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  1. <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
  2. <html xmlns="http://www.w3.org/1999/xhtml">
  3. <head>
  4. <meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
  5. <title>Untitled Document</title>
  6. <link href="../nav/welcomepop.css" rel="stylesheet" type="text/css"></link>
  7.  
  8. <link href="../nav/css/custom-theme/jquery-ui-1.8.10.custom.css" rel="stylesheet" type="text/css"></link>
  9. <?php include '../script.php'; ?>
  10. <?php include 'functions.php'; ?>
  11. <?php include '../Check.php';?>
  12.  
  13. <script type="text/javascript" src="../src/lib/jquery-ui-1.8.10.custom.min.js"></script>
  14.     <script>
  15.     $(function() {
  16.         $( "#hisint" ).buttonset();
  17.         $( "#HEA_Insect" ).buttonset();
  18.         $( "#HEA_Food" ).buttonset();
  19.         $( "#HEA_OtherAll" ).buttonset();
  20.         $( "#HEA_Driver" ).buttonset();
  21.        
  22.         $("#accordion").accordion({ header: "h2", autoHeight: false,
  23.             navigation: true
  24.                              });
  25.        
  26.         $( "input:submit, input:button, a.edit" ).button();
  27.  
  28.     });
  29.     </script>
  30. </head>
  31.  
  32. <body>
  33.  
  34.  
  35.  
  36. <?php
  37. $RES_ID = $_GET['rid'];
  38. $HEA_ID = $_GET['heaid'];
  39. $pro = $_GET['pro'];
  40. include '../cCustomConnect.php';
  41. if ($HEA_ID > 0)
  42. {
  43.  
  44.  
  45. $Health = mssql_query("Select
  46. *
  47. from
  48. Health
  49. where
  50. HEA_ID = '$HEA_ID'
  51. ");
  52.  
  53.  
  54.  
  55. $HEA_LivingWill = mssql_result($Health,0,'HEA_LivingWill');
  56. $HEA_Medical_Power_Attorney = mssql_result($Health,0,'HEA_Medical_Power_Attorney');
  57. $HEA_POLST = mssql_result($Health,0,'HEA_POLST');
  58. $HEA_MOST = mssql_result($Health,0,'HEA_MOST');
  59. $HEA_DNR = mssql_result($Health,0,'HEA_DNR');
  60.  
  61.  
  62. $HEA_LastUser = mssql_result($Health,0,'HEA_LastUser');
  63. $HEA_DateStamp = mssql_result($Health,0,'HEA_DateStamp');
  64. $HEA_Vision = mssql_result($Health,0,'HEA_Vision');
  65. $HEA_Hearing = mssql_result($Health,0,'HEA_Hearing');
  66. $HEA_Mobility = mssql_result($Health,0,'HEA_Mobility');
  67. $HEA_Falls = mssql_result($Health,0,'HEA_Falls');
  68. $HEA_Food = mssql_result($Health,0,'HEA_Food');
  69. $HEA_FoodPref = mssql_result($Health,0,'HEA_FoodPref');
  70. $HEA_FoodDetails = mssql_result($Health,0,'HEA_FoodDetails');
  71. $HEA_Insect = mssql_result($Health,0,'HEA_Insect');
  72. $HEA_InsectDetails = mssql_result($Health,0,'HEA_InsectDetails');
  73. $HEA_Driver = mssql_result($Health,0,'HEA_Driver');
  74. $HEA_Make = mssql_result($Health,0,'HEA_Make');
  75. $HEA_Model = mssql_result($Health,0,'HEA_Model');
  76. $HEA_Year = mssql_result($Health,0,'HEA_Year');
  77. $HEA_Color = mssql_result($Health,0,'HEA_Color');
  78. $HEA_Plate = mssql_result($Health,0,'HEA_Plate');
  79. $HEA_ParkArea = mssql_result($Health,0,'HEA_ParkArea');
  80. $HEA_Care = mssql_result($Health,0,'HEA_Care');
  81.  
