contrib/forms/patient_intake_history/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8 ?>
   9
  10 <html>
  11 <head>
  12 <title>Patient intake history</title>
  13 <? include("../../acog_printable_v.css"); ?>
  14 </head>
  15
  16 <body>
  17 <?
  18    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  19    if ($fres){
  20      $patient = sqlFetchArray($fres);
  21    }
  22    $fres=sqlStatement("select * from form_patient_intake_history where id=$id");
  23    if ($fres){
  24      $fdata = sqlFetchArray($fres);
  25    }
  26    $fres=sqlStatement("select * from form_patient_intake_history_ros where id=".$fdata['linked_ros_id']);
  27    if ($fres){
  28      $fros = sqlFetchArray($fres);
  29    }
  30 ?>
  31   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  32     <tr>
  33       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  34     </tr>
  35     <tr>
  36       <td align="left" valign="bottom" nowrap class="fibody3"> <? echo (($fdata{'pih_patient'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  37       New patient </td>
  38     </tr>
  39     <tr>
  40       <td align="left" valign="bottom" nowrap class="fibody3"><? echo (($fdata{'pih_patient'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  41       Established patient </td>
  42     </tr>
  43     <tr>
  44       <td align="left" valign="bottom" nowrap class="fibody3"><? echo (($fdata{'pih_consultation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  45       Consultation</td>
  46     </tr>
  47     <tr>
  48       <td align="left" valign="bottom" nowrap class="fibody3"><? echo (($fdata{'pih_report_sent'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  49       Report sent: <? echo $fdata{'pih_report_sent_date'}; ?>&nbsp</td>
  50     </tr>
  51 </table>
  52 <div class="srvChapter">Patient Intake history</div>
  53 <div style="border: solid 1.5pt black; background-color: white;">
  54 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  55   <tr>
  56     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  57       <tr align="left" valign="bottom" class="fibody">
  58         <td width="40%" class="bordR">Patient name:<?
  59           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  60           ?>&nbsp</td>
  61         <td width="20%" class="bordR">Birth date: <?
  62           echo $patient{'DOB'};
  63           ?>&nbsp</td>
  64         <td width="20%" class="bordR">ID No: <?
  65           echo $patient{'id'};
  66           ?>&nbsp</td>
  67         <td width="20%">Date: <?
  68         echo date('Y-m-d');
  69         ?>&nbsp</td>
  70       </tr>
  71     </table>
  72 </td>
  73   </tr>
  74   <tr>
  75     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  76       <tr align="left" valign="bottom">
  77         <td colspan="3" class="fibody2">Address:<? echo $fdata{'address'}; ?>&nbsp</td></tr>
  78       <tr align="left" valign="bottom">
  79         <td width="50%" class="fibody2" id="bordR">City: <? echo $fdata{'city'}; ?>&nbsp</td>
  80         <td width="50%" colspan="2" class="fibody2">State/ZIP: <? echo $fdata{'state'}; ?>&nbsp</td>
  81       </tr>
  82       <tr align="left" valign="bottom">
  83         <td class="fibody2" id="bordR">Home telephone: <? echo $fdata{'home_phone'}; ?>&nbsp</td>
  84         <td colspan="2" class="fibody2">Work telephone: <? echo $fdata{'work_phone'}; ?>&nbsp</td>
  85       </tr>
  86       <tr align="left" valign="bottom">
  87         <td class="fibody2" id="bordR">Employer: <? echo $fdata{'employer'}; ?>&nbsp</td>
  88         <td width="25%" class="fibody2" id="bordR">Insurance: <? echo $fdata{'insurance'}; ?>&nbsp</td>
  89         <td width="25%" class="fibody2">Policy No: <? echo $fdata{'policy_no'}; ?>&nbsp</td>
  90       </tr>
  91       <tr align="left" valign="bottom">
  92         <td class="fibody2" id="bordR">Name you would like us to use: <? echo $fdata{'name_to_use'}; ?> </td>
  93         <td colspan="2" class="fibody2">Primary language: <? echo $fdata{'primary_language'}; ?>&nbsp</td>
  94       </tr>
  95     </table></td>
  96   </tr>
  97   <tr>
  98     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  99       <tr align="left" valign="bottom">
 100         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 101         <td colspan="2" class="fibody2">Emergency contact: <? echo $fdata{'partner_emergency_contact'}; ?>&nbsp</td>
 102         </tr>
 103       <tr align="left" valign="bottom">
 104         <td rowspan="2" valign="top" class="fibody2" id="bordR"><? echo $fdata{'partner_name'}; ?>&nbsp</td>
 105         <td colspan="2" class="fibody2">Relationship: <? echo $fdata{'relationship'}; ?>&nbsp</td>
 106         </tr>
 107       <tr align="left" valign="bottom">
 108         <td width="30%" class="fibody2" id="bordR">Home telephone:
 109           <? echo $fdata{'partner_home_phone'}; ?>&nbsp</td>
 110         <td width="30%" class="fibody2">Work telephone:
 111           <? echo $fdata{'partner_work_phone'}; ?>&nbsp</td>
 112       </tr>
 113     </table></td>
 114   </tr>
 115   <tr>
 116     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 117       <tr>
 118         <td align="left" valign="bottom" class="fibody2">Referred by:
 119           <? echo $fdata{'referred_by'}; ?>&nbsp</td>
 120       </tr>
 121       <tr>
 122         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 123           <? echo $fdata{'why_come_to_office'}; ?>&nbsp</td>
 124       </tr>
 125       <tr>
 126         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 127           <? echo (($fdata{'primary_care_visit'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 128           Primary care visit or
 129           <? echo (($fdata{'primary_care_visit'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 130           Gynecology only </td>
 131       </tr>
 132       <tr>
 133         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 134           <? echo (($fdata{'new_problem'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 135           yes &nbsp;&nbsp;&nbsp;&nbsp;
 136           <? echo (($fdata{'new_problem'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 137           no</td>
 138       </tr>
 139       <tr>
 140         <td align="left" valign="bottom" class="fibody2">Please, describe your problem, including, where it is, how severe it is, and how long it has lasted <br>
 141           <? echo $fdata{'problem_description'}; ?>&nbsp</td>
 142       </tr>
 143     </table></td>
 144   </tr>
 145 </table>
 146 </div>
 147 <h2 align="center"><small>If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.</small></h2>
 148 <p align="center">&nbsp;</p>
 149 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 150   </h2>
 151 <div style="border: solid 1.5pt black; background-color: white;">
 152     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 153       <tr>
 154         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 155           <tr align="left" valign="bottom">
 156             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 157             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 158           </tr>
 159           <tr align="left" valign="bottom">
 160             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 161               <? echo $fdata{'last_period_date'}; ?>&nbsp</td>
 162             <td class="fibody2"><? echo $fdata{'gh_notes_1'}; ?>&nbsp</td>
 163           </tr>
 164           <tr align="left" valign="bottom">
 165             <td nowrap class="fibody2" id="bordR">Age periods began:
 166               <? echo $fdata{'periods_began'}; ?>&nbsp</td>
 167             <td class="fibody2"><? echo $fdata{'gh_notes_2'}; ?>&nbsp</td>
 168           </tr>
 169           <tr align="left" valign="bottom">
 170             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 171               <? echo $fdata{'period_lenght'}; ?>&nbsp</td>
 172             <td class="fibody2"><? echo $fdata{'gh_notes_3'}; ?>&nbsp</td>
 173           </tr>
 174           <tr align="left" valign="bottom">
 175             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 176               <? echo $fdata{'period_days_between'}; ?>&nbsp</td>
 177             <td class="fibody2"><? echo $fdata{'gh_notes_4'}; ?>&nbsp</td>
 178           </tr>
 179           <tr align="left" valign="bottom">
 180             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 181               <? echo (($fdata{'period_changes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 182 Yes
 183 <? echo (($fdata{'pih_gh_recent_changes_periods'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 184 No</td>
 185             <td class="fibody2"><? echo $fdata{'gh_notes_5'}; ?>&nbsp</td>
 186           </tr>
 187           <tr align="left" valign="bottom">
 188             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 189               <? echo (($fdata{'sexually_active'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 190 Yes
 191 <? echo (($fdata{'sexually_active'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 192 No</td>
 193             <td class="fibody2"><? echo $fdata{'gh_notes_6'}; ?>&nbsp</td>
 194           </tr>
 195           <tr align="left" valign="bottom">
 196             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 197               <? echo (($fdata{'ever_had_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 198 Yes
