337 lines
23 KiB
PHP
Executable File
337 lines
23 KiB
PHP
Executable File
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<style type="text/css">
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<!--
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.healtpg div.cls_005{font-family:Times,serif;font-size:18.0px;color:rgb(0,0,0);font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg span.cls_001{font-family:Tahoma,serif;font-size:16px;color:rgb(0,0,0);
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line-height: 18px; font-weight:normal;font-style:normal;text-decoration: none;}
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.healtpg span.cls_002{font-family:Tahoma,serif;font-size:12.1px;color:rgb(0,0,0);
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line-height: 16px; font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg div.cls_002{font-family:Times,serif;font-size:14.1px;color:rgb(0,0,0);
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line-height: 18px; font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg span.cls_004{font-family:Tahoma,serif;font-size:13px;color:rgb(0,0,0);
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line-height: 16px; font-weight:normal;font-style:normal;line-height: 17px;text-decoration: none;}
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.healtpg div.cls_004{font-family:Tahoma,serif;font-size:11.1px;color:rgb(0,0,0);
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line-height: 14px; font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg span.cls_005{font-family:Tahoma,serif;font-size:10.1px;color:rgb(0,0,255);
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line-height: 14px; font-weight:normal;font-style:normal;text-decoration: none;}
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.healtpg span.cls_006{font-family:Tahoma,serif;font-size:9.1px;color:rgb(0,0,0);
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line-height: 13px; font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg div.cls_006{font-family:Tahoma,serif;font-size:9.1px;color:rgb(0,0,0);
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line-height: 13px; font-weight:bold;font-style:normal;text-decoration: none;}
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.healtpg span.cls_003{font-family:Tahoma,serif;font-size:10px;color:rgb(0,0,0);
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line-height: 14px; font-weight:normal;font-style:normal;text-decoration: none;font-weight: normal;}
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.healtpg div.cls_003{font-family:Tahoma,serif;font-size:8.0px;color:rgb(0,0,0);
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line-height: 12px; font-weight:normal;font-style:normal;text-decoration: none;}
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ul{padding: 0;margin: 0;}
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.healtpg .checkbox ul li{list-style: none;display: inline-block;padding: 0 20px;margin-top: 15px;position: relative;}
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/*.checkbox ul li:after{position: absolute;content: "";top: 1px;left: 0;width: 6px;height: 6px;border: 1px solid #000;-webkit-box-shadow: 1px 1px 0px 0px rgba(50, 50, 50, 1);*/
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/*-moz-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);
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box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);}*/
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.healtpg p span b{position: relative;display: inline-block;}
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.healtpg span{display: inline-block;}
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.healtpg p{padding: 0;margin: 0;}
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/*p span b:after{position: absolute;content: "";top: 3px;left: 0;width: 6px;height: 6px;border: 1px solid #000;-webkit-box-shadow: 1px 1px 0px 0px rgba(50, 50, 50, 1);*/
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/*-moz-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);
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box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);}*/
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.healtpg table{border-collapse: collapse;width: 100%;}
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.healtpg .sectable td{font-size: 11px;line-height: 22px;height: 14px;font-family:Tahoma,serif;font-weight: normal;border: 1px solid #000;padding: 0 5px;}
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-->
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</style>
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<script type="text/javascript" src="63aa2336-4034-11eb-8b25-0cc47a792c0a_id_63aa2336-4034-11eb-8b25-0cc47a792c0a_files/wz_jsgraphics.js"></script>
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</head>
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<body>
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<div style="position:relative;width:720px;height:980px;overflow:hidden;top:0;margin: 0 auto;">
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<div class="inner-col healtpg" style="padding-bottom: 40px;
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border-bottom: 1px solid #000;">
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<div>
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<span class="cls_001" style="text-align: center; display: block;font-weight: 500;">REQUIRED EMPLOYEE HEALTH ASSESSMENT </span>
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<div>
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<div style="text-align: center;">
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<table style="width: 314px;margin: 0 auto;">
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<tr style="text-align: center;">
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<td>
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<span class="cls_006">
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<input type="checkbox" id="hewalt1" style="border-radius: 0px;
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width: 10px;margin: 0;box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);-webkit-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);
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-moz-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);position: relative;top: -20px;
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height: 10px;">
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<label for="hewalt1" style="padding-left: 20px;position: relative;
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top: 0px;">Initial</label></span>
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</td>
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<td>
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<span class="cls_006">
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<input type="checkbox" id="hewalt1" style="border-radius: 0px;
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width: 10px;margin: 0;box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);-webkit-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);
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-moz-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);position: relative;top: 0;
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height: 10px;">
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<label for="hewalt1" style="padding-left: 20px;position: relative;
