contrib/forms/physician_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>Physician history</title>
  13
  14 <?
  15    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  16    if ($fres){
  17      $patient = sqlFetchArray($fres);
  18    }
  19
  20    $fres=sqlStatement("select * from form_physician_history where id='".$id."'");
  21    if ($fres){
  22      $fdata = sqlFetchArray($fres);
  23    }
  24 ?>
  25 <? include("../../acog_printable_v.css"); ?>
  26 </head>
  27
  28 <body>
  29 <table width="70%"  border="0" cellspacing="0" cellpadding="4" style="">
  30   <tr>
  31     <td width="120" align="left" valign="top" class="srvCaption">Patient name:</td>
  32     <td align="left" valign="top" class="fibody5"><?  echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};?></td>
  33   </tr>
  34   <tr>
  35     <td width="120" align="left" valign="top" class="srvCaption">Birth date: </td>
  36     <td align="left" valign="top" class="fibody5"><?          echo $patient{'DOB'};          ?></td>
  37   </tr>
  38   <tr>
  39     <td width="120" align="left" valign="top" class="srvCaption">ID No:</td>
  40     <td align="left" valign="top" class="fibody5"><?          echo $patient{'id'};          ?></td>
  41   </tr>
  42   <tr>
  43     <td width="120" align="left" valign="top" class="srvCaption">Date</td>
  44     <td align="left" valign="top" class="fibody5"><?        echo $fdata['date'];        ?></td>
  45   </tr>
  46 </table>
  47 <div class="srvChapter">Physician history</div>
  48 <div style="border: solid 2px black; background-color:#FFFFFF;">
  49 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  50   <tr>
  51     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  52       <tr align="left" valign="baseline">
  53         <td width="25%" class="fibody2" id="bordR"><? echo (($fdata{'established'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  54           New patient </td>
  55         <td width="25%" class="fibody2" id="bordR"><? echo (($fdata{'established'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  56           Established patient </td>
  57         <td width="20%"   class="fibody2" id="bordR"><? echo (($fdata{'consultation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  58           Consultation</td>
  59         <td width="30%" valign="top" class="fibody2"><? echo (($fdata{'report_sent'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?> Report sent <? echo $fdata{'report_sent_date'}; ?></td>
  60         </tr>
  61       <tr align="left" valign="top">
  62         <td colspan="2" class="fibody2" id="bordR">Primary care physician:<br>
  63           <? echo $fdata{'primary_care'}; ?></td>
  64         <td colspan="2" class="fibody2">Who sent patient:<br>
  65           <? echo $fdata{'who_sent'}; ?></td>
  66       </tr>
  67       <tr align="left" valign="top">
  68         <td colspan="2" class="fibody2" id="bordR"> Other physician(s):<br> <? echo $fdata{'other_physician'}; ?> </td>
  69         <td colspan="2" class="fibody2">&nbsp;</td>
  70       </tr>
  71     </table></td>
  72   </tr>
  73   <tr>
  74     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  75       <tr align="left" valign="baseline">
  76         <td width="50%" class="ficaption2" id="bordR">Chief complaint (CC) (<small>Required for all visits except preventive</small>):</td>
  77         <td width="50%" class="ficaption2">Current prescription medications:          </td>
  78       </tr>
  79       <tr align="left" valign="baseline">
  80         <td width="50%"   class="fibody5" id="bordR"><? echo $fdata{'chief_complaint'}; ?> &nbsp;</td>
  81         <td width="50%"   class="fibody5"><? echo $fdata{'current_prescription'}; ?> &nbsp;</td>
  82       </tr>
  83       <tr align="left" valign="baseline">
  84         <td width="50%" valign="top" class="ficaption2" id="bordR">History of present ilness (HPI): <br> </td>
  85         <td width="50%" valign="top" class="ficaption2">Current nonpresription, complementary, and alternative medications:          </td>
  86       </tr>
  87       <tr align="left" valign="baseline">
  88         <td width="50%" valign="top"   class="fibody5" id="bordR"><? echo $fdata{'hpi'}; ?>&nbsp;</td>
  89         <td width="50%" valign="top"   class="fibody5"><? echo $fdata{'current_nonprescription'}; ?>&nbsp;</td>
  90       </tr>
  91     </table></td>
  92   </tr>
  93   <tr>
  94     <td class="fibody2">&nbsp;</td>
  95   </tr>
  96   <tr>
  97     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  98       <tr align="left" valign="top">
  99         <td width="200" class="ficaption2">Changes since last visit </td>
 100         <td width="40" align="center" class="ficaption2">yes</td>
 101         <td width="40" align="center" class="ficaption2" id="bordR">no</td>
 102         <td colspan="2" align="center" class="ficaption2">Notes</td>
 103         </tr>
 104       <tr align="left" valign="top">
 105         <td width="200" class="fibody2">Illnesses</td>
 106         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_ill'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 107         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_ill'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 108         <td colspan="2" rowspan="7" valign="top" class="fibody5"><? echo $fdata{'ph_lvch_notes'}; ?>&nbsp;</td>
 109         </tr>
 110       <tr align="left" valign="top">
 111         <td width="200" class="fibody2">Surgery</td>
 112         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_surg'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 113         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_surg'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 114       </tr>
 115       <tr align="left" valign="top">
 116         <td width="200" class="fibody2">New medications </td>
 117         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_newmed'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 118         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_newmed'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 119       </tr>
 120       <tr align="left" valign="top">
 121         <td width="200" class="fibody2">Change in family history </td>