 199 <? echo (($fdata{'ever_had_sex'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 200 No</td>
 201             <td class="fibody2"><? echo $fdata{'gh_notes_7'}; ?>&nbsp</td>
 202           </tr>
 203           <tr align="left" valign="bottom">
 204             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 205               <? echo $fdata{'number_of_partners'}; ?>&nbsp</td>
 206             <td class="fibody2"><? echo $fdata{'gh_notes_8'}; ?>&nbsp</td>
 207           </tr>
 208           <tr align="left" valign="bottom">
 209             <td nowrap class="fibody2" id="bordR">Sexual partners are
 210               <? echo (($fdata{'partners'} == 'men')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 211               Men
 212               <? echo (($fdata{'partners'} == 'women')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 213               Women
 214               <? echo (($fdata{'partners'} == 'both')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 215               Both </td>
 216             <td class="fibody2"><? echo $fdata{'gh_notes_9'}; ?>&nbsp</td>
 217           </tr>
 218           <tr align="left" valign="bottom">
 219             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 220               <? echo $fdata{'present_birth_control'}; ?>&nbsp</td>
 221             <td class="fibody2"><? echo $fdata{'gh_notes_10'}; ?>&nbsp</td>
 222           </tr>
 223           <tr align="left" valign="bottom">
 224             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 225               <? echo (($fdata{'pills_iud'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 226 Yes
 227 <? echo (($fdata{'pills_iud'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 228 No </td>
 229             <td class="fibody2"><? echo $fdata{'gh_notes_11'}; ?>&nbsp</td>
 230           </tr>
 231           <tr align="left" valign="bottom">
 232             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 233               <? echo $fdata{'pills_how_long'}; ?>&nbsp</td>
 234             <td class="fibody2"><? echo $fdata{'gh_notes_12'}; ?>&nbsp</td>
 235           </tr>
 236           <tr align="left" valign="bottom">
 237             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 238               <? echo $fdata{'pap_test'}; ?>&nbsp</td>
 239             <td class="fibody2"><? echo $fdata{'gh_notes_13'}; ?>&nbsp</td>
 240           </tr>
 241           <tr align="left" valign="bottom">
 242             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 243               <? echo (($fdata{'breast_self_exam'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 244               Yes
 245               <? echo (($fdata{'breast_self_exam'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 246               No</td>
 247             <td class="fibody2"><? echo $fdata{'gh_notes_14'}; ?>&nbsp</td>
 248           </tr>
 249           <tr align="left" valign="bottom">
 250             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 251               <? echo (($fdata{'des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 252 Yes
 253 <? echo (($fdata{'des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 254 No </td>
 255             <td class="fibody2"><? echo $fdata{'gh_notes_15'}; ?>&nbsp</td>
 256           </tr>
 257         </table></td>
 258       </tr>
 259     </table>
 260   </div>
 261   <p align="center">&nbsp;</p>
 262   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 263   </h2>
 264   <div style="border: solid 1.5pt black; background-color:#FFFFFF;">
 265     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 266       <tr>
 267         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 268             <tr align="left" valign="bottom">
 269               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 270               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 271               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 272               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 273               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 274               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 275             </tr>
 276             <tr align="left" valign="bottom">
 277               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 278               <td width="50" nowrap class="fibody2" id="bordR"><? echo $fdata{'oh_pregnancies'}; ?>&nbsp</td>
 279               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 280               <td width="50" nowrap class="fibody2" id="bordR"><? echo $fdata{'oh_abortions'}; ?>&nbsp</td>
 281               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 282               <td width="50" nowrap class="fibody2"><? echo $fdata{'oh_miscarriages'}; ?>&nbsp</td>
 283             </tr>
 284             <tr align="left" valign="bottom">
 285               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 286               <td width="50" nowrap class="fibody2" id="bordR"><? echo $fdata{'oh_premature_births'}; ?>&nbsp</td>
 287               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 288               <td width="50" nowrap class="fibody2" id="bordR"><? echo $fdata{'oh_live_births'}; ?>&nbsp</td>
 289               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 290               <td width="50" nowrap class="fibody2"><? echo $fdata{'oh_living_children'}; ?>&nbsp</td>
 291             </tr>
 292         </table></td>
 293       </tr>
 294       <tr>
 295         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 296             <tr align="center" valign="middle">
 297               <td class="ficaption2" id="bordR">No</td>
 298               <td class="ficaption2" id="bordR">birth date </td>
 299               <td class="ficaption2" id="bordR">weight at birth </td>
 300               <td class="ficaption2" id="bordR">baby's sex </td>
 301               <td class="ficaption2" id="bordR">weeks pregnant </td>
 302               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 303               <td class="ficaption2">physician's notes</td>
 304             </tr>
 305 <?
 306   $bi = 0;
 307   while ($bi<4) {
 308     $n = $bi+1;
 309     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 310     print <<<EOL
 311         <tr align="left" valign="bottom">
 312           <td nowrap class="fibody2" id="bordR">$n.</td>
 313           <td nowrap class="fibody2" id="bordR">${oh_ch_date}&nbsp;</td>
 314           <td nowrap class="fibody2" id="bordR">${oh_ch_width}&nbsp;</td>
 315           <td nowrap class="fibody2" id="bordR">${oh_ch_sex}&nbsp;</td>
 316           <td nowrap class="fibody2" id="bordR">${oh_ch_weeks}&nbsp;</td>
 317           <td nowrap class="fibody2" id="bordR">${oh_ch_delivery}&nbsp;</td>
 318           <td nowrap class="fibody2">${oh_ch_notes}&nbsp;</td>
 319         </tr>
 320 EOL;
 321      $bi++;
 322   }
 323 ?>
 324         </table></td>
 325       </tr>
 326       <tr>
 327         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 328             <tr align="left" valign="bottom">
 329               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 330               <td class="fibody2"><? echo $fdata{'oh_complications'}; ?>&nbsp</td>
 331             </tr>
 332         </table></td>
 333       </tr>
 334       <tr>
 335         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 336             <tr align="left" valign="bottom">
 337               <td colspan="2" class="fibody2"><? echo (($fdata{'oh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 338               diabetes
 339                 <? echo (($fdata{'oh_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 340               hypertension/high blood pressure
 341               <? echo (($fdata{'oh_preemclampsia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 342               preeclampsia/foxemia
 343               <? echo (($fdata{'oh_complic_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 344               other </td>
 345             </tr>
 346             <tr align="left" valign="bottom">
 347               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 348                   <? echo (($fdata{'oh_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 349               no
 350               <? echo (($fdata{'oh_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 351               yes, How treated </td>
 352               <td class="fibody2"><? echo $fdata{'oh_depression_treated'}; ?>&nbsp</td>
 353             </tr>
 354         </table></td>
 355       </tr>
 356     </table>
 357   </div>
 358   <p align="center">&nbsp;</p>
 359   <h2 align="center"><a name="cm"></a>Current medications <br>
 360     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 361   </h2>
 362   <div style="border: solid 1.5pt black; background-color: white;">
 363     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 364       <tr align="center">
 365         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 366         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 367         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 368         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 369         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 370         <td valign="top" class="ficaption2">Who prescribed</td>
 371       </tr>
 372 <?