  82. $HEA_Pendant = mssql_result($Health,0,'HEA_Pendant');
  83. $HEA_Storage = mssql_result($Health,0,'HEA_Storage');
  84.  
  85. $HEA_History1 = mssql_result($Health,0,'HEA_History1');
  86. $HEA_History2 = mssql_result($Health,0,'HEA_History2');
  87. $HEA_History3 = mssql_result($Health,0,'HEA_History3');
  88. $HEA_History4 = mssql_result($Health,0,'HEA_History4');
  89. $HEA_History5 = mssql_result($Health,0,'HEA_History5');
  90. $HEA_History6 = mssql_result($Health,0,'HEA_History6');
  91. $HEA_History7 = mssql_result($Health,0,'HEA_History7');
  92. $HEA_History8 = mssql_result($Health,0,'HEA_History8');
  93. $HEA_History9 = mssql_result($Health,0,'HEA_History9');
  94. $HEA_History10 = mssql_result($Health,0,'HEA_History10');
  95. $HEA_History11 = mssql_result($Health,0,'HEA_History11');
  96. $HEA_History12 = mssql_result($Health,0,'HEA_History12');
  97. $HEA_History13 = mssql_result($Health,0,'HEA_History13');
  98. $HEA_History14 = mssql_result($Health,0,'HEA_History14');
  99. $HEA_History15 = mssql_result($Health,0,'HEA_History15');
  100. $HEA_History16 = mssql_result($Health,0,'HEA_History16');
  101.  
  102. $HEA_Height = mssql_result($Health,0,'HEA_Height');
  103. $HEA_Weight = mssql_result($Health,0,'HEA_Weight');
  104. $HEA_OtherIll = mssql_result($Health,0,'HEA_OtherIll');
  105. $HEA_HistoryDetails = mssql_result($Health,0,'HEA_HistoryDetails');
  106. $HEA_HospName = mssql_result($Health,0,'HEA_HospName');
  107. $HEA_HospPhone = mssql_result($Health,0,'HEA_HospPhone');
  108. $HEA_PhyName1 = mssql_result($Health,0,'HEA_PhyName1');
  109. $HEA_PhyAddress1 = mssql_result($Health,0,'HEA_PhyAddress1');
  110. $HEA_PhyPhone1 = mssql_result($Health,0,'HEA_PhyPhone1');
  111. $HEA_PhyFax1 = mssql_result($Health,0,'HEA_PhyFax1');
  112. $HEA_PhyEmail1 = mssql_result($Health,0,'HEA_PhyEmail1');
  113. $HEA_PhySpecialty1 = mssql_result($Health,0,'HEA_PhySpecialty1');
  114. $HEA_PhyName2 = mssql_result($Health,0,'HEA_PhyName2');
  115. $HEA_PhyAddress2 = mssql_result($Health,0,'HEA_PhyAddress2');
  116. $HEA_PhyPhone2 = mssql_result($Health,0,'HEA_PhyPhone2');
  117. $HEA_PhyFax2 = mssql_result($Health,0,'HEA_PhyFax2');
  118. $HEA_PhyEmail2 = mssql_result($Health,0,'HEA_PhyEmail2');
  119. $HEA_PhySpecialty2 = mssql_result($Health,0,'HEA_PhySpecialty2');
  120. $HEA_OtherAll = mssql_result($Health,0,'HEA_OtherAll');
  121. $HEA_OtherDetails = mssql_result($Health,0,'HEA_OtherDetails');
  122.  
  123.  
  124. }
  125.  
  126. $resinfo = mssql_query("Select
  127. *
  128. from
  129. Residents
  130. where
  131. RES_ID = '$RES_ID'
  132. ");
  133.  
  134. $PeopleIDY = mssql_result($resinfo,0,'RES_PeopleIDY');
  135.  
  136. ?>
  137. <!--Force IE6 into quirks mode with this comment tag-->
  138. <div id="maincontentform">
  139.  
  140. <form action="LifeHealthScriptcopy.php" method="post" />
  141. <input name="RES_ID" type="hidden" value="<?php echo $RES_ID ?>" />
  142. <input name="USR_ID" type="hidden" value="<?php echo $USR_ID ?>" />
  143.  