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top: 0px;">Annual</label></span>
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</td>
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<td>
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<span class="cls_006">
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<input type="checkbox" id="hewalt1" style="border-radius: 0px;
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width: 10px;margin: 0;box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);-webkit-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);
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-moz-box-shadow:1px 1px 0px 0px rgba(50, 50, 50, 1);position: relative;top: 0;
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height: 10px;">
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<label for="hewalt1" style="padding-left: 20px;position: relative;
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top: 0px;">Other</label></span>
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</td>
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</tr>
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</table>
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</div>
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<p><span class="cls_004" style="padding-top: 10px;">Name:
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<u style="font-family: Times,serif;width: 200px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=_na($cg->fname,'')." "._na($cg->mid_name,'')." "._na($cg->lname,'')?></u>
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Date of Birth:
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<u style="font-family: Times,serif;width: 200px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=_na($cg->dob,'')?></u>
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Sex:
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">M</label>
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<img src="<?php if($cg->gender == 'Male') echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">F</label>
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<img src="<?php if($cg->gender == 'Female') echo $tick ; ?>" style="width: 12px;" alt="">
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</span>
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</p>
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<p><span class="cls_004" style="padding-top: 10px;">Address:
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<u style="font-family: Times,serif;width: 660px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;">
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<?=$cg->address1?> <?=$cg->city1?> <?=$cg->state1?></u></span>
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</p>
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</div>
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<p><span class="cls_004" style="padding-top: 10px;">Emergency Contact:
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<u style="font-family: Times,serif;width: 260px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=$cg->Emergency_Contact_Name?></u>
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Relationship:
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<u style="font-family: Times,serif;width: 250px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=$cg->Emergency_Contact_Relationship?></u>
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</span>
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</p>
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<p><span class="cls_004" style="padding-top: 10px;">Emergency Address/Phone number:
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<u style="font-family: Times,serif;width: 500px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=_na($cg->$Emergency_Contact_Address,'')?></u> </span>
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</p>
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</div>
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<div class="secondSec">
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<p><span class="cls_004" style="padding-top: 15px;">Indicate if you are suffering from or have a history of the following conditions: </span>
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</p>
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<table class="sectable">
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<tr>
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<td style="width: 210px;"><b>CONDITION</b></td>
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<td style="width: 40px;"><b>YES </b></td>
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<td style="width: 40px;"><b>NO</b></td>
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<td style="width: 210px;"><b>CONDITION</b></td>
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<td style="width: 40px;"><b>YES </b></td>
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<td style="width: 40px;"><b>NO</b></td>
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</tr>
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<tr>
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<td>DIABETES</td>
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<td><img src="<?php if($eha->diabetes == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->diabetes == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>BACK PAIN </td>
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<td><img src="<?php if($eha->back_pain == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->back_pain == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>KIDNEY DISEASE </td>
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<td><img src="<?php if($eha->kidney_disease == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->kidney_disease == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>PAIN ON URINATION</td>
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<td><img src="<?php if($eha->pain_urination == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->pain_urination == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>HEART DISEASE </td>
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<td><img src="<?php if($eha->heart_disease == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->heart_disease == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>CHANGE IN BOWEL HABITS </td>
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<td><img src="<?php if($eha->change_bowel_habit == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->change_bowel_habit == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>HIGH BLOOD PRESSURE </td>
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<td><img src="<?php if($eha->high_blood_pressure == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->high_blood_pressure == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>INCREASED THIRST </td>
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<td><img src="<?php if($eha->increased_thirst == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->increased_thirst == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>ARTHRITIS</td>
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<td><img src="<?php if($eha->arthritis == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->arthritis == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>PERSISTENT SORES/LUMPS </td>
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<td><img src="<?php if($eha->diabetes == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->diabetes == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>MENTAL ILLNESS </td>
