<!-- BEGIN hmrn/data/staging.tt -->
[% sites = hmrn_data.params.staging; # PROCESS dumper.tt dump = sites %]
[% BLOCK build_checkbox %]
<tr>
<td class="label" align="right">
<span title="[% span %]" class="[% span ? 'acronym' : 'normal' %]">
[% IF NOT label; field | ucfirst; ELSE; label; END %]</span>:
</td>
<td class="normal" align="center">
[% IF cols == 2;
field_left = field _ '_left'; field_right = field _ '_right'
%]
<input type="checkbox" name="[% field_left %]" value="1"
[% 'checked' IF sites.${field_left} %] />
<input type="checkbox" name="[% field_right %]" value="1"
[% 'checked' IF sites.${field_right} %] />
[% ELSE %]
<input type="checkbox" name="[% field %]" value="1"
[% 'checked' IF sites.${field} %] />
[% END %]
</td>
</tr>
[% END %]
<div class="indent">
<form method="post" name="involvement" id="involvement"
action="[% app_url %]/hmrn_data/staging/[% data.id %]/[% patient.id %]">
<table class="indent">
<tr>
<td style="border: none; vertical-align: top">
<h4>Nodal involvement:</h4>
<table class="yhhn indent">
<tr>
<th>Site</th>
<th>L | R</th>
</tr>
[% INCLUDE build_checkbox
label = "Waldeyer's ring"
field = 'waldeyer'
span = 'tonsillar, adenoidal, pharangeal'
%]
[% INCLUDE build_checkbox
field = 'neck'
cols = 2
span = 'cervical, supraclavicular, occipital, preauricular'
%]
[% INCLUDE build_checkbox
field = 'infraclavicular'
cols = 2
%]
[% INCLUDE build_checkbox
label = 'Axillary/Pectoral'
field = 'axillary'
cols = 2
%]
[% INCLUDE build_checkbox
field = 'arm'
cols = 2
span = 'epitrochlear & brachial'
%]
[% INCLUDE build_checkbox
field = 'thymus'
%]
[% INCLUDE build_checkbox
field = 'hilar'
cols = 2
%]
[% INCLUDE build_checkbox
field = 'mediastinal'
%]
<tr><td id="diaphragm" colspan="2"></tr>
[% INCLUDE build_checkbox
label = 'Para-aortic'
field = 'para_aortic'
%]
[% INCLUDE build_checkbox
label = 'Spleen (palpable)'
field = 'spleen'
%]
[% INCLUDE build_checkbox
field = 'mesenteric'
%]
[% INCLUDE build_checkbox
field = 'iliac'
cols = 2
%]
[% INCLUDE build_checkbox
label = 'Inguinal/Femoral'
field = 'inguinal'
cols = 2
%]
[% INCLUDE build_checkbox
field = 'popliteal'
cols = 2
%]
<tr><td colspan="2" class="borderless"> </td></tr>
[% INCLUDE build_checkbox
label = 'Bulky disease'
field = 'bulky'
%]
[% INCLUDE build_checkbox
label = 'Check CT scan'
field = 'check_ct'
%]
</table>
</td>
<td class="borderless"> </td>
<td style="border: none; vertical-align: top">
<h4>Extranodal involvement:</h4>
<table class="yhhn indent">
<tr>
<th>Site</th>
<th>L | R</th>
</tr>
[% INCLUDE build_checkbox
field = 'blood'
%]
[% INCLUDE build_checkbox
field = 'bone'
%]
[% INCLUDE build_checkbox
label = 'CNS'
field = 'cns'
%]
[% INCLUDE build_checkbox
label = 'GIT'
field = 'git'
span = 'gastro-intestinal tract'
%]
[% INCLUDE build_checkbox
label = 'GU'
field = 'gu'
span = 'genito-urinary tract'
%]
[% INCLUDE build_checkbox
field = 'liver'
%]
[% INCLUDE build_checkbox
field = 'marrow'
%]
[% INCLUDE build_checkbox
field = 'muscle'
%]
[% INCLUDE build_checkbox
field = 'orbit'
cols = 2
%]
[% INCLUDE build_checkbox
field = 'pericardium'
%]
[% INCLUDE build_checkbox
field = 'pulmonary'
cols = 2
%]
[% INCLUDE build_checkbox
label = 'Salivary gland'
field = 'salivary_gland'
cols = 2
%]
[% INCLUDE build_checkbox
field = 'skin'
%]
[% INCLUDE build_checkbox
field = 'thyroid'
%]
<tr>
<td class="right" colspan="2">
<span style="vertical-align: top">Other:</span>
<textarea rows="2" cols="15"
name="details">[% sites.details %]</textarea>
</td>
</tr>
[% INCLUDE build_checkbox
field = 'extensive'
span = 'extensive organ involvement'
%]
</table>
</td>
</tr>
[% IF user_can_enter_data %]
<tr class="borderless" align="center">
<td colspan="2">[% site.html.submit %] [% site.html.reset %]</td>
</tr>
[% END %]
</table>
</form>
</div>
<!-- END hmrn/data/staging.tt -->