  144. <table width="650" border="0" id="maintable">
  145.   <tr class="odd">
  146.     <td>Current Care Type:</td>
  147.     <td colspan="4"><strong><span style="line-height:28px">
  148.       <select name="HEA_Care" id="HEA_Care">
  149.         <option value="" <?php if($HEA_Care == ' '){echo 'selected="selected"' ;}?>>Select</option>
  150.         <option value="1" <?php if($HEA_Care == '1'){echo 'selected="selected"' ;}?>>IL</option>
  151.         <option value="2" <?php if($HEA_Care == '2'){echo 'selected="selected"' ;}?>>AL</option>
  152.         <option value="3" <?php if($HEA_Care == '3'){echo 'selected="selected"' ;}?>>ALZ</option>
  153.       </select>
  154.     </span></strong></td>
  155.   </tr>
  156.   <tr>
  157.     <td>Fall Risks:</td>
  158.     <td colspan="4"><span style="line-height:28px">
  159.       <select name="HEA_Vision" id="select2">
  160.         <option value="" <?php if($HEA_Vision == ' '){echo 'selected="selected"' ;}?>>Select Vision</option>
  161.         <option value="1" <?php if($HEA_Vision == '1'){echo 'selected="selected"' ;}?>>Good</option>
  162.         <option value="2" <?php if($HEA_Vision == '2'){echo 'selected="selected"' ;}?>>Impaired</option>
  163.         <option value="3" <?php if($HEA_Vision == '3'){echo 'selected="selected"' ;}?>>Legally Blind</option>
  164.       </select>
  165.       <select name="HEA_Hearing" id="select3">
  166.         <option value="" <?php if($HEA_Hearing == ' '){echo 'selected="selected"' ;}?>>Select Hearing</option>
  167.         <option value="1" <?php if($HEA_Hearing == '1'){echo 'selected="selected"' ;}?>>Good</option>
  168.         <option value="2" <?php if($HEA_Hearing == '2'){echo 'selected="selected"' ;}?>>Impaired</option>
  169.         <option value="3" <?php if($HEA_Hearing == '3'){echo 'selected="selected"' ;}?>>Deaf</option>
  170.         <option value="4" <?php if($HEA_Hearing == '4'){echo 'selected="selected"' ;}?>>Hearing Aids</option>
  171.       </select>
  172.       <select name="HEA_Mobility" id="select4">
  173.         <option value="" <?php if($HEA_Mobility == ' '){echo 'selected="selected"' ;}?>>Select Mobility</option>
  174.         <option value="1" <?php if($HEA_Mobility == '1'){echo 'selected="selected"' ;}?>>Good</option>
  175.         <option value="2" <?php if($HEA_Mobility == '2'){echo 'selected="selected"' ;}?>>Cane</option>
  176.         <option value="3" <?php if($HEA_Mobility == '3'){echo 'selected="selected"' ;}?>>Walker</option>
  177.         <option value="4" <?php if($HEA_Mobility == '4'){echo 'selected="selected"' ;}?>>Scooter</option>
  178.         <option value="5" <?php if($HEA_Mobility == '5'){echo 'selected="selected"' ;}?>>Wheel Chair Manual</option>
  179.         <option value="6" <?php if($HEA_Mobility == '6'){echo 'selected="selected"' ;}?>>Wheel Chair Power</option>
  180.       </select>
  181.       <br />
  182.       Recent Falls in last 6 Months:
  183.       <select name="HEA_Falls" id="select5">
  184.         <option value=""  <?php if($HEA_Falls == ' '){echo 'selected="selected"' ;}?>>Select</option>
  185.         <option value="0" <?php if($HEA_Falls == '0'){echo 'selected="selected"' ;}?>>0</option>
  186.         <option value="1" <?php if($HEA_Falls == '1'){echo 'selected="selected"' ;}?>>1</option>
  187.         <option value="2" <?php if($HEA_Falls == '2'){echo 'selected="selected"' ;}?>>2</option>
  188.         <option value="3" <?php if($HEA_Falls == '3'){echo 'selected="selected"' ;}?>>3</option>
  189.         <option value="4" <?php if($HEA_Falls == '4'){echo 'selected="selected"' ;}?>>4+</option>
  190.       </select>
  191.     </span></td>
  192.   </tr>
  193.   <tr class="odd">
  194.     <td rowspan="3">Allergies:</td>
  195.     <td colspan="4">Food :<span style="line-height:28px">
  196.            <span id="HEA_Food">
  197.         <input type="radio" name="HEA_Food" id="f1" value="yes" <?php if($HEA_Food == 'yes'){echo 'checked="checked"' ;}?>  />
  198.  <label for="f1">Yes</label>
  199.        