 373   $bi = 0;
 374   while ($bi<5) {
 375   $bi2 = $bi+5;
 376       list ($pres_drug, $pres_dosage, $pres_who) = explode('|~', $fdata["pres_drug_rec_".$bi] );
 377       list ($pres_drug1, $pres_dosage1, $pres_who1) = explode('|~', $fdata["pres_drug_rec_".$bi2] );
 378     print <<<EOL
 379       <tr>
 380         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage}&nbsp;</td>
 381         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug}&nbsp;</td>
 382         <td align="left" valign="top" class="fibody2" id="bordR">${pres_who}&nbsp;</td>
 383         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug1}&nbsp;</td>
 384         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage1}&nbsp;</td>
 385         <td align="left" valign="top" class="fibody2">${pres_who1}&nbsp;</td>
 386       </tr>
 387 EOL;
 388      $bi++;
 389   }
 390 ?>
 391     </table>
 392   </div>
 393   <p align="center">&nbsp;</p>
 394   <h2 align="center"><a name="fh"></a>Family history <br>
 395   </h2>
 396   <div style="border: solid 1.5pt black; background-color: white;">
 397     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 398       <tr>
 399         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 400           <tr align="left" valign="bottom">
 401             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 402               <? echo (($fdata{'fh_mother'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 403               living
 404               <? echo (($fdata{'fh_mother'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 405               deceased - cause:
 406               <? echo $fdata{'fh_mother_dec_cause'}; ?>
 407               Age:
 408               <? echo $fdata{'fh_mother_dec_age'}; ?>&nbsp</td>
 409             <td width="50%" nowrap class="fibody2">father:
 410               <? echo (($fdata{'fh_father'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 411 living
 412 <? echo (($fdata{'fh_father'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 413 deceased - cause:
 414 <? echo $fdata{'fh_father_dec_cause'}; ?>
 415 Age:
 416 <? echo $fdata{'fh_father_dec_age'}; ?>&nbsp</td>
 417           </tr>
 418           <tr align="left" valign="bottom">
 419             <td nowrap class="fibody2">Siblings: Num.living:
 420               <? echo $fdata{'fh_sibl_living'}; ?>
 421               , num.deceased:
 422               <? echo $fdata{'fh_sib_deceased'}; ?>
 423               , cause(s)/age(s): </td>
 424             <td nowrap class="fibody2"><? echo $fdata{'fh_sib_dec_cause'}; ?>&nbsp</td>
 425           </tr>
 426           <tr align="left" valign="bottom">
 427             <td nowrap class="fibody2">Children: Num.living:
 428               <? echo $fdata{'fh_children_living'}; ?>
 429 , num.deceased:
 430 <? echo $fdata{'fh_children_deceased'}; ?>
 431 , cause(s)/age(s):</td>
 432             <td nowrap class="fibody2"><? echo $fdata{'fh_children_dec_cause'}; ?>&nbsp</td>
 433           </tr>
 434         </table></td>
 435       </tr>
 436       <tr>
 437         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 438           <tr valign="bottom">
 439             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 440             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 441             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 442             <td align="center" class="ficaption2">Physician's notes </td>
 443           </tr>
 444           <tr align="left" valign="bottom">
 445             <td nowrap class="fibody2" id="bordR">diabetes</td>
 446             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 447             <td class="fibody2" id="bordR"><? echo $fdata{'fh_diabetes_info'}; ?>&nbsp</td>
 448             <td class="fibody2"><? echo $fdata{'fh_notes_1'}; ?>&nbsp</td>
 449           </tr>
 450           <tr align="left" valign="bottom">
 451             <td nowrap class="fibody2" id="bordR">Stroke</td>
 452             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 453             <td class="fibody2" id="bordR"><? echo $fdata{'fh_stroke_info'}; ?>&nbsp</td>
 454             <td class="fibody2"><? echo $fdata{'fh_notes_2'}; ?>&nbsp</td>
 455           </tr>
 456           <tr align="left" valign="bottom">
 457             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 458             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_heart_disease'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 459             <td class="fibody2" id="bordR"> <? echo $fdata{'fh_heart_disease_info'}; ?>&nbsp</td>
 460             <td class="fibody2"><? echo $fdata{'fh_notes_3'}; ?>&nbsp</td>
 461           </tr>
 462           <tr align="left" valign="bottom">
 463             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 464             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fhbllod_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 465             <td class="fibody2" id="bordR"><? echo $fdata{'fhbllod_clots_info'}; ?>&nbsp</td>
 466             <td class="fibody2"><? echo $fdata{'fh_notes_4'}; ?>&nbsp</td>
 467           </tr>
 468           <tr align="left" valign="bottom">
 469             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 470             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 471             <td class="fibody2" id="bordR"><? echo $fdata{'fh_high_pressure_info'}; ?>&nbsp</td>
 472             <td class="fibody2"><? echo $fdata{'fh_notes_5'}; ?>&nbsp</td>
 473           </tr>
 474           <tr align="left" valign="bottom">
 475             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 476             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_high_cholesterol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 477             <td class="fibody2" id="bordR"><? echo $fdata{'fh_high_cholesterol_info'}; ?>&nbsp</td>
 478             <td class="fibody2"><? echo $fdata{'fh_notes_6'}; ?>&nbsp</td>
 479           </tr>
 480           <tr align="left" valign="bottom">
 481             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 482             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_osteoporosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 483             <td class="fibody2" id="bordR"><? echo $fdata{'fh_osteoporosis_info'}; ?>&nbsp</td>
 484             <td class="fibody2"><? echo $fdata{'fh_notes_7'}; ?>&nbsp</td>
 485           </tr>
 486           <tr align="left" valign="bottom">
 487             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 488             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 489             <td class="fibody2" id="bordR"><? echo $fdata{'fh_hepatitis_info'}; ?>&nbsp</td>
 490             <td class="fibody2"><? echo $fdata{'fh_notes_8'}; ?>&nbsp</td>
 491           </tr>
 492           <tr align="left" valign="bottom">
 493             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 494             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 495             <td class="fibody2" id="bordR"><? echo $fdata{'fh_hiv_info'}; ?>&nbsp</td>
 496             <td class="fibody2"><? echo $fdata{'fh_notes_9'}; ?>&nbsp</td>
 497           </tr>
 498           <tr align="left" valign="bottom">
 499             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 500             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_tuberculosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 501             <td class="fibody2" id="bordR"><? echo $fdata{'fh_tuberculosis_info'}; ?>&nbsp</td>
 502             <td class="fibody2"><? echo $fdata{'fh_notes_10'}; ?>&nbsp</td>
 503           </tr>
 504           <tr align="left" valign="bottom">
 505             <td nowrap class="fibody2" id="bordR">Birth defects </td>
 506             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'dh_birth_defects'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 507             <td class="fibody2" id="bordR"><? echo $fdata{'dh_birth_defects_info'}; ?>&nbsp</td>
 508             <td class="fibody2"><? echo $fdata{'fh_notes_11'}; ?>&nbsp</td>
 509           </tr>
 510           <tr align="left" valign="bottom">
 511             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
 512             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_alcohol_drugs'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 513             <td class="fibody2" id="bordR"><? echo $fdata{'fh_alcohol_drugs_info'}; ?>&nbsp</td>
 514             <td class="fibody2"><? echo $fdata{'fh_notes_12'}; ?>&nbsp</td>
 515           </tr>
 516           <tr align="left" valign="bottom">
 517             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
 518             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_breast_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 519             <td class="fibody2" id="bordR"><? echo $fdata{'fh_breast_cancer_info'}; ?>&nbsp</td>
 520             <td class="fibody2"><? echo $fdata{'fh_notes_13'}; ?>&nbsp</td>
 521           </tr>
 522           <tr align="left" valign="bottom">
 523             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
 524             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_colon_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 525             <td class="fibody2" id="bordR"><? echo $fdata{'fh_colon_cancer_info'}; ?>&nbsp</td>
 526             <td class="fibody2"><? echo $fdata{'fh_notes_14'}; ?>&nbsp</td>
 527           </tr>
 528           <tr align="left" valign="bottom">
 529             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
 530             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_ovarian_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 531             <td class="fibody2" id="bordR"><? echo $fdata{'fh_ovarian_cancer'}; ?>&nbsp</td>
 532             <td class="fibody2"><? echo $fdata{'fh_notes_15'}; ?>&nbsp</td>
 533           </tr>
 534           <tr align="left" valign="bottom">
 535             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
 536             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_uterine_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 537             <td class="fibody2" id="bordR"><? echo $fdata{'fh_uterine_cancer_info'}; ?>&nbsp</td>
 538             <td class="fibody2"><? echo $fdata{'fh_notes_16'}; ?>&nbsp</td>
 539           </tr>
 540           <tr align="left" valign="bottom">
 541             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
 542             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_mental_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 543             <td class="fibody2" id="bordR"><? echo $fdata{'fh_mental_illness_info'}; ?>&nbsp</td>
 544             <td class="fibody2"><? echo $fdata{'fh_notes_17'}; ?>&nbsp</td>
 545           </tr>
 546           <tr align="left" valign="bottom">
 547             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
 548             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_alzheimer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 549             <td class="fibody2" id="bordR"><? echo $fdata{'fh_alzheimer_info'}; ?>&nbsp</td>
 550             <td class="fibody2"><? echo $fdata{'fh_notes_18'}; ?>&nbsp</td>
 551           </tr>
 552           <tr align="left" valign="bottom">
 553             <td nowrap class="fibody2" id="bordR">Other</td>
 554             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'fh_other_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 555             <td class="fibody2" id="bordR"><? echo $fdata{'fh_other_illness_info'}; ?>&nbsp</td>
 556             <td class="fibody2"><? echo $fdata{'fh_notes_19'}; ?>&nbsp</td>
 557           </tr>
 558         </table></td>
 559       </tr>
 560     </table>
 561   </div>
 562   <p align="center">&nbsp;</p>
 563   <h2 align="center"><a name="sh"></a>Social history <br>
 564   </h2>
 565   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
 566     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 567       <tr>
 568         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 569           <tr align="left" valign="bottom">
 570             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
 571             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 572             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 573             <td align="center" class="ficaption2">physician's notes                           </td>
 574           </tr>
 575           <tr align="left" valign="bottom">
 576             <td nowrap class="fibody2" id="bordR">Ever smoked? Current smoking: packs/day:
 577               <? echo $fdata{'sh_smoked_packs'}; ?>
 578               , years:
 579               <? echo $fdata{'sh_smoked_years'}; ?>&nbsp</td>
 580             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_smoked'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 581             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_smoked'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 582             <td class="fibody2"><? echo $fdata{'sh_notes_1'}; ?>&nbsp</td>
 583           </tr>
 584           <tr align="left" valign="bottom">
 585             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
 586               <? echo $fdata{'sh_alcohol_drinks_day'}; ?>
 587               ,
 588               drinks/week:
 589               <? echo $fdata{'sh_alcohol_drinks_week'}; ?>
 590               ,
 591               type of drink:
 592               <? echo $fdata{'sh_alcohol_drinks_type'}; ?>&nbsp</td>
 593             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_alcohol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 594             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_alcohol'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 595             <td class="fibody2"><? echo $fdata{'sh_notes_2'}; ?>&nbsp</td>
 596           </tr>
 597           <tr align="left" valign="bottom">
 598             <td nowrap class="fibody2" id="bordR">Drug use </td>
 599             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_drug'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 600             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_drug'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 601             <td class="fibody2"><? echo $fdata{'sh_notes_3'}; ?>&nbsp</td>
 602           </tr>
 603           <tr align="left" valign="bottom">
 604             <td nowrap class="fibody2" id="bordR">seat belt use </td>
 605             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_seat_belt'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 606             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_seat_belt'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 607             <td class="fibody2"><? echo $fdata{'sh_notes_4'}; ?>&nbsp</td>
 608           </tr>
 609           <tr align="left" valign="bottom">
 610             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
 611               <? echo $fdata{'sh_exercise_info'}; ?>&nbsp</td>
 612             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 613             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_exercise'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 614             <td width="400" class="fibody2"><? echo $fdata{'sh_notes_5'}; ?>&nbsp</td>
 615           </tr>
 616           <tr align="left" valign="bottom">
 617             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
 618               <? echo $fdata{'sh_dairy_daily'}; ?>&nbsp</td>
