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mcdlee/exam_confirm.php

Last active December 25, 2015 16:19
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Raw
exam_confirm.php
<html>
<head>
<title>檢查證明書</title>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
</head>
<body>
<table style="border: 5px double rgb(0,0,0)">
<tr>
<td>
<h1 align="center">檢查證明書</h1>
<p>
<?php echo "<b>","$patient_name","</b>";
if($gender=="Male")
{
echo "先生";
}
else
{
echo "女士";
}
?>，病歷號碼為
<?php echo "$chart_number"; ?>，
國民身份證字號為<?php echo "$id_number"; ?>，
生於<?php echo "$BD_year","年","$BD_month","月","$BD_day","日"; ?>。</p>
<p>
於<?php echo "$exam_year","年","$exam_month","月","$exam_day","日","$exam_hour","時","$exam_minute","分"; ?>
因接受<?php echo "$exam"; ?>，
注射<?php echo "$drug_name", " ", "$drug_dosage", "毫居里" ; ?>，特此證明。(以下空白)
</p>
<p>
高雄榮總核醫科 <br /><br /><br /><br /><br /><br />
</p>
<p align="right"><?php echo "$exam_year","年","$exam_month","月","$exam_day","日" ; ?></p>
</td>
</tr></table>
</body>
</html>
Raw
exam_form.php
<html>
<head><title>開立檢查證明書</title></head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<body>
<h3>請輸入下列表單</h3>
<form method="POST" action="exam_confirm.php">
受檢者姓名：<input type="text" name="patient_name" />
病歷號碼：<input type="text" name="chart_number" />
身分證字號：<input type="text" name="id_number" />
受檢者性別：<select name="gender">
<option>Male</option>
<option>Female</option>
</select><br />
受檢者出生年月日：
<input type="text" name="BD_year" lenth="5" /> 年
<select name="BD_month">
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>月
<select name="BD_day">
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select>日<br />
檢查項目：
<select name="exam">
<option>心肌血流灌注造影</option>
<option>心室摶出分率及心室壁收縮檢查</option>
<option>全身性骨骼造影</option>
<option></option>
<option></option>
</select>
檢查日期：
<select name="exam_year">
<option>2013</option>
<option>2014</option>
<option>2015</option>
</select>年
<select name="exam_month">
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>月
<select name="exam_day">
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
</select>日
注射時間：
<select name="exam_hour">
<option>0</option>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
</select>
<select name="exam_minute">
<option>0</option>
<option>1</option>
<option>2</option>
<option>3</option>
<option>4</option>
<option>5</option>
<option>6</option>
<option>7</option>
<option>8</option>
<option>9</option>
<option>10</option>
<option>11</option>
<option>12</option>
<option>13</option>
<option>14</option>
<option>15</option>
<option>16</option>
<option>17</option>
<option>18</option>
<option>19</option>
<option>20</option>
<option>21</option>
<option>22</option>
<option>23</option>
<option>24</option>
<option>25</option>
<option>26</option>
<option>27</option>
<option>28</option>
<option>29</option>
<option>30</option>
<option>31</option>
<option>32</option>
<option>33</option>
<option>34</option>
<option>35</option>
<option>36</option>
<option>37</option>
<option>38</option>
<option>39</option>
<option>40</option>
<option>41</option>
<option>42</option>
<option>43</option>
<option>44</option>
<option>45</option>
<option>46</option>
<option>47</option>
<option>48</option>
<option>49</option>
<option>50</option>
<option>51</option>
<option>52</option>
<option>53</option>
<option>54</option>
<option>55</option>
<option>56</option>
<option>57</option>
<option>58</option>
<option>59</option>
</select>
<br />
注射藥物：
<select name="drug_name">
<option>Tl-201 (鉈-201)</option>
<option>Tc-99m labeled RBC (鎝-99m 標誌紅血球)</option>
<option>Tc-99m MDP (鎝-99m MDP)</option>
<option>Tc-99m DTPA (鎝-99m DTPA)</option>
<option>Tc-99m (鎝-99m)</option>
<option>Tc-99m DMSA (鎝-99m DMSA)</option>
<option>Tc-99m MIBI (鎝-99m MIBI)</option>
<option>Tc-99m DISIDA (鎝-99m DISIDA)</option>
</select>
<input type="text" name="drug_dosage" /> mCi <br />
<input type="submit" />
<body>
</html>
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