  200.         <input name="HEA_Food" type="radio" id="f2" value="no"  <?php if($HEA_Food == 'no'){echo 'checked="checked"' ;}?> />
  201.  <label for="f2">No</label>
  202.  </span>
  203.  
  204.      
  205.       <textarea name="HEA_FoodDetails" id="fooddetails" cols="60" rows="1" class="text1"><?php if($HEA_FoodDetails != ' '){echo $HEA_FoodDetails ;}?></textarea>
  206.       <br />
  207.       Preference:
  208.       <label>
  209.         <select name="HEA_FoodPref" id="HEA_FoodPref">
  210.           <option value="" <?php if($HEA_FoodPref == ' '){echo 'selected="selected"' ;}?>>Select Preference</option>
  211.           <option value="1" <?php if($HEA_FoodPref == '1'){echo 'selected="selected"' ;}?>>No Preference</option>
  212.           <option value="2" <?php if($HEA_FoodPref == '2'){echo 'selected="selected"' ;}?>>Diabetes</option>
  213.           <option value="3" <?php if($HEA_FoodPref == '3'){echo 'selected="selected"' ;}?>>Vegetarian</option>
  214.           <option value="4" <?php if($HEA_FoodPref == '4'){echo 'selected="selected"' ;}?>>Vegan</option>
  215.         </select>
  216.       </label>
  217.     </span></td>
  218.   </tr>
  219.   <tr class="odd">
  220.     <td colspan="4">Insect:<span style="line-height:28px">
  221.                  <span id="HEA_Insect">
  222.         <input type="radio" name="HEA_Insect" id="i1" value="yes" <?php if($HEA_Insect == 'yes'){echo 'checked="checked"' ;}?>  />
  223.  <label for="i1">Yes</label>
  224.        
  225.         <input name="HEA_Insect" type="radio" id="i2" value="no"  <?php if($HEA_Insect == 'no'){echo 'checked="checked"' ;}?> />
  226.  <label for="i2">No</label>
  227.  </span>
  228.       <textarea name="HEA_InsectDetails" id="fooddetails2" cols="60" rows="1"  class="text1"><?php if($HEA_InsectDetails != ' '){echo $HEA_InsectDetails ;}?></textarea>
  229.     </span></td>
  230.   </tr>
  231.   <tr class="odd">
  232.     <td colspan="4">Other/Meds:<span style="line-height:28px">
  233.                        <span id="HEA_OtherAll">
  234.         <input type="radio" name="HEA_OtherAll" id="o1" value="yes" <?php if($HEA_OtherAll == 'yes'){echo 'checked="checked"' ;}?>  />
  235.  <label for="o1">Yes</label>
  236.        
  237.         <input name="HEA_OtherAll" type="radio" id="o2" value="no"  <?php if($HEA_OtherAll == 'no'){echo 'checked="checked"' ;}?> />
  238.  <label for="o2">No</label>
  239.  </span>
  240.  
