<!-- BEGIN [% component.name %] -->
[% # PROCESS dumper.tt dump = dataset %]
<div class="indent imaging">
<form method="post" name="imaging-[% scan_type %][% setnum IF setnum %]"
id="imaging-[% scan_type %][% setnum IF setnum %]"
action="[% app_url %]/hmrn_data/imaging/[% data.id %]/[% patient.id %]">
[% IF NOT dataset; # is data entry %]
<p class="bold indent">
New scan:
<select name="scan_sequence">
<option value="">-- select --</option>
<option value="initial">initial scan</option>
<option value="followup" [% 'selected=1' IF ndatasets # previous data %]>
follow-up</option>
</select>
date:
<input type="text" size="5" name="scan_date" />
</p>
<input type="hidden" name="scan_type" value="[% scan_type %]" />
<input type="hidden" name="dataset" value="[% ndatasets + 1 %]" />
[% ELSE %]
<p class="indent">
<span class="bold">[% foo.setnum || 'initial' | ucfirst %] scan</span>
on <span class="bold">[% date OR '1/1/1900' %]</span>
[ <a href="[% app_url %]/hmrn/imaging_edit/[% data.id %]/[% patient.id
%]?scan_type=[% scan_type %];setnum=[% setnum %]">edit</a> ]
</p>
[% END %]
<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'
%]
[% IF NOT dataset %]
<tr><td id="diaphragm" colspan="2"></tr>
[% END %]
[% 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
%]
[% IF NOT dataset %]
<tr><td colspan="2" class="borderless"> </td></tr>
[% END %]
[% INCLUDE build_checkbox
label = 'Bulky disease'
field = 'bulky'
%]
[% INCLUDE build_checkbox
label = 'Check scan'
field = 'check_scan'
%]
[% INCLUDE build_checkbox
field = 'extensive'
span = 'extensive organ involvement'
%]
</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="label" colspan="2">
<span style="vertical-align: top"><b>Other:</b></span>
[% IF dataset %]
<span class="bkgd_white">[% dataset.other %]</span>
[% ELSE %]
<textarea rows="2" cols="15"
name="details"></textarea>
[% END %]
</td>
</tr>
</table>
</td>
</tr>
[% IF user_can_enter_data AND NOT dataset # allow data entry %]
<tr class="borderless" align="center">
<td colspan="2">[% site.html.submit %] [% site.html.reset %]</td>
</tr>
[% END %]
</table>
</form>
</div>
<!-- END [% component.name %] -->