12px'>Type A</option> <option style='font-size:12px'>Type B</option> <option style='font-size:12px'>Type C</option> </select> </td> </tr> <tr> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:bold;color:gray'><br>Previously on PD?</td> <td colspan="4" style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:bold;color:gray'><br>If yes, what was the reason for shifting to HD?</td> <td style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:bold;color:gray'>PF TYPE<br> <select name="pfType" style="font-size:12px;color:black;width:100%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"> <option style='font-size:12px'><?php echo $pfType;?></option> <option style='font-size:12px'>REG</option> <option style='font-size:12px'>SRP</option> <option style='font-size:12px'>HMO</option> <option style='font-size:12px'>PCSO</option> </select> </td> </tr> <tr> <td style='background:#EFFBFB;border:none;font-size:12px'> <center><select name="onPD" style="width:100px;height:30px;font-size:12px;color:black;border:1px solid lightgray;background:#fff;text-align:center"> <option><?php echo $pd; ?></option> <option>No</option> <option>Yes</option> </select></center> </td> <td colspan="5" style='background:#EFFBFB;border:none;font-size:12px'> <textarea rows="2" name="HDReasons" style="color:black;width:100%;border:1px solid lightgray;border-radius:5px;background:white"><?php echo $pdreason; ?></textarea> </td> </tr> <tr> <td colspan="1" style='background:#EFFBFB;border:none;font-size:12px'> <b style="font-size:12px;color:gray">Renal Diagnoses:</b><br><textarea rows="2" name="renaldiagnosis" style="color:black;width:100%;border:1px solid lightgray;border-radius:5px;background:white"><?php echo $renaldiagnosis;?></textarea> </td> <td colspan="5" style='background:#EFFBFB;border:none;font-size:12px'> <table style='background:white;border:none;width:100%'> <tr> <td style='width:35%;border:none;background:white'><b style="font-size:12px;color:gray">Dialyzer:</b></td> <td style='width:32%;border:none;background:white'><b style="font-size:12px;color:gray">EPO:</b></td> <td style='width:33%;border:none;background:white'><b style="font-size:12px;color:gray">Package:</b></td> </tr> <tr> <td style='width:30%;border:none;background:white'> <select name="dialyzer" style="width:100%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:#ffc3c3" required> <option><?php echo $ptINDialyzer;?>---<?php echo $ptINDialyzerID;?></option> <?php $getMed = mysql_query("SELECT * FROM `medicines` WHERE `type`= 'Dialyzer'"); while($myMT = mysql_fetch_array($getMed)){ ?> <option id = "<?php echo $myMT['medicine_id'];?>" style="font-size:12px;color:black;"> <?php echo $myMT['medicine_desc'];?>---<?php echo $myMT['medicine_id'];?></option> <?php }?> </select> </td> <td style='width:40%;border:none;background:white'> <select name="PatientEPO" style="width:100%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:#ffc3c3" required> <option><?php echo $getMyEPO;?>---<?php echo $getMyEPOID;?></option> <?php $getEPO = mysql_query("SELECT * FROM `medicines` WHERE `medicine_desc` LIKE '%Eryth%' ORDER BY `medicine_desc` ASC "); while($myEPO= mysql_fetch_array($getEPO)){ ?> <option id = "<?php echo $myEPO['medicine_id'];?>" style="font-size:12px;color:black;"> <?php echo $myEPO['medicine_desc'];?>---<?php echo $myEPO['medicine_id'];?></option> <?php }?> </select> </td> <td style='width:30%;border:none;background:white'> <select name="package" style="width:100%;font-size:12px;color:black;border;1px solid lightgry;border:1px solid lightgray;background:#ffc3c3" required> <option><?php echo $PackageCodeName;?>---<?php echo $ptINPackageCode;?></option> <?php //Arnel E. $getPackage = mysql_query("SELECT * FROM `package_header` WHERE `active`= '1' ORDER BY `package_code` ASC"); while($mypack = mysql_fetch_array($getPackage)){ ?> <option id = "<?php echo $mypack['package_hdr_id'];?>" style="font-size:12px;color:black;"> <?php echo $mypack['package_code'];?>---<?php echo $mypack['package_hdr_id'];?></option> <?php }?> </select> </td> </tr> </table> </td> </tr> <tr> <td colspan="6" style='background:#EFFBFB;border:none;font-size:12px;border-bottom:1px solid lightgray;font-weight:bold;color:gray'><br>Co-morbidities:</td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>1. <input type="text" name="comordities1" value="<?php echo $comordities1;?>" style="font-size:12px;color:black;width:90%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left" ></td> <td colspan="4" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>2. <input type="text" name="comordities2" value="<?php echo $comordities2;?>" style="font-size:12px;color:black;width:95%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"></td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>3. <input type="text" name="comordities3" value="<?php echo $comordities3;?>" style="font-size:12px;color:black;width:90%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"></td> <td colspan="4" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>4. <input type="text" name="comordities4" value="<?php echo $comordities4;?>" style="font-size:12px;color:black;width:95%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"></td> </tr> <tr> <td colspan="2" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>5. <input type="text" name="comordities5" value="<?php echo $comordities5;?>" style="font-size:12px;color:black;width:90%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"></td> <td colspan="4" style='background:#EFFBFB;border:none;font-size:12px;font-size:12px;color:gray'>6. <input type="text" name="comordities6" value="<?php echo $comordities6;?>" style="font-size:12px;color:black;width:95%;border:1px solid lightgray;background:white;border-top:1px solid white;text-align:left"></td> </tr> <tr> <td colspan="6" style='background:#EFFBFB;border:none;font-size:12px'> <center> <br><input type="submit" name="updaterecord" value="Save" style="width:100px;height:30px;border:1px solid gray;border-radius:5px;font-size:12px;font-weight:normal" class='lightGradient'> <a href='main_new.php?view=100&sview=100&sid=M1&action=&tab=0#id-0'> <input type="button" name="close" value="Close" style="width:100px;height:30px;border:1px solid gray;border-radius:5px;font-size:12px;font-weight:normal" class='lightGradient'></a><br><br> </center></td> </tr> </table></center> </form> </td> </tr> </table> </div>

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