  241.       (For Emergency Fact Sheet)<br />
  242.       <textarea name="HEA_OtherDetails" id="HEA_OtherDetails" cols="60" rows="2"  class="text1"><?php if($HEA_OtherDetails != ' '){echo $HEA_OtherDetails ;}?></textarea>
  243.     </span></td>
  244.   </tr>
  245.   <tr>
  246.     <td>Stats:</td>
  247.     <td colspan="4">Height(ft.):
  248.       <input type="text" name="HEA_Height" id="HEA_Height" <?php if($HEA_Height != ' '){echo 'value="' . $HEA_Height . '"' ;}?> />
  249.       Weight(lbs):
  250.       <input type="text" name="HEA_Weight" id="HEA_Weight" <?php if($HEA_Weight != ' '){echo 'value="' . $HEA_Weight . '"' ;}?> /></td>
  251.   </tr>
  252.   <tr class="odd">
  253.     <td rowspan="2">History of:</td>
  254.     <td colspan="4">
  255.           <span id="hisint">
  256.      
  257.     <input name="HEA_History1" type="checkbox" id="h1" value="on" <?php if($HEA_History1 == 'on'){echo 'checked="checked"' ;}?>  />
  258.     <label for="h1">Diabetes</label>
  259.     <input name="HEA_History2" type="checkbox" id="h2" value="on" <?php if($HEA_History2 == 'on'){echo 'checked="checked"' ;}?>  />
  260.     <label for="h2">Depression</label>
  261.     <input name="HEA_History3" type="checkbox" id="h3" value="on" <?php if($HEA_History3 == 'on'){echo 'checked="checked"' ;}?>  />
  262.     <label for="h3">High Blood Pressure</label>
  263.     <input name="HEA_History4" type="checkbox" id="h4" value="on" <?php if($HEA_History4 == 'on'){echo 'checked="checked"' ;}?>  />
  264.     <label for="h4">Asthma</label>
  265.     <input name="HEA_History5" type="checkbox" id="h5" value="on" <?php if($HEA_History5 == 'on'){echo 'checked="checked"' ;}?>  />
  266.     <label for="h5">Hearing Loss</label>
  267.     <input name="HEA_History6" type="checkbox" id="h6" value="on" <?php if($HEA_History6 == 'on'){echo 'checked="checked"' ;}?>  />
  268.     <label for="h6">Respiratory</label>
  269.     <input name="HEA_History7" type="checkbox" id="h7" value="on" <?php if($HEA_History7 == 'on'){echo 'checked="checked"' ;}?>  />
  270.     <label for="h7">Heart Disease</label>
  271.     <input name="HEA_History8" type="checkbox" id="h8" value="on" <?php if($HEA_History8 == 'on'){echo 'checked="checked"' ;}?>  />
  272.     <label for="h8">Pacemaker </label>
  273.     <input name="HEA_History9" type="checkbox" id="h9" value="on" <?php if($HEA_History9 == 'on'){echo 'checked="checked"' ;}?>  />
  274.     <label for="h9">Stroke</label>
  275.     <input name="HEA_History10" type="checkbox" id="h10" value="on" <?php if($HEA_History10 == 'on'){echo 'checked="checked"' ;}?>  />
  276.     <label for="h10">Cancer</label>
  277.     <input name="HEA_History11" type="checkbox" id="h11" value="on" <?php if($HEA_History11 == 'on'){echo 'checked="checked"' ;}?>  />
  278.     <label for="h11">Confusion or Memory Loss</label>
  279.     <input name="HEA_History12" type="checkbox" id="h12" value="on" <?php if($HEA_History12 == 'on'){echo 'checked="checked"' ;}?>  />
  280.     <label for="h12">Dementia/Alzheimer</label>
  281.         <input name="HEA_History13" type="checkbox" id="h13" value="on" <?php if($HEA_History13 == 'on'){echo 'checked="checked"' ;}?>  />
  282.     <label for="h13">Parkinson Disease</label>
  283.     <input name="HEA_History14" type="checkbox" id="h14" value="on" <?php if($HEA_History14 == 'on'){echo 'checked="checked"' ;}?>  />
  284.     <label for="h14">Eye Disease</label>
  285.     <input name="HEA_History15" type="checkbox" id="h15" value="on" <?php if($HEA_History15 == 'on'){echo 'checked="checked"' ;}?>  />
  286.     <label for="h15">Arthritis</label>
  287.     <input name="HEA_History16" type="checkbox" id="h16" value="on" <?php if($HEA_History16 == 'on'){echo 'checked="checked"' ;}?>  />
  288.     <label for="h16">Neurological Disease</label>
  289.  
