You can not select more than 25 topics
Topics must start with a letter or number, can include dashes ('-') and can be up to 35 characters long.
265 lines
15 KiB
265 lines
15 KiB
<?xml version="1.0"?>
|
|
<odoo>
|
|
|
|
<record id="action_report_adult_details" model="ir.actions.report">
|
|
<field name="name">Adult Care Details</field>
|
|
<field name="model">res.partner</field>
|
|
<field name="report_type">qweb-pdf</field>
|
|
<field name="report_name">adult_daycare_center.adult_care_details_report</field>
|
|
<field name="report_file">adult_daycare_center.adult_care_details_report</field>
|
|
<field name="binding_model_id" ref="model_res_partner"/>
|
|
<field name="binding_type">report</field>
|
|
</record>
|
|
|
|
<template id="adult_care_details_report">
|
|
<t t-call="web.html_container">
|
|
<t t-call="web.external_layout">
|
|
<div class="page">
|
|
<t t-foreach="docs" t-as="data">
|
|
<center><span style="font-size:25px;"><strong>Member : <t t-esc="data['name']"/></strong></span></center>
|
|
<br/>
|
|
<span><strong style="font-size:25px;">Application Information</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Social Security Number</strong></td>
|
|
<td><t t-esc="data['social_security_no']"/></td>
|
|
<td><strong>Referred By</strong></td>
|
|
<td><t t-esc="data['referred_by_id'].name"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Medicare Number</strong></td>
|
|
<td><t t-esc="data['medicare_no']"/></td>
|
|
<td><strong>Marital Status</strong></td>
|
|
<td><t t-esc="data['marital_status']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Medicaid Number</strong></td>
|
|
<td><t t-esc="data['medicaid_no']"/></td>
|
|
<td><strong>Place of Birth</strong></td>
|
|
<td><t t-esc="data['place_birth']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Birth Date</strong></td>
|
|
<td><t t-esc="data['birth_date']"/></td>
|
|
<td><strong>Age</strong></td>
|
|
<td><t t-esc="data['age']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Responsible Party/Guardian</strong></td>
|
|
<td><t t-esc="data['responsible_id'].name"/></td>
|
|
<td><strong>Primary Care</strong></td>
|
|
<td><t t-esc="data['care_provider_id'].name"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Responsible Address</strong></td>
|
|
<td><t t-esc="data['responsible_address']"/></td>
|
|
<td><strong>Primary Care Address</strong></td>
|
|
<td><t t-esc="data['care_provider_address']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Responsible Telephone</strong></td>
|
|
<td><t t-esc="data['responsible_telephone']"/></td>
|
|
<td><strong>Primary Care Telephone</strong></td>
|
|
<td><t t-esc="data['care_provider_telephone']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Present Living Arrangements</strong></td>
|
|
<td><t t-esc="data['present_living']"/></td>
|
|
<td><strong>Living with whom</strong></td>
|
|
<td><t t-esc="data['living_with_whom']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Relationship with whom their living</strong></td>
|
|
<td><t t-esc="data['living_with']"/></td>
|
|
<td><strong>Nearest Responsible Relative</strong></td>
|
|
<td><t t-esc="data['nearest_relative']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>If Employed, where</strong></td>
|
|
<td><t t-esc="data['employed_at']"/></td>
|
|
<td><strong>Business Phone</strong></td>
|
|
<td><t t-esc="data['business_phone']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Why interested in joining the program?</strong></td>
|
|
<td colspan="2"><t t-esc="data['interest_program']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Have you had previous experience in an Adult Daycare Program?</strong></td>
|
|
<td colspan="2"><t t-esc="data['previous_experience']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>If yes, Where and When?</strong></td>
|
|
<td colspan="2"><t t-esc="data['where_when']"/></td>
|
|
</tr>
|
|
</table>
|
|
<br/>
|
|
</span>
|
|
|
|
<span><strong style="font-size:25px;">Medical Details</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Physician</strong></td>
|
|
<td><t t-esc="data['physician_id']"/></td>
|
|
<td><strong>Travel By</strong></td>
|
|
<td><t t-esc="data['travel_by']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Address</strong></td>
|
|
<td><t t-esc="data['physician_address']"/></td>
|
|
<td><strong>Is Need Travel Assistance</strong></td>
|
|
<td><t t-esc="data['travel_assistance']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Phone</strong></td>
|
|
<td><t t-esc="data['physician_phone']"/></td>
|
|
<td/>
|
|
<td/>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Present Diagnoses/Medical Problems</strong></td>
|
|