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<td><img src="<?php if($eha->mental_illness == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->mental_illness == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>INFECTIOUS DISEASE </td>
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<td><img src="<?php if($eha->infectious_disease == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->infectious_disease == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>EPILEPSY/CONVULSIONS </td>
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<td><img src="<?php if($eha->epilepsy == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->epilepsy == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>CANCER</td>
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<td><img src="<?php if($eha->cancer == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->cancer == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>SWELLING IN THE EXTREMITIES </td>
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<td><img src="<?php if($eha->swelling_extremities == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->swelling_extremities == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>ANY OTHER PHYSICAL DISABILITY </td>
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<td><img src="<?php if($eha->other_disability == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->other_disability == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>ALLERGIES</td>
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<td></td>
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<td></td>
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<td></td>
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<td></td>
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<td></td>
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</tr>
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</table>
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<p><span class="cls_004" style="padding-top: 2px; text-align: center; display: block;">TURBERCULOSIS QUESTIONNAIRE</span>
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</p>
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<p><span class="cls_004" style="padding-top: 0px; text-align: center; display: block;">Indicate if you have been experiencing the following conditions</span>
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</p>
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<table class="sectable">
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<tr>
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<td style="width: 210px;"><b>CONDITION</b></td>
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<td style="width: 40px;"><b>YES</b></td>
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<td style="width: 40px;"><b>NO</b></td>
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<td style="width: 210px;"><b>CONDITION</b></td>
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<td style="width: 40px;"><b>YES</b></td>
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<td style="width: 40px;"><b>NO</b></td>
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</tr>
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<tr>
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<td>PERSISTENT COUGH FOR < 3 WEEKS </td>
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<td><img src="<?php if($eha->cough_3_weeks == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->cough_3_weeks == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>UNEXPLAINED WEIGHT LOSS </td>
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<td><img src="<?php if($eha->unexplained_weight_loss == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->unexplained_weight_loss == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>BLOOD IN THE SPUTUM </td>
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<td><img src="<?php if($eha->blood_sputum == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->blood_sputum == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>LOSS OF APPETITE </td>
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<td><img src="<?php if($eha->appetite_loss == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->appetite_loss == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>LOSS OF APPETITE</td>
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<td><img src="<?php if($eha->diabetes == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->diabetes == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>HOARSENESS</td>
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<td><img src="<?php if($eha->hoarseness == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->hoarseness == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>NIGHT SWEATS </td>
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<td><img src="<?php if($eha->night_sweat == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->night_sweat == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>FATIGUE</td>
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<td><img src="<?php if($eha->fatigue == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->fatigue == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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<tr>
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<td>CHEST PAIN </td>
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<td><img src="<?php if($eha->chest_pain == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->chest_pain == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td>FEVER</td>
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<td><img src="<?php if($eha->fever == 1) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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<td><img src="<?php if($eha->fever == 0) echo $tick ; ?>" style="width: 12px;" alt=""></td>
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</tr>
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</table>
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<p style="padding-top: 2px;"><span class="cls_004" style="">Have you had a positive PPD reading?
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<img src="<?php if($eha->positive_ppd == 1) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">Yes</label>
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<img src="<?php if($eha->positive_ppd == 0) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">No</label>
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</span>
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</p>
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<p><span class="cls_004" style="">Are you under the care of a physician?
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<img src="<?php if($eha->under_care == 1) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">Yes</label>
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<img src="<?php if($eha->under_care == 0) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">No</label>
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Reason
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<u style="font-family: Times,serif;width: 350px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;">dddd</u>
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</span>
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</p>
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<p><span class="cls_004" style="">Do you take depressants, stimulants, narcotic drugs that alter your behavior?