  290.       </span>
  291.  
  292.    
  293.     </td>
  294.   </tr>
  295.   <tr class="odd">
  296.     <td colspan="4">Other Illness:
  297.       <input name="HEA_OtherIll" type="text" id="HEA_OtherIll" size="50" <?php if($HEA_OtherIll != ' '){echo 'value="' . $HEA_OtherIll . '"' ;}?> />
  298.       <br />
  299.       History Explanation for all checked:<br />
  300.       <span style="line-height:28px">
  301.       <textarea name="HEA_HistoryDetails" id="HEA_HistoryDetails" cols="60" rows="2"  class="text1"><?php if($HEA_HistoryDetails != ' '){echo $HEA_HistoryDetails ;}?></textarea>
  302.       </span></td>
  303.   </tr>
  304.   <tr>
  305.     <td>Hospital Preference:</td>
  306.     <td colspan="4">Name:
  307.       <input name="HEA_HospName" type="text" id="HEA_HospName" size="40" <?php if($HEA_HospName != ' '){echo 'value="' . $HEA_HospName . '"' ;}?> />
  308.       Phone:
  309.       <input name="HEA_HospPhone" type="text" id="HEA_HospPhone" size="12" <?php if($HEA_HospPhone != ' '){echo 'value="' . $HEA_HospPhone . '"' ;}?> /></td>
  310.   </tr>
  311.   <tr class="odd">
  312.     <td rowspan="6">Physician(s):</td>
  313.     <td> Name: <br /></td>
  314.     <td><input name="HEA_PhyName1" type="text" id="HEA_PhyName1" size="25" <?php if($HEA_PhyName1 != ' '){echo 'value="' . $HEA_PhyName1 . '"' ;}?> /></td>
  315.     <td>Name:</td>
  316.     <td><input name="HEA_PhyName2" type="text" id="HEA_PhyName2" size="25" <?php if($HEA_PhyName2 != ' '){echo 'value="' . $HEA_PhyName2 . '"' ;}?> /></td>
  317.     </tr>
  318.   <tr class="odd">
  319.     <td>Address: </td>
  320.     <td><span style="line-height:28px">
  321.       <textarea name="HEA_PhyAddress1" id="HEA_PhyAddress1" cols="25" rows="2"  class="text1"><?php if($HEA_PhyAddress1 != ' '){echo $HEA_PhyAddress1 ;}?></textarea>
  322.     </span></td>
  323.     <td>Address: </td>
  324.     <td><span style="line-height:28px">
  325.       <textarea name="HEA_PhyAddress2" id="HEA_PhyAddress2" cols="25" rows="2"  class="text1"><?php if($HEA_PhyAddress2 != ' '){echo $HEA_PhyAddress2 ;}?></textarea>
  326.     </span></td>
  327.     </tr>
  328.   <tr class="odd">
  329.     <td>Phone:</td>
  330.     <td><input name="HEA_PhyPhone1" type="text" id="HEA_PhyPhone1" size="25" <?php if($HEA_PhyPhone1 != ' '){echo 'value="' . $HEA_PhyPhone1 . '"' ;}?> /></td>
  331.     <td>Phone:</td>
  332.     <td><input name="HEA_PhyPhone2" type="text" id="HEA_PhyPhone2" size="25" <?php if($HEA_PhyPhone2 != ' '){echo 'value="' . $HEA_PhyPhone2 . '"' ;}?> /></td>
  333.     </tr>
  334.   <tr class="odd">
  335.     <td>Fax:</td>
  336.     <td><input name="HEA_PhyFax1" type="text" id="HEA_PhyFax1" size="25" <?php if($HEA_PhyFax1 != ' '){echo 'value="' . $HEA_PhyFax1 . '"' ;}?> /></td>
  337.     <td>Fax:</td>
  338.     <td><input name="HEA_PhyFax2" type="text" id="HEA_PhyFax2" size="25" <?php if($HEA_PhyFax2 != ' '){echo 'value="' . $HEA_PhyFax2 . '"' ;}?> /></td>
  339.   </tr>
  340.   <tr class="odd">
  341.     <td>Email: </td>