 619             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_dairy'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 620             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_dairy'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 621             <td width="400" class="fibody2"><? echo $fdata{'sh_notes_6'}; ?>&nbsp</td>
 622           </tr>
 623           <tr align="left" valign="bottom">
 624             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
 625             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_hazards'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 626             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_hazards'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 627             <td width="400" class="fibody2"><? echo $fdata{'sh_notes_7'}; ?>&nbsp</td>
 628           </tr>
 629           <tr align="left" valign="bottom">
 630             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
 631             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_abuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 632             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_abuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 633             <td width="400" class="fibody2"><? echo $fdata{'sh_notes_8'}; ?>&nbsp</td>
 634           </tr>
 635           <tr align="left" valign="bottom">
 636             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
 637             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_living_will'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 638             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_living_will'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 639             <td class="fibody2"><? echo $fdata{'sh_notes_9'}; ?>&nbsp</td>
 640           </tr>
 641           <tr align="left" valign="bottom">
 642             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
 643             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_donor'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 644             <td align="center" valign="middle" class="fibody2" id="bordR"><? echo (($fdata{'pih_donor'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 645             <td class="fibody2"><? echo $fdata{'sh_notes_10'}; ?>&nbsp</td>
 646           </tr>
 647         </table></td>
 648       </tr>
 649     </table>
 650   </div>
 651   <p align="center">&nbsp;</p>
 652   <h2 align="center"><a name="pp"></a>Personal profile <br>
 653   </h2>
 654   <div style="border: solid 1.5pt black; background-color: white;">
 655     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 656       <tr>
 657         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
 658           <? echo (($fdata{'pih_pp_orientation'} == 'hetero')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 659         heterosexual
 660         <? echo (($fdata{'pih_pp_orientation'} == 'homo')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 661         homosexual
 662         <? echo (($fdata{'pih_pp_orientation'} == 'bi')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 663         bisexual </td>
 664       </tr>
 665       <tr>
 666         <td align="left" valign="bottom" class="fibody2">Marital status:
 667           <? echo (($fdata{'pih_pp_status'} == 'married')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 668         married
 669         &nbsp;&nbsp;
 670         <? echo (($fdata{'pih_pp_status'} == 'partner')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 671         living with partner&nbsp;&nbsp;        <? echo (($fdata{'pih_pp_status'} == 'single')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 672         single
 673         &nbsp;&nbsp;
 674         <? echo (($fdata{'pih_pp_status'} == 'widowed')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 675         widowed&nbsp;&nbsp;        <? echo (($fdata{'pih_pp_status'} == 'divorced')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 676         divorced </td>
 677       </tr>
 678       <tr>
 679         <td align="left" valign="bottom" class="fibody2">Number of living children:
 680         <? echo $fdata{'pp_living_children'}; ?>&nbsp</td>
 681       </tr>
 682       <tr>
 683         <td align="left" valign="bottom" class="fibody2">Number of people in household:
 684         <? echo $fdata{'pp_number_household'}; ?>&nbsp</td>
 685       </tr>
 686       <tr>
 687         <td align="left" valign="bottom" class="fibody2">School completed:
 688           <? echo (($fdata{'pih_pp_education'} == 'highschool')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 689         high school
 690         <? echo (($fdata{'pih_pp_education'} == 'aadegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 691         some college/AA degree
 692         <? echo (($fdata{'pih_pp_education'} == 'college')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 693         college
 694         <? echo (($fdata{'pih_pp_education'} == 'gdegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 695         graduate degree
 696         <? echo (($fdata{'pih_pp_education'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 697         other </td>
 698       </tr>
 699       <tr>
 700         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
 701         <? echo $fdata{'pp_current_job'}; ?>&nbsp</td>
 702       </tr>
 703       <tr>
 704         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
 705           <? echo (($fdata{'pp_travel_outside_us'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 706           yes
 707           <? echo (($fdata{'pp_travel_outside_us'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 708           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
 709           <? echo $fdata{'pp_travel_outside_locations'}; ?>
 710         </span></td>
 711       </tr>
 712     </table>
 713   </div>
 714   <p align="center">&nbsp;</p>
 715   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
 716   </h2>
 717   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
 718     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 719       <tr>
 720         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 721             <tr align="left" valign="bottom">
 722               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
 723               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
 724               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 725               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
 726               <td align="center" class="ficaption2">Physician's notes </td>
 727             </tr>
 728             <tr align="left" valign="bottom">
 729               <td nowrap class="fibody2" id="bordR">Asthma</td>
 730               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_asthma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 731                   <? echo $fdata{'pih_ih_asthma_date'}; ?>&nbsp</td>
 732               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_asthma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 733               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_asthma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 734               <td class="fibody2"><? echo $fdata{'ih_notes_1'}; ?>&nbsp</td>
 735             </tr>
 736             <tr align="left" valign="bottom">
 737               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
 738               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_pneumonia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 739                   <? echo $fdata{'pih_ih_pneumonia_date'}; ?>&nbsp</td>
 740               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_pneumonia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 741               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_pneumonia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 742               <td class="fibody2"><? echo $fdata{'ih_notes_2'}; ?>&nbsp</td>
 743             </tr>
 744             <tr align="left" valign="bottom">
 745               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
 746               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_kidney'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 747                   <? echo $fdata{'pih_ih_kidney_date'}; ?>&nbsp</td>
 748               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_kidney'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 749               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_kidney'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 750               <td class="fibody2"><? echo $fdata{'ih_notes_3'}; ?>&nbsp</td>
 751             </tr>
 752             <tr align="left" valign="bottom">
 753               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 754               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_tuber'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 755                   <? echo $fdata{'pih_ih_tuber_date'}; ?>&nbsp</td>
 756               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_tuber'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 757               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_tuber'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 758               <td class="fibody2"><? echo $fdata{'ih_notes_4'}; ?>&nbsp</td>
 759             </tr>
 760             <tr align="left" valign="bottom">
 761               <td nowrap class="fibody2" id="bordR">Fibroids</td>
 762               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_fibroids'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 763                   <? echo $fdata{'pih_ih_fibroids_date'}; ?>&nbsp</td>
 764               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_fibroids'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 765               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_fibroids'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 766               <td class="fibody2"><? echo $fdata{'ih_notes_5'}; ?>&nbsp</td>
 767             </tr>
 768             <tr align="left" valign="bottom">
 769               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
 770               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_sexually'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 771                   <? echo $fdata{'pih_ih_sexually_date'}; ?>&nbsp</td>
 772               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_sexually'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 773               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_sexually'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 774               <td class="fibody2"><? echo $fdata{'ih_notes_6'}; ?>&nbsp</td>
 775             </tr>
 776             <tr align="left" valign="bottom">
 777               <td nowrap class="fibody2" id="bordR">Infertility</td>
 778               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_infertil'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 779                   <? echo $fdata{'pih_ih_infertil_date'}; ?>&nbsp</td>
 780               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_infertil'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 781               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_infertil'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 782               <td class="fibody2"><? echo $fdata{'ih_notes_7'}; ?>&nbsp</td>
 783             </tr>
 784             <tr align="left" valign="bottom">
 785               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
 786               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 787                   <? echo $fdata{'pih_ih_hiv_date'}; ?>&nbsp</td>
 788               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hiv'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 789               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hiv'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 790               <td class="fibody2"><? echo $fdata{'ih_notes_8'}; ?>&nbsp</td>
 791             </tr>
 792             <tr align="left" valign="bottom">
 793               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
 794               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_heart'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 795                   <? echo $fdata{'pih_ih_heart_date'}; ?>&nbsp</td>
 796               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_heart'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 797               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_heart'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 798               <td class="fibody2"><? echo $fdata{'ih_notes_9'}; ?>&nbsp</td>
 799             </tr>
 800             <tr align="left" valign="bottom">
 801               <td nowrap class="fibody2" id="bordR">Diabetes</td>
 802               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 803                   <? echo $fdata{'pih_ih_diabetes_date'}; ?>&nbsp</td>
 804               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_diabetes'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 805               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_diabetes'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 806               <td class="fibody2"><? echo $fdata{'ih_notes_10'}; ?>&nbsp</td>
 807             </tr>
 808             <tr align="left" valign="bottom">
 809               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 810               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 811                   <? echo $fdata{'pih_ih_high_pressure_date'}; ?>&nbsp</td>
 812               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_high_pressure'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 813               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_high_pressure'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 814               <td class="fibody2"><? echo $fdata{'ih_notes_11'}; ?>&nbsp</td>
 815             </tr>
 816             <tr align="left" valign="bottom">
 817               <td nowrap class="fibody2" id="bordR">Stroke</td>
 818               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 819                   <? echo $fdata{'pih_ih_stroke_date'}; ?>&nbsp</td>
 820               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_stroke'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 821               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_stroke'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 822               <td class="fibody2"><? echo $fdata{'ih_notes_12'}; ?>&nbsp</td>
 823             </tr>
 824             <tr align="left" valign="bottom">
 825               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
 826               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_rheumatic'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 827                   <? echo $fdata{'pih_ih_rheumatic_date'}; ?>&nbsp</td>
 828               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_rheumatic'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 829               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_rheumatic'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 830               <td class="fibody2"><? echo $fdata{'ih_notes_13'}; ?>&nbsp</td>
 831             </tr>
 832             <tr align="left" valign="bottom">
 833               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 834               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 835                   <? echo $fdata{'pih_ih_blood_clots_date'}; ?>&nbsp</td>