<td><t t-esc="data['present_medical']"/></td>
|
|
<td><strong>Other Disability</strong></td>
|
|
<td><t t-esc="data['other_disability']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Weight</strong></td>
|
|
<td><t t-esc="data['weight']"/></td>
|
|
<td><strong>Height</strong></td>
|
|
<td><t t-esc="data['height']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Dentist</strong></td>
|
|
<td><t t-esc="data['dentist_id']"/></td>
|
|
<td><strong>Address</strong></td>
|
|
<td><t t-esc="data['dentist_address']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Phone Number</strong></td>
|
|
<td><t t-esc="data['dentist_phone']"/></td>
|
|
<td><strong>Date of Last Visit</strong></td>
|
|
<td><t t-esc="data['dentist_last_visit']"/></td>
|
|
</tr>
|
|
</table>
|
|
<br/>
|
|
</span>
|
|
|
|
<span t-if="data['daycare_activities_ids']"><strong style="font-size:25px;">Activity</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Name</strong></td>
|
|
<td><strong>Product</strong></td>
|
|
<td><strong>Notes</strong></td>
|
|
<td><strong>Time In</strong></td>
|
|
<td><strong>Time Out</strong></td>
|
|
<td><strong>Responsible By</strong></td>
|
|
</tr>
|
|
<tr t-foreach="data['daycare_activities_ids']" t-as="rec">
|
|
<td><t t-esc="rec['name'].name"/></td>
|
|
<td><t t-esc="rec['product_id'].name"/></td>
|
|
<td><t t-esc="rec['notes']"/></td>
|
|
<td><t t-esc="rec['time_in']"/></td>
|
|
<td><t t-esc="rec['time_out']"/></td>
|
|
<td><t t-esc="rec['responsible'].name"/></td>
|
|
</tr>
|
|
</table>
|
|
<br/>
|
|
</span>
|
|
|
|
<span><strong style="font-size:25px;">Emergency Care Information</strong>
|
|
<strong style="font-size:20px;">Emergency Contact#1</strong>
|
|
<br/>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Full Name</strong></td>
|
|
<td><t t-esc="data['emergency_name']"/></td>
|
|
<td><strong>Relationship To Applicant</strong></td>
|
|
<td><t t-esc="data['applicant_relationship']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Address</strong></td>
|
|
<td><t t-esc="data['emergency_address']"/></td>
|
|
<td><strong>Phone</strong></td>
|
|
<td><t t-esc="data['emergency_phone']"/></td>
|
|
</tr>
|
|
</table>
|
|
<br/>
|
|
<strong style="font-size:20px;">Emergency Contact#2</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Full Name</strong></td>
|
|
<td><t t-esc="data['emergency_name_1']"/></td>
|
|
<td><strong>Relationship To Applicant</strong></td>
|
|
<td><t t-esc="data['applicant_relationship_2']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Address</strong></td>
|
|
<td><t t-esc="data['emergency_address_1']"/></td>
|
|
<td><strong>Phone</strong></td>
|
|
<td><t t-esc="data['emergency_phone_1']"/></td>
|
|
</tr>
|
|
</table>
|
|
<br/>
|
|
</span>
|
|
|
|
<span><strong style="font-size:25px;">Service</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td><strong>Transportation Provided By</strong></td>
|
|
<td><t t-esc="data['transportation']"/></td>
|
|
<td><strong>Arrive Time</strong></td>
|
|
<td><t t-esc="data['arrival_time']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td><strong>Departure Time</strong></td>
|
|
<td><t t-esc="data['departure_time']"/></td>
|
|
<td><strong>Special Diet?</strong></td>
|
|
<td><t t-esc="data['special_diet']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>If yes, Give Details</strong></td>
|
|
<td colspan="2"><t t-esc="data['diet_detail']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>List of Allergies</strong></td>
|
|
<td colspan="2"><t t-esc="data['allergies']"/></td>
|
|
</tr>
|
|
</table>
|
|
</span>
|
|
|
|
<span><strong style="font-size:25px;">Contract and Commitment</strong>
|
|
<table class="table table-borderless">
|
|
<tr>
|
|
<td colspan="2"><strong>I acknowledge that the participation in this program will be paid by</strong></td>
|
|
<td colspan="2"><t t-esc="data['paid_by']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Name of person/party responsible for mentioned above</strong></td>
|
|
<td colspan="2"><t t-esc="data['paid_by_name']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Phone number of person to pay bill</strong></td>
|
|
<td colspan="2"><t t-esc="data['paid_by_phone']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Your email</strong></td>
|
|
<td colspan="2"><t t-esc="data['your_email']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Hospital Choice</strong></td>
|
|
<td colspan="2"><t t-esc="data['hospital_name']"/></td>
|
|
</tr>
|
|
<tr>
|
|
<td colspan="2"><strong>Digital Signature</strong></td>
|
|
<td colspan="2"><t t-esc="data['name']"/></td>
|
|
</tr>
|
|
</table>
|
|
</span>
|
|
|
|
</t>
|
|
</div>
|
|
</t>
|
|
</t>
|
|
</template>
|
|
|
|
</odoo>
|