  342.     <td><input name="HEA_PhyEmail1" type="text" id="HEA_PhyEmail1" size="25" <?php if($HEA_PhyEmail1 != ' '){echo 'value="' . $HEA_PhyEmail1 . '"' ;}?> /></td>
  343.     <td>Email: </td>
  344.     <td><input name="HEA_PhyEmail2" type="text" id="HEA_PhyEmail2" size="25" <?php if($HEA_PhyEmail2 != ' '){echo 'value="' . $HEA_PhyEmail2 . '"' ;}?> /></td>
  345.     </tr>
  346.   <tr class="odd">
  347.     <td>Specialty:</td>
  348.     <td><input name="HEA_PhySpecialty1" type="text" id="HEA_PhySpecialty1" size="25" <?php if($HEA_PhySpecialty1 != ' '){echo 'value="' . $HEA_PhySpecialty1 . '"' ;}?> /></td>
  349.     <td>Specialty:</td>
  350.     <td><input name="HEA_PhySpecialty2" type="text" id="HEA_PhySpecialty2" size="25" <?php if($HEA_PhySpecialty2 != ' '){echo 'value="' . $HEA_PhySpecialty2 . '"' ;}?> /></td>
  351.     </tr>
  352.   <tr >
  353.     <td rowspan="4">Auto Info:</td>
  354.     <td>Driver:</td>
  355.     <td colspan="3">
  356.                            <span id="HEA_Driver">
  357.         <input type="radio" name="HEA_Driver" id="d1" value="yes" <?php if($HEA_Driver == 'yes'){echo 'checked="checked"' ;}?>  />
  358.  <label for="d1">Yes</label>
  359.        
  360.         <input name="HEA_Driver" type="radio" id="d2" value="no"  <?php if($HEA_Driver == 'no'){echo 'checked="checked"' ;}?> />
  361.  <label for="d2">No</label>
  362.  </span>
  363.  
  364. &nbsp;</td>
  365.     </tr>
  366.   <tr>
  367.     <td>Make:</td>
  368.     <td><input type="text" name="HEA_Make" id="Car" <?php if($HEA_Make != ' '){echo 'value="' . $HEA_Make . '"' ;}?> /></td>
  369.     <td>Model:</td>
  370.     <td><input type="text" name="HEA_Model" id="Car2" <?php if($HEA_Model != ' '){echo 'value="' . $HEA_Model . '"' ;}?> /></td>
  371.   </tr>
  372.   <tr>
  373.     <td>Year:</td>
  374.     <td><input type="text" name="HEA_Year" id="Car4" <?php if($HEA_Year != ' '){echo 'value="' . $HEA_Year . '"' ;}?> /></td>
  375.     <td>Color:</td>
  376.     <td><input type="text" name="HEA_Color" id="Car5" <?php if($HEA_Color != ' '){echo 'value="' . $HEA_Color . '"' ;}?> /></td>
  377.   </tr>
  378.   <tr>
  379.     <td>Plate:</td>
  380.     <td><input type="text" name="HEA_Plate" id="Car3" <?php if($HEA_Plate != ' '){echo 'value="' . $HEA_Plate . '"' ;}?> /></td>
  381.     <td>Parking:</td>
  382.     <td><input type="text" name="HEA_ParkArea" id="Car6" <?php if($HEA_ParkArea != ' '){echo 'value="' . $HEA_ParkArea . '"' ;}?> /></td>
  383.   </tr>
  384.   <tr>
  385.     <td>Other Info:</td>
  386.     <td>Pendant:</td>
  387.     <td><input type="text" name="HEA_Pendant" id="Car6" <?php if($HEA_Pendant != ' '){echo 'value="' . $HEA_Pendant . '"' ;}?> /></td>
  388.     <td>Storage:</td>
  389.     <td><input type="text" name="HEA_Storage" id="Car6" <?php if($HEA_Storage != ' '){echo 'value="' . $HEA_Storage . '"' ;}?> /></td>
  390.   </tr>
  391.   <tr>
  392.   <td colspan="1">Previous Address in REPS:</td>
  393.   <td colspan="4">
  394.       <?php
  395.         include '../ConnectREPS13.php';
  396.  