 836               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_clots'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 837               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_clots'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 838               <td class="fibody2"><? echo $fdata{'ih_notes_14'}; ?>&nbsp</td>
 839             </tr>
 840             <tr align="left" valign="bottom">
 841               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
 842               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_eating_disorder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 843                   <? echo $fdata{'pih_ih_eating_disorder_date'}; ?>&nbsp</td>
 844               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_eating_disorder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 845               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_eating_disorder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 846               <td class="fibody2"><? echo $fdata{'ih_notes_15'}; ?>&nbsp</td>
 847             </tr>
 848             <tr align="left" valign="bottom">
 849               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
 850               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_autoimmune'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 851                   <? echo $fdata{'pih_ih_autoimmune_date'}; ?>&nbsp</td>
 852               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_autoimmune'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 853               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_autoimmune'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 854               <td class="fibody2"><? echo $fdata{'ih_notes_16'}; ?>&nbsp</td>
 855             </tr>
 856             <tr align="left" valign="bottom">
 857               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
 858               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_chickenpox'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 859                   <? echo $fdata{'pih_ih_chickenpox_date'}; ?>&nbsp</td>
 860               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_chickenpox'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 861               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_chickenpox'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 862               <td class="fibody2"><? echo $fdata{'ih_notes_17'}; ?>&nbsp</td>
 863             </tr>
 864             <tr align="left" valign="bottom">
 865               <td nowrap class="fibody2" id="bordR">Cancer</td>
 866               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 867                   <? echo $fdata{'pih_ih_cancer_date'}; ?>&nbsp</td>
 868               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cancer'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 869               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cancer'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 870               <td class="fibody2"><? echo $fdata{'ih_notes_18'}; ?>&nbsp</td>
 871             </tr>
 872             <tr align="left" valign="bottom">
 873               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
 874               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_reflux'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 875                   <? echo $fdata{'pih_ih_reflux_date'}; ?>&nbsp</td>
 876               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_reflux'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 877               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_reflux'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 878               <td class="fibody2"><? echo $fdata{'ih_notes_19'}; ?>&nbsp</td>
 879             </tr>
 880             <tr align="left" valign="bottom">
 881               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
 882               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 883                   <? echo $fdata{'pih_ih_depression_date'}; ?>&nbsp</td>
 884               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 885               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_depression'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 886               <td class="fibody2"><? echo $fdata{'ih_notes_20'}; ?>&nbsp</td>
 887             </tr>
 888             <tr align="left" valign="bottom">
 889               <td nowrap class="fibody2" id="bordR">Anemia</td>
 890               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_anemia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 891                   <? echo $fdata{'pih_ih_anemia_date'}; ?>&nbsp</td>
 892               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_anemia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 893               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_anemia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 894               <td class="fibody2"><? echo $fdata{'ih_notes_21'}; ?>&nbsp</td>
 895             </tr>
 896             <tr align="left" valign="bottom">
 897               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
 898               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_transf'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 899                   <? echo $fdata{'pih_ih_blood_transf_date'}; ?>&nbsp</td>
 900               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_transf'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 901               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_blood_transf'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 902               <td class="fibody2"><? echo $fdata{'ih_notes_22'}; ?>&nbsp</td>
 903             </tr>
 904             <tr align="left" valign="bottom">
 905               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
 906               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_seizures'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 907                   <? echo $fdata{'pih_ih_seizures_date'}; ?>&nbsp</td>
 908               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_seizures'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 909               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_seizures'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 910               <td class="fibody2"><? echo $fdata{'ih_notes_23'}; ?>&nbsp</td>
 911             </tr>
 912             <tr align="left" valign="bottom">
 913               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
 914               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bowel_problems'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 915                   <? echo $fdata{'pih_ih_bowel_problems_date'}; ?>&nbsp</td>
 916               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bowel_problems'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 917               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bowel_problems'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 918               <td class="fibody2"><? echo $fdata{'ih_notes_24'}; ?>&nbsp</td>
 919             </tr>
 920             <tr align="left" valign="bottom">
 921               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
 922               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_glaucoma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 923                   <? echo $fdata{'pih_ih_glaucoma_date'}; ?>&nbsp</td>
 924               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_glaucoma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 925               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_glaucoma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 926               <td class="fibody2"><? echo $fdata{'ih_notes_25'}; ?>&nbsp</td>
 927             </tr>
 928             <tr align="left" valign="bottom">
 929               <td nowrap class="fibody2" id="bordR">Cataracts</td>
 930               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cataracts'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 931                   <? echo $fdata{'pih_ih_cataracts_date'}; ?>&nbsp</td>
 932               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cataracts'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 933               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_cataracts'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 934               <td class="fibody2"><? echo $fdata{'ih_notes_26'}; ?>&nbsp</td>
 935             </tr>
 936             <tr align="left" valign="bottom">
 937               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
 938               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_joint_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 939                   <? echo $fdata{'pih_ih_joint_pain_date'}; ?>&nbsp</td>
 940               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_joint_pain'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 941               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_joint_pain'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 942               <td class="fibody2"><? echo $fdata{'ih_notes_27'}; ?>&nbsp</td>
 943             </tr>
 944             <tr align="left" valign="bottom">
 945               <td nowrap class="fibody2" id="bordR">Broken bones </td>
 946               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_broken_bones'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 947                   <? echo $fdata{'pih_ih_broken_bones_date'}; ?>&nbsp</td>
 948               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_broken_bones'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 949               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_broken_bones'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 950               <td class="fibody2"><? echo $fdata{'ih_notes_28'}; ?>&nbsp</td>
 951             </tr>
 952             <tr align="left" valign="bottom">
 953               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
 954               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 955                   <? echo $fdata{'pih_ih_hepatitis_date'}; ?>&nbsp</td>
 956               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hepatitis'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 957               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_hepatitis'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 958               <td class="fibody2"><? echo $fdata{'ih_notes_29'}; ?>&nbsp</td>
 959             </tr>
 960             <tr align="left" valign="bottom">
 961               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
 962               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_thyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 963                   <? echo $fdata{'pih_ih_thyroid_date'}; ?>&nbsp</td>
 964               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_thyroid'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 965               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_thyroid'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 966               <td class="fibody2"><? echo $fdata{'ih_notes_30'}; ?>&nbsp</td>
 967             </tr>
 968             <tr align="left" valign="bottom">
 969               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
 970               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_galibladder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 971                   <? echo $fdata{'pih_ih_galibladder_date'}; ?>&nbsp</td>
 972               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_galibladder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 973               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_galibladder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 974               <td class="fibody2"><? echo $fdata{'ih_notes_31'}; ?>&nbsp</td>
 975             </tr>
 976             <tr align="left" valign="bottom">
 977               <td nowrap class="fibody2" id="bordR">Headaches</td>
 978               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_headaches'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 979                   <? echo $fdata{'pih_ih_headaches_date'}; ?>&nbsp</td>
 980               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_headaches'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 981               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_headaches'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 982               <td class="fibody2"><? echo $fdata{'ih_notes_32'}; ?>&nbsp</td>
 983             </tr>
 984             <tr align="left" valign="bottom">
 985               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
 986               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 987                   <? echo $fdata{'pih_ih_des_date'}; ?>&nbsp</td>
 988               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 989               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_des'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 990               <td class="fibody2"><? echo $fdata{'ih_notes_33'}; ?>&nbsp</td>
 991             </tr>
 992             <tr align="left" valign="bottom">
 993               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
 994               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bleeding_disorders'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 995                   <? echo $fdata{'pih_ih_bleeding_disorders_date'}; ?>&nbsp</td>
 996               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bleeding_disorders'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 997               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_bleeding_disorders'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 998               <td class="fibody2"><? echo $fdata{'ih_notes_34'}; ?>&nbsp</td>
 999             </tr>
1000             <tr align="left" valign="bottom">
1001               <td nowrap class="fibody2" id="bordR">other</td>
1002               <td class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1003                   <? echo $fdata{'pih_ih_other_date'}; ?>&nbsp</td>
1004               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_other'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1005               <td align="center" class="fibody2" id="bordR"><? echo (($fdata{'pih_ih_other'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1006               <td class="fibody2"><? echo $fdata{'ih_notes_35'}; ?>&nbsp</td>
1007             </tr>
1008             <tr align="left" valign="bottom">
1009               <td colspan="5" nowrap class="fibody3"><? echo $fdata{'pih_ih_extended_info'}; ?>&nbsp</td>
1010             </tr>
1011         </table></td>
1012       </tr>
1013     </table>
1014   </div>
1015   <p align="center">&nbsp;</p>
1016   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
1017   </h2>
1018   <div style="border: solid 1.5pt black; background-color: white;">
1019     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1020       <tr>
1021         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
1022         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
1023         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
1024       </tr>
1025 <?