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<img src="<?php if($eha->change_behaviour == 1) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">Yes</label>
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<img src="<?php if($eha->change_behaviour == 0) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
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top: 0px;">No</label>
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</span>
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</p>
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<p><span class="cls_004" style="">Do you take prescription medications?
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<img src="<?php if($eha->prescription_medications == 1) echo $tick ; ?>" style="width: 12px;" alt="">
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<label for="hewalt1" style="padding-left: 8px;position: relative;
|
|
top: 0px;">Yes</label>
|
|
<img src="<?php if($eha->prescription_medications == 0) echo $tick ; ?>" style="width: 12px;" alt="">
|
|
<label for="hewalt1" style="padding-left: 8px;position: relative;
|
|
top: 0px;">No</label>
|
|
No If yes, which medications?
|
|
<u style="font-family: Times,serif;width: 220px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;">dddd</u>
|
|
</span>
|
|
</p>
|
|
<p><span class="cls_004" style="">If required in your position, would you be willing to have screening test for drugs/alcohol done on your blood /urine as a condition for employment?
|
|
<img src="<?php if($eha->screening_test == 1) echo $tick ; ?>" style="width: 12px;" alt="">
|
|
<label for="hewalt1" style="padding-left: 8px;position: relative;
|
|
top: 0px;">Yes</label>
|
|
<img src="<?php if($eha->screening_test == 0) echo $tick ; ?>" style="width: 12px;" alt="">
|
|
<label for="hewalt1" style="padding-left: 8px;position: relative;
|
|
top: 0px;">No</label>
|
|
</span>
|
|
</p>
|
|
<p><span class="cls_004" style="padding-top: 0px;">Have you had any operations or hospitalization for illnesses past 5 years? Reason:
|
|
<!-- <table style="width: 170PX;display: inline-table;
|
|
position: relative;font-size: 13px;
|
|
line-height: 17px;
|
|
top: 0px;">
|
|
<tr>
|
|
<td style="border-bottom: 1px solid #000;height: 18px;">dddddddddd</td>
|
|
</tr>
|
|
</table> -->
|
|
<u style="font-family: Tahoma,serif;
|
|
font-size: 14px;line-height: 18px;text-decoration: none;border-bottom: 1px solid #000;"><?=$eha->screening_test_explain?></u>
|
|
</span>
|
|
</p>
|
|
<p><span class="cls_004" style="padding-top: 0px;">Name of Physician:
|
|
<u style="font-family: Times,serif;width: 330px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=$eha->name_of_physician?></u>
|
|
Telephone:
|
|
<u style="font-family: Times,serif;width: 190px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"><?=$eha->tel_of_physician?></u>
|
|
</span>
|
|
</p>
|
|
<p><span class="cls_004" style="padding-bottom: 10px;">I have read the above and declare that I have had no injury, illness or ailment other than as specifically identified. I certify that I am not habituated or addicted to any depressants, stimulants, narcotics, drugs, alcohol or other substances that may alter my behavior. </span>
|
|
</p>
|
|
<p><span class="cls_004" style="padding-top: 0px;"><b style="font-size: 12px;">Employee Signature:</b>
|
|
<u style="font-family: Times,serif;width: 394px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"></u>
|
|
<span style="padding-left: 12px;">Date:
|
|
<u style="font-family: Times,serif;width: 120px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"></u>
|
|
</span><br>
|
|
<b style="font-size: 12px;">RN Signature:</b>
|
|
<u style="font-family: Times,serif;width: 437px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"></u>
|
|
<span style="padding-left: 10px;">Date:
|
|
<u style="font-family: Times,serif;width: 120px;display: inline-block;font-size: 13px;line-height: 14px;text-decoration: none;border-bottom: 1px solid #000;"></u>
|
|
</span>
|
|
</span>
|
|
</p>
|
|
</div>
|
|
</div>
|
|
</div>
|