  397.  
  398. $repscon = @mssql_query("Select
  399. a.Address1,
  400. a.Address2,
  401. a.City,
  402. a.State,
  403. a.ZipCode
  404. from
  405. People p
  406. LEFT JOIN
  407. PeopleAddress pa
  408. ON pa.PeopleIDY = p.PeopleIDY
  409. Left Join
  410. Address a
  411. ON pa.AddressIDY = a.AddressIDY
  412. where
  413. p.PeopleIDY = '$PeopleIDY'");
  414.  
  415.        
  416.              $Address1 = mssql_result($repscon,0,'Address1');
  417.              $Address2 = mssql_result($repscon,0,'Address2');
  418.              $City = mssql_result($repscon,0,'City');
  419.              $State = mssql_result($repscon,0,'State');
  420.              $ZipCode = mssql_result($repscon,0,'ZipCode');
  421.  
  422.         echo  $Address1 . ' ' .  $Address2 . ' ' .  $City . ', ' .  $State . ' ' .  $ZipCode . ' ';
  423.        
  424.         ?></td>
  425.  
  426.   </tr>
  427.     <tr>   
  428. <td colspan="1">Resident Has:</td>
  429.   <td colspan="4">
  430.   | Living Will
  431.   <input type="checkbox" name="HEA_LivingWill" id="HEA_LivingWill" <?php if($HEA_LivingWill)  { echo  'checked="checked"' ; }?> />
  432.    
  433.    
  434.    | Medical Power of Attorney
  435.   <input type="checkbox" name="HEA_Medical_Power_Attorney" id="HEA_Medical_Power_Attorney" <?php if($HEA_Medical_Power_Attorney)  { echo  'checked="checked"' ; }?> />
  436.    
  437.    
  438.    | POLST
  439.   <input type="checkbox" name="HEA_POLST" id="HEA_POLST" <?php if($HEA_POLST)  { echo  'checked="checked"' ; }?> />
  440.    
  441.    
  442.    | MOST
  443.   <input type="checkbox" name="HEA_MOST" id="HEA_MOST" <?php if($HEA_MOST)  { echo  'checked="checked"' ; }?> />
  444.    
  445.    
  446.    | DNR
  447.   <input type="checkbox" name="HEA_DNR" id="HEA_DNR" <?php if($HEA_DNR)  { echo  'checked="checked"' ; }?> />
  448.    |
  449.   <td>
  450.   </tr>
  451.  
  452. </table>
  453.  
  454. <br />
  455. <?php
  456. if ($pro == 1)
  457. {
  458. echo '<input type="submit" name="back" class="formbutton" id="Submit" value="Save and Back to Profile" />';
  459. }
  460. else
  461. {
  462. echo '<input type="submit" name="save" class="formbutton" id="Submit" value="Save" />';
  463. }
  464.  
  465. ?>
  466.  
  467. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  468. <input type="submit" name="next" class="formbutton" id="Submit2" value="Save and Next to Life" />
  469. &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
  470. <?php
  471. if ($pro == 1)
  472. {
  473. echo '<input type="button" name="back" class="formbutton" id="Submit" value="Back" onCLick="history.back()" />';   
  474. }
  475. else
  476. {
  477. echo '<input type="button" name="Cancel" class="formbutton" id="Cancel" value="Cancel" onclick="javascript:parent.Shadowbox.close();" />
  478. '; 
  479. }
  480.  
  481. ?>
  482. <br />
  483.   </p>
  484.   </form>
  485. </div>
  486. </body>
  487. </html>
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