1026 $ii = 0;
1027 while ($ii<6){
1028 list ($op_reason, $op_date, $op_hospital)= explode('|~', $fdata["op_rec_".$ii] );
1029 print <<<EOL
1030       <tr>
1031         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_reason}&nbsp;</td>
1032         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_date}&nbsp;</td>
1033         <td align="left" valign="bottom" class="fibody2">${op_hospital}&nbsp;</td>
1034       </tr>
1035 EOL;
1036 $ii++;
1037 }
1038 ?>
1039     </table>
1040   </div>
1041   <p align="center">&nbsp;</p>
1042   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
1043   </h2>
1044   <div style="border: solid 1.5pt black; background-color: white;">
1045     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1046       <tr valign="bottom">
1047         <td align="left" class="ficaption2" id="bordR">Type</td>
1048         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
1049         <td align="left" class="ficaption2" id="bordR">Type</td>
1050         <td width="90" align="center" nowrap class="ficaption2">date</td>
1051       </tr>
1052 <?
1053 $ii = 0;
1054 while ($ii<6){
1055 $ij = $ii+6;
1056 list ($ii_type, $ii_date)= explode('|~', $fdata["ii_rec_".$ii] );
1057 list ($ii_type1, $ii_date1)= explode('|~', $fdata["ii_rec_".$ij] );
1058
1059 print <<<EOL
1060    <tr valign="bottom">
1061      <td align="left" class="fibody2" id="bordR">${ii_type}&nbsp;</td>
1062      <td align="left" nowrap class="fibody2" id="bordR">${ii_date}&nbsp;</td>
1063      <td align="left" class="fibody2" id="bordR">${ii_type1}&nbsp;</td>
1064      <td align="left" nowrap class="fibody2">${ii_date1}&nbsp;</td>
1065    </tr>
1066 EOL;
1067 $ii++;
1068 }
1069 ?>
1070     </table>
1071   </div>
1072   <p align="center">&nbsp;</p>
1073   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
1074   </h2>
1075   <div style="border: solid 1.5pt black; background-color: white;">
1076     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1077       <tr valign="bottom">
1078         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
1079         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
1080         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
1081         <td width="90" align="center" class="ficaption2">date</td>
1082       </tr>
1083       <tr valign="bottom">
1084         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
1085         <td align="left" nowrap class="fibody2" id="bordR">
1086           <? echo $fdata{'imm_tetanus'}; ?>&nbsp;</td>
1087         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
1088         <td align="left" valign="bottom" nowrap class="fibody2">
1089           <? echo $fdata{'imm_influenza'}; ?>&nbsp;</td>
1090       </tr>
1091       <tr valign="bottom">
1092         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
1093         <td align="left" nowrap class="fibody2" id="bordR">
1094           <? echo $fdata{'imm_hepatitis_a'}; ?>&nbsp;</td>
1095         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
1096         <td align="left" valign="bottom" nowrap class="fibody2">
1097           <? echo $fdata{'imm_hepatitis_b'}; ?>&nbsp;</td>
1098       </tr>
1099       <tr valign="bottom">
1100         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
1101         <td align="left" nowrap class="fibody2" id="bordR">
1102           <? echo $fdata{'imm_varicella'}; ?>&nbsp;</td>
1103         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
1104         <td align="left" valign="bottom" nowrap class="fibody2">
1105           <? echo $fdata{'imm_pneumococcal'}; ?>&nbsp;</td>
1106       </tr>
1107       <tr valign="bottom">
1108         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
1109         <td align="left" nowrap class="fibody2" id="bordR">
1110           <? echo $fdata{'imm_mmr'}; ?>&nbsp;</td>
1111         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
1112         <? echo $fdata{'imm_tuberculosis_skin'}; ?>&nbsp;
1113         , result:
1114         <? echo $fdata{'imm_tuberculosis_result'}; ?>&nbsp</td>
1115         <td align="left" valign="bottom" nowrap class="fibody2">
1116           <? echo $fdata{'imm_tuberculosis'}; ?>&nbsp;</td>
1117       </tr>
1118     </table>
1119   </div>
1120   <p align="center">&nbsp;</p>
1121   <div style="border: solid 1.5pt black; background-color: white;">
1122     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1123       <tr>
1124         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
1125         <? echo $fdata{'imm_extended_info'}; ?>&nbsp</td>
1126       </tr>
1127     </table>
1128   </div>
1129   <p align="center">&nbsp;</p>
1130   <h2 align="center"><a ></a>Review of systems<br>
1131     <small>Please check (x), if any of the following symptoms
1132 apply to you now or since adulthood</small> </h2>
1133   <div style="border: solid 2px black; background-color: white;">
1134     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1135       <tr>
1136         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
1137         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
1138         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
1139         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
1140         <td align="center" valign="top" class="ficaption2">physician's notes </td>
1141       </tr>
1142       <tr valign="bottom">
1143         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
1144         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1145         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1146         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1147         <td align="left" class="fibody2">&nbsp;</td>
1148       </tr>
1149       <tr valign="bottom">
1150         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
1151         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1152         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1153         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1154         <td align="left" class="fibody2"><? echo $fros{'ros_notes_1'}; ?></td>
1155       </tr>
1156       <tr valign="bottom">
1157         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
1158         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_gain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1159         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_gain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1160         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_weight_gain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1161         <td align="left" class="fibody2"><? echo $fros{'ros_notes_2'}; ?></td>
1162       </tr>
1163       <tr valign="bottom">
1164         <td align="left" class="fibody4"  id="bordR" >Fever</td>
1165         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fever_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1166         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fever_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1167         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fever_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1168         <td align="left" class="fibody2"><? echo $fros{'ros_notes_3'}; ?></td>
1169       </tr>
1170       <tr valign="bottom">
1171         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
1172         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fatigue_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1173         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fatigue_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1174         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_fatigue_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1175         <td align="left" class="fibody2"><? echo $fros{'ros_notes_4'}; ?></td>
1176       </tr>
1177       <tr valign="bottom">
1178         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
1179         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_height_change_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1180         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_height_change_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1181         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_height_change_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1182         <td align="left" class="fibody2"><? echo $fros{'ros_notes_5'}; ?></td>
1183       </tr>
1184       <tr valign="bottom">
1185         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
1186         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1187         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1188         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1189         <td align="left" class="fibody2">&nbsp;</td>
1190       </tr>
1191       <tr valign="bottom">
1192         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
1193         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dvision_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1194         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dvision_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1195         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dvision_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1196         <td align="left" class="fibody2"><? echo $fros{'ros_notes_6'}; ?></td>
1197       </tr>
1198       <tr valign="bottom">
1199         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
1200         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spots_eyes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1201         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spots_eyes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1202         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spots_eyes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1203         <td align="left" class="fibody2"><? echo $fros{'ros_notes_7'}; ?></td>
1204       </tr>
1205       <tr valign="bottom">
1206         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
1207         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vis_changes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1208         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vis_changes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1209         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vis_changes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1210         <td align="left" class="fibody2"><? echo $fros{'ros_notes_8'}; ?></td>
1211       </tr>
1212       <tr valign="bottom">
1213         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
1214         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_glasses_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1215         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_glasses_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1216         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_glasses_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1217         <td align="left" class="fibody2"><? echo $fros{'ros_notes_9'}; ?></td>
1218       </tr>
1219       <tr valign="bottom">
1220         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
1221         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1222         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1223         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1224         <td align="left" class="fibody2">&nbsp;</td>
1225       </tr>
1226       <tr valign="bottom">
1227         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
1228         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_earaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1229         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_earaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1230         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_earaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1231         <td align="left" class="fibody2"><? echo $fros{'ros_notes_10'}; ?></td>
1232       </tr>
1233       <tr valign="bottom">
1234         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
1235         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_ringing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1236         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_ringing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1237         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_ringing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1238         <td align="left" class="fibody2"><? echo $fros{'ros_notes_11'}; ?></td>
1239       </tr>
1240       <tr valign="bottom">
1241         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
1242         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hearing_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1243         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hearing_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1244         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hearing_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1245         <td align="left" class="fibody2"><? echo $fros{'ros_notes_12'}; ?></td>
1246       </tr>
1247       <tr valign="bottom">
1248         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
1249         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sinus_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1250         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sinus_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1251         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sinus_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1252         <td align="left" class="fibody2"><? echo $fros{'ros_notes_13'}; ?></td>
1253       </tr>
1254       <tr valign="bottom">
1255         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
1256         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sore_throat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1257         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sore_throat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1258         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sore_throat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1259         <td align="left" class="fibody2"><? echo $fros{'ros_notes_14'}; ?></td>
1260       </tr>
1261       <tr valign="bottom">
1262         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
1263         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_mouth_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1264         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_mouth_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1265         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_mouth_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1266         <td align="left" class="fibody2"><? echo $fros{'ros_notes_15'}; ?></td>
1267       </tr>
1268       <tr valign="bottom">
1269         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
1270         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dental_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1271         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dental_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1272         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dental_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1273         <td align="left" class="fibody2"><? echo $fros{'ros_notes_16'}; ?></td>
1274       </tr>
1275       <tr valign="bottom">
1276         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
1277         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1278         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1279         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1280         <td align="left" class="fibody2">&nbsp;</td>
1281       </tr>
1282       <tr valign="bottom">
1283         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
1284         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chest_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1285         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chest_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1286         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chest_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1287         <td align="left" class="fibody2"><? echo $fros{'ros_notes_17'}; ?></td>
1288       </tr>
1289       <tr valign="bottom">
1290         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
1291         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_difficulty_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1292         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_difficulty_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1293         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_difficulty_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1294         <td align="left" class="fibody2"><? echo $fros{'ros_notes_18'}; ?></td>
1295       </tr>
1296       <tr valign="bottom">
1297         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
1298         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_swelling_legs_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1299         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_swelling_legs_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1300         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_swelling_legs_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1301         <td align="left" class="fibody2"><? echo $fros{'ros_notes_19'}; ?></td>
1302       </tr>
1303       <tr valign="bottom">
1304         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