 122         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_famhist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 123         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_famhist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 124       </tr>
 125       <tr align="left" valign="top">
 126         <td width="200" class="fibody2">New allergies </td>
 127         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_newallerg'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 128         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_newallerg'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 129       </tr>
 130       <tr align="left" valign="top">
 131         <td width="200" class="fibody2">Change in gynecologic history </td>
 132         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_gynhist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 133         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_gynhist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 134       </tr>
 135       <tr align="left" valign="top">
 136         <td width="200" class="fibody2">Change in obstetric history </td>
 137         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_obsthist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 138         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_obsthist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 139       </tr>
 140     </table></td>
 141   </tr>
 142   <tr>
 143     <td class="fibody2">&nbsp;</td>
 144   </tr>
 145   <tr>
 146     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 147       <tr align="left" valign="top">
 148         <td width="225" class="fibody2"><a name="allergies"></a>Allergies (describe reaction):
 149           <? echo (($fdata{'ph_allergies_none'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 150 none</td>
 151         <td class="fibody5"><? echo $fdata{'ph_allergies_data'}; ?></td>
 152       </tr>
 153     </table></td>
 154     </tr>
 155   <tr>
 156     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 157       <tr align="left" valign="top">
 158         <td width="70%" class="fibody2" id="bordR">Last cervical cancer screening:
 159           <? echo (($fdata{'cancer_scr_cytology'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 160           Cytology
 161           <? echo $fdata{'cancer_scr_cytology_date'}; ?>
 162           <? echo (($fdata{'cancer_scr_hpv'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 163           HPV test
 164           <? echo $fdata{'cancer_scr_hpv_date'}; ?></td>
 165         <td width="30%" class="fibody5"><? echo $fdata{'cancer_scr_notes'}; ?></td>
 166       </tr>
 167       <tr align="left" valign="top">
 168         <td width="70%" class="fibody2" id="bordR">last mammogram:
 169           <? echo $fdata{'last_mammogram'}; ?></td>
 170         <td class="fibody5"><? echo $fdata{'last_mammogram_notes'}; ?></td>
 171       </tr>
 172       <tr align="left" valign="top">
 173         <td width="70%" class="fibody2" id="bordR">Last colorectal screening:
 174           <? echo $fdata{'last_colorectal'}; ?></td>
 175         <td class="fibody5"><? echo $fdata{'last_colorectal_notes'}; ?></td>
 176       </tr>
 177     </table></td>
 178   </tr>
 179 </table>
 180 </div>
 181 <p>&nbsp;</p>
 182 <h2 align="center"><a name="gh"></a>Gynecologic history (PH)</h2>
 183 <div style="border: solid 2px black; background-color:#FFFFFF;">
 184   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 185     <tr align="left" valign="top">
 186       <td colspan="4"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 187         <tr align="left" valign="top">
 188           <td   class="fibody2">Imp</td>
 189           <td   class="fibody2"><? echo $fdata{'gh_imp'}; ?></td>
 190           <td   class="fibody2">Age at menarche </td>
 191           <td   class="fibody2"><? echo $fdata{'gh_age_at_menarche'}; ?></td>
 192           <td   class="fibody2">Length of flow </td>
 193           <td   class="fibody2"><? echo $fdata{'gh_length_of_flow'}; ?></td>
 194           <td   class="fibody2">Interval between periods </td>
 195           <td   class="fibody2"><? echo $fdata{'gh_interval_periods'}; ?></td>
 196           <td   class="fibody2">Recent changes </td>
 197           <td   class="fibody2"><? echo $fdata{'gh_recent_changes'}; ?></td>
 198         </tr>
 199       </table></td>
 200     </tr>
 201     <tr align="left" valign="top">
 202       <td colspan="4"   class="fibody2">Sexually active:
 203         <? echo (($fdata{'gh_sexually_active'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 204         Yes
 205         <? echo (($fdata{'gh_sexually_active'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 206         No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ever had sex:
 207         <? echo (($fdata{'gh_had_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 208 Yes
 209 <? echo (($fdata{'gh_had_sex'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 210 No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Number of partners (Lifetime)
 211 <? echo $fdata{'gh_partners'}; ?></td>
 212       </tr>
 213     <tr align="left" valign="top">
 214       <td colspan="4"   class="fibody2">Partners are:
 215         <? echo (($fdata{'gh_partners_are'} == 'men')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 216         men
 217         <? echo (($fdata{'gh_partners_are'} == 'women')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 218         women
 219         <? echo (($fdata{'ph_gh_partners_are'} == 'both')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 220         both</td>
 221       </tr>
 222     <tr align="left" valign="top">
 223       <td width="202" nowrap class="fibody2">Current method of contraception: </td>
 224       <td width="30%"   class="fibody5"><? echo $fdata{'gh_method_contraception'}; ?>&nbsp;</td>
 225       <td width="161" nowrap class="fibody2">Past contraceptive history:</td>
 226       <td width="34%"   class="fibody5"><? echo $fdata{'gh_contraceptive_history'}; ?>&nbsp;</td>
 227     </tr>
 228   </table>
 229 </div>
 230 <p>&nbsp;</p>
 231 <h2 align="center"><a name="oh"></a>Obstetric history (PH)</h2>
 232 <div style="border: solid 2px black; background-color:#FFFFFF; page-break-