git.plutz.net Git - confetti/blob - templates/edit_prescription.sh

   1 # Copyright 2016 Paul Hänsch
   2 #
   3 # This file is part of Confetti.
   4 #
   5 # Confetti is free software: you can redistribute it and/or modify
   6 # it under the terms of the GNU Affero General Public License as published by
   7 # the Free Software Foundation, either version 3 of the License, or
   8 # (at your option) any later version.
   9 #
  10 # Confetti is distributed in the hope that it will be useful,
  11 # but WITHOUT ANY WARRANTY; without even the implied warranty of
  12 # MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  13 # GNU Affero General Public License for more details.
  14 #
  15 # You should have received a copy of the GNU Affero General Public License
  16 # along with Confetti.  If not, see <http://www.gnu.org/licenses/>.
  17
  18 cat <<END_HTML
  19 <form class="prescription" action="?action=update_prescription" method="POST">
  20
  21 <label for="insurance">$(l10n insurance)</label>
  22 <input id="insurance" name="insurance" value="" placeholder="$(l10n insurance)">
  23 <label for="name">$(l10n name)</label>
  24 <textarea id="name" name="name" placeholder="$(l10n name)"></textarea>
  25 <label for="bday">$(l10n bday)</label>
  26 <input id="bday" name="bday" value="" placeholder="$(l10n bday)">
  27
  28 <label for="date">$(l10n date)</label>
  29 <input id="date" name="date" value="" placeholder="$(l10n date)">
  30
  31 <label for="addcontrib">$(l10n addcontrib)</label>
  32 <input id="addcontrib" name="addcontrib" value="" placeholder="$(l10n addcontrib)">
  33 <input type="checkbox" id="contribconfirm" name="contribconfirm" value="true">
  34 <label for="contribconfirm">$(l10n contribconfirm)</label>
  35
  36 <h2>$(l10n prescription_by_catalogue)</h2>
  37 <input type="radio" id="prescfirst" name="prescno" value="first">
  38 <label for="prescfirst">$(l10n prescfirst)</label>
  39 <input type="radio" id="prescfollow1" name="prescno" value="follow1">
  40 <label for="prescfollow1">$(l10n prescfollow1)</label>
  41 <input type="radio" id="prescfollow2" name="prescno" value="follow2">
  42 <label for="prescfollow2">$(l10n prescfollow2)</label>
  43 <input type="radio" id="prescother" name="prescno" value="other">
  44 <label for="prescother">$(l10n prescother)</label>
  45 <input type="radio" id="presccontinual" name="prescno" value="continual">
  46 <label for="presccontinual">$(l10n presccontinual)</label>
  47
  48 <input type="checkbox" id="grouptherapy" name="grouptherapy" value="true">
  49 <label for="grouptherapy">$(l10n grouptherapy)</label>
  50 <input type="checkbox" id="housecall" name="housecall" value="true">
  51 <label for="housecall">$(l10n housecall)</label>
  52 <input type="checkbox" id="report" name="report" value="true">
  53 <label for="report">$(l10n report)</label>
  54
  55 <label for="quantity">$(l10n quantity)</label>
  56 <input id="quantity" name="quantity" value="" placeholder="$(l10n quantity)">
  57 <label for="remidy">$(l10n remidy)</label>
  58 <textarea id="remidy" name="remidy" placeholder="$(l10n remidy)"></textarea>
  59 <label for="quantity_weekly">$(l10n quantity_weekly)</label>
  60 <input id="quantity_weekly" name="quantity_weekly" value="" placeholder="$(l10n quantity_weekly)">
  61
  62 <label for="indicator">$(l10n indicator)</label>
  63 <input id="indicator" name="indicator" value="" placeholder="$(l10n indicator)">
  64 <label for="icd10">$(l10n icd10)</label>
  65 <input id="icd10" name="icd10" value="" placeholder="$(l10n icd10)">
  66
  67 <input type="checkbox" id="prescreviewed" name="prescreviewed" value="true">
  68 <label for="prescreviewed">$(l10n prescreviewed)</label>
  69
  70
  71 </form>
  72 END_HTML