1305         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rapid_heartbeat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1306         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rapid_heartbeat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1307         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rapid_heartbeat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1308         <td align="left" class="fibody2"><? echo $fros{'ros_notes_20'}; ?></td>
1309       </tr>
1310       <tr valign="bottom">
1311         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
1312         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1313         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1314         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1315         <td align="left" class="fibody2">&nbsp;</td>
1316       </tr>
1317       <tr valign="bottom">
1318         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
1319         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1320         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1321         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1322         <td align="left" class="fibody2"><? echo $fros{'ros_notes_21'}; ?></td>
1323       </tr>
1324       <tr valign="bottom">
1325         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
1326         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_wheezing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1327         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_wheezing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1328         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_wheezing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1329         <td align="left" class="fibody2"><? echo $fros{'ros_notes_22'}; ?></td>
1330       </tr>
1331       <tr valign="bottom">
1332         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
1333         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spitting_blood_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1334         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spitting_blood_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1335         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_spitting_blood_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1336         <td align="left" class="fibody2"><? echo $fros{'ros_notes_23'}; ?></td>
1337       </tr>
1338       <tr valign="bottom">
1339         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
1340         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_breath_shortness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1341         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_breath_shortness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1342         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_breath_shortness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1343         <td align="left" class="fibody2"><? echo $fros{'ros_notes_24'}; ?></td>
1344       </tr>
1345       <tr valign="bottom">
1346         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
1347         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chronic_cough_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1348         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chronic_cough_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1349         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_chronic_cough_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1350         <td align="left" class="fibody2"><? echo $fros{'ros_notes_25'}; ?></td>
1351       </tr>
1352       <tr valign="bottom">
1353         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
1354         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1355         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1356         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1357         <td align="left" class="fibody2">&nbsp;</td>
1358       </tr>
1359       <tr valign="bottom">
1360         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
1361         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_diarrhea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1362         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_diarrhea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1363         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_diarrhea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1364         <td align="left" class="fibody2"><? echo $fros{'ros_notes_26'}; ?></td>
1365       </tr>
1366       <tr valign="bottom">
1367         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
1368         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_bloody_stool_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1369         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_bloody_stool_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1370         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_bloody_stool_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1371         <td align="left" class="fibody2"><? echo $fros{'ros_notes_27'}; ?></td>
1372       </tr>
1373       <tr valign="bottom">
1374         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
1375         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nausea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1376         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nausea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1377         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nausea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1378         <td align="left" class="fibody2"><? echo $fros{'ros_notes_28'}; ?></td>
1379       </tr>
1380       <tr valign="bottom">
1381         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
1382         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_constipation_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1383         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_constipation_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1384         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_constipation_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1385         <td align="left" class="fibody2"><? echo $fros{'ros_notes_29'}; ?></td>
1386       </tr>
1387       <tr valign="bottom">
1388         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
1389         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_gas_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1390         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_gas_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1391         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_gas_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1392         <td align="left" class="fibody2"><? echo $fros{'ros_notes_30'}; ?></td>
1393       </tr>
1394       <tr valign="bottom">
1395         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
1396         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1397         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1398         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1399         <td align="left" class="fibody2">&nbsp;</td>
1400       </tr>
1401       <tr valign="bottom">
1402         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
1403         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_blood_urine_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1404         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_blood_urine_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1405         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_blood_urine_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1406         <td align="left" class="fibody2"><? echo $fros{'ros_notes_31'}; ?></td>
1407       </tr>
1408       <tr valign="bottom">
1409         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
1410         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1411         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1412         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1413         <td align="left" class="fibody2"><? echo $fros{'ros_notes_32'}; ?></td>
1414       </tr>
1415       <tr valign="bottom">
1416         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
1417         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_urgency_urinate_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1418         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_urgency_urinate_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1419         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_urgency_urinate_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1420         <td align="left" class="fibody2"><? echo $fros{'ros_notes_33'}; ?></td>
1421       </tr>
1422       <tr valign="bottom">
1423         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
1424         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1425         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1426         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1427         <td align="left" class="fibody2"><? echo $fros{'ros_notes_34'}; ?></td>
1428       </tr>
1429       <tr valign="bottom">
1430         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
1431         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_incomplete_emptying_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1432         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_incomplete_emptying_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1433         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_incomplete_emptying_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1434         <td align="left" class="fibody2"><? echo $fros{'ros_notes_35'}; ?></td>
1435       </tr>
1436       <tr valign="bottom">
1437         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
1438         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_unint_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1439         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_unint_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1440         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_unint_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1441         <td align="left" class="fibody2"><? echo $fros{'ros_notes_36'}; ?></td>
1442       </tr>
1443       <tr valign="bottom">
1444         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
1445         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lifting_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1446         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lifting_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1447         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lifting_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1448         <td align="left" class="fibody2"><? echo $fros{'ros_notes_37'}; ?></td>
1449       </tr>
1450       <tr valign="bottom">
1451         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
1452         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1453         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1454         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1455         <td align="left" class="fibody2"><? echo $fros{'ros_notes_38'}; ?></td>
1456       </tr>
1457       <tr valign="bottom">
1458         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
1459         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_periods_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1460         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_periods_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1461         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_periods_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1462         <td align="left" class="fibody2"><? echo $fros{'ros_notes_39'}; ?></td>
1463       </tr>
1464       <tr valign="bottom">
1465         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
1466         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pms_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1467         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pms_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1468         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pms_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1469         <td align="left" class="fibody2"><? echo $fros{'ros_notes_40'}; ?></td>
1470       </tr>
1471       <tr valign="bottom">
1472         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
1473         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_intercourse_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1474         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_intercourse_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1475         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_painful_intercourse_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1476         <td align="left" class="fibody2"><? echo $fros{'ros_notes_41'}; ?></td>
1477       </tr>
1478       <tr valign="bottom">
1479         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
1480         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vaginal_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1481         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vaginal_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1482         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_vaginal_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1483         <td align="left" class="fibody2"><? echo $fros{'ros_notes_42'}; ?></td>
1484       </tr>
1485       <tr valign="bottom">
1486         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
1487         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1488         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1489         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1490         <td align="left" class="fibody2">&nbsp;</td>
1491       </tr>
1492       <tr valign="bottom">
1493         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
1494         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_weakness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1495         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_weakness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1496         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_weakness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1497         <td align="left" class="fibody2"><? echo $fros{'ros_notes_43'}; ?></td>
1498       </tr>
1499       <tr valign="bottom">
1500         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
1501         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1502         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1503         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_muscle_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1504         <td align="left" class="fibody2"><? echo $fros{'ros_notes_44'}; ?></td>
1505       </tr>
1506       <tr valign="bottom">
1507         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
1508         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1509         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1510         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1511         <td align="left" class="fibody2">&nbsp;</td>
1512       </tr>
1513       <tr valign="bottom">
1514         <td align="left" class="fibody4"  id="bordR" >Rash</td>
1515         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rash_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1516         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rash_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1517         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_rash_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1518         <td align="left" class="fibody2"><? echo $fros{'ros_notes_45'}; ?></td>
1519       </tr>
1520       <tr valign="bottom">
1521         <td align="left" class="fibody4"  id="bordR" >Sores</td>
1522         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1523         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1524         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1525         <td align="left" class="fibody2"><? echo $fros{'ros_notes_46'}; ?></td>
1526       </tr>
1527       <tr valign="bottom">
1528         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
1529         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dry_skin_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1530         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dry_skin_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1531         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dry_skin_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1532         <td align="left" class="fibody2"><? echo $fros{'ros_notes_47'}; ?></td>
1533       </tr>
1534       <tr valign="bottom">
1535         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
1536         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_moles_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1537         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_moles_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1538         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_moles_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1539         <td align="left" class="fibody2"><? echo $fros{'ros_notes_48'}; ?></td>
1540       </tr>
1541       <tr valign="bottom">
1542         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
1543         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1544         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1545         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1546         <td align="left" class="fibody2">&nbsp;</td>
1547       </tr>
1548       <tr valign="bottom">
1549         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
1550         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_breast_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1551         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_breast_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1552         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_pain_breast_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1553         <td align="left" class="fibody2"><? echo $fros{'ros_notes_49'}; ?></td>
1554       </tr>
1555       <tr valign="bottom">
1556         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
1557         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nipple_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1558         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nipple_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1559         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_nipple_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1560         <td align="left" class="fibody2"><? echo $fros{'ros_notes_50'}; ?></td>
1561       </tr>
1562       <tr valign="bottom">
1563         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
1564         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lumps_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1565         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lumps_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1566         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_lumps_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1567         <td align="left" class="fibody2"><? echo $fros{'ros_notes_51'}; ?></td>
1568       </tr>
1569       <tr valign="bottom">
1570         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
1571         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1572         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1573         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1574         <td align="left" class="fibody2">&nbsp;</td>
1575       </tr>
1576       <tr valign="bottom">
1577         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
1578         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dizziness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1579         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dizziness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1580         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_dizziness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1581         <td align="left" class="fibody2"><? echo $fros{'ros_notes_52'}; ?></td>
1582       </tr>
1583       <tr valign="bottom">
1584         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
1585         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_seizures_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1586         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_seizures_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1587         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_seizures_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1588         <td align="left" class="fibody2"><? echo $fros{'ros_notes_53'}; ?></td>
1589       </tr>
1590       <tr valign="bottom">
1591         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
1592         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_numbness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1593         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_numbness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1594         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_numbness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1595         <td align="left" class="fibody2"><? echo $fros{'ros_notes_54'}; ?></td>
1596       </tr>
1597       <tr valign="bottom">
1598         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
1599         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_trouble_walking_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1600         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_trouble_walking_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1601         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_trouble_walking_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1602         <td align="left" class="fibody2"><? echo $fros{'ros_notes_55'}; ?></td>
1603       </tr>
1604       <tr valign="bottom">
1605         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
1606         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_memory_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1607         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_memory_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1608         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_memory_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1609         <td align="left" class="fibody2"><? echo $fros{'ros_notes_56'}; ?></td>
1610       </tr>
1611       <tr valign="bottom">
1612         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
1613         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_freq_headaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1614         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_freq_headaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1615         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_freq_headaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1616         <td align="left" class="fibody2"><? echo $fros{'ros_notes_57'}; ?></td>
1617       </tr>
1618       <tr valign="bottom">
1619         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
1620         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1621         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1622         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1623         <td align="left" class="fibody2">&nbsp;</td>
1624       </tr>
1625       <tr valign="bottom">
1626         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
1627         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_depression_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1628         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_depression_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1629         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_depression_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1630         <td align="left" class="fibody2"><? echo $fros{'ros_notes_58'}; ?></td>
1631       </tr>
1632       <tr valign="bottom">
1633         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
1634         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_anxiety_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1635         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_anxiety_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1636         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_anxiety_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1637         <td align="left" class="fibody2"><? echo $fros{'ros_notes_59'}; ?></td>
1638       </tr>
1639       <tr valign="bottom">
1640         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
1641         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1642         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1643         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1644         <td align="left" class="fibody2">&nbsp;</td>
1645       </tr>
1646       <tr valign="bottom">
1647         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
1648         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hair_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1649         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hair_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1650         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hair_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1651         <td align="left" class="fibody2"><? echo $fros{'ros_notes_60'}; ?></td>
1652       </tr>
1653       <tr valign="bottom">
1654         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
1655         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_heat_cold_intolerance_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1656         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_heat_cold_intolerance_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1657         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_heat_cold_intolerance_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1658         <td align="left" class="fibody2"><? echo $fros{'ros_notes_61'}; ?></td>
1659       </tr>
1660       <tr valign="bottom">
1661         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
1662         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_thirst_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1663         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_thirst_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1664         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_abnormal_thirst_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1665         <td align="left" class="fibody2"><? echo $fros{'ros_notes_62'}; ?></td>
1666       </tr>
1667       <tr valign="bottom">
1668         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
1669         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hot_flashes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1670         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hot_flashes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1671         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_hot_flashes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1672         <td align="left" class="fibody2"><? echo $fros{'ros_notes_63'}; ?></td>
1673       </tr>
1674       <tr valign="bottom">
1675         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
1676         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1677         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1678         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1679         <td align="left" class="fibody2">&nbsp;</td>
1680       </tr>
1681       <tr valign="bottom">
1682         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
1683         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_bruises_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1684         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_bruises_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1685         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_frequent_bruises_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1686         <td align="left" class="fibody2"><? echo $fros{'ros_notes_64'}; ?></td>
1687       </tr>
1688       <tr valign="bottom">
1689         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
1690         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_cuts_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1691         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_cuts_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1692         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_cuts_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1693         <td align="left" class="fibody2"><? echo $fros{'ros_notes_65'}; ?></td>
1694       </tr>
1695       <tr valign="bottom">
1696         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
1697         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_enlarged_nodes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1698         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_enlarged_nodes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1699         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_enlarged_nodes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1700         <td align="left" class="fibody2"><? echo $fros{'ros_notes_66'}; ?></td>
1701       </tr>
1702       <tr valign="bottom">
1703         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
1704         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1705         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1706         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1707         <td align="left" class="fibody2">&nbsp;</td>
1708       </tr>
1709       <tr valign="bottom">
1710         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
1711         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_med_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1712         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_med_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1713         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_med_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1714         <td align="left" class="fibody2"><? echo $fros{'ros_notes_68'}; ?></td>
1715       </tr>
1716       <tr valign="bottom">
1717         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
1718         <td colspan="4" align="left" class="fibody2"><? echo $fros{'ros_med_allergy_reaction'}; ?></td>
1719       </tr>
1720       <tr valign="bottom">
1721         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
1722         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_latex_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1723         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_latex_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1724         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_latex_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1725         <td align="left" class="fibody2"><? echo $fros{'ros_notes_69'}; ?></td>
1726       </tr>
1727       <tr valign="bottom">
1728         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
1729         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_other_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1730         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_other_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1731         <td align="center" class="fibody2"  id="bordR" ><? echo (($fros{'ros_other_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1732         <td align="left" class="fibody2"><? echo $fros{'ros_notes_70'}; ?></td>
1733       </tr>
1734       <tr valign="bottom">
1735         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
1736         <td colspan="4" align="left" class="fibody2"><? echo $fros{'ros_other_allergy_reaction_'}; ?></td>
1737       </tr>
1738     </table>
1739   </div>
1740   <p align="center">&nbsp;</p>
1741   <div style="border: solid 2px black; background-color: white;">
1742     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1743       <tr valign="bottom">
1744         <td colspan="2" align="left" class="fibody2">Form completed by
1745           <? echo (($fdata{'pih_completed_by'} == 'patient')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1746         patient
1747         <? echo (($fdata{'pih_completed_by'} == 'nurse')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1748         office nurse
1749         <? echo (($fdata{'pih_completed_by'} == 'physician')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1750         physician
1751         <? echo (($fdata{'pih_completed_by'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1752         other:
1753         <? echo $fdata{'pih_completed_by_other'}; ?>&nbsp</td>
1754       </tr>
1755       <tr valign="bottom">
1756         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
1757       </tr>
1758       <tr valign="bottom">
1759         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
1760         <? echo $fdata{'pih_date_reviewed_1'}; ?>&nbsp</td>
1761         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
1762       </tr>
1763       <tr valign="bottom">
1764         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
1765       </tr>
1766       <tr valign="bottom">
1767         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1768           <? echo $fdata{'pih_date_reviewed_2'}; ?>
1769         </span></td>
1770         <td height="46" align="left" class="fibody2">Physician signature: </td>
1771       </tr>
1772       <tr valign="bottom">
1773         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1774           <? echo $fdata{'pih_date_reviewed_3'}; ?>
1775         </span> </td>
1776         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1777       </tr>
1778       <tr valign="bottom">
1779         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1780           <? echo $fdata{'pih_date_reviewed_4'}; ?>
1781         </span> </td>
1782         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1783       </tr>
1784       <tr valign="bottom">
1785         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1786           <? echo $fdata{'pih_date_reviewed_5'}; ?>
1787         </span> </td>
1788         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1789       </tr>
1790       <tr valign="bottom">
1791         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1792           <? echo $fdata{'pih_date_reviewed_6'}; ?>
1793         </span> </td>
1794         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1795       </tr>
1796     </table>
1797   </div>
1798   <p align="center">&nbsp;</p>
1799 </body>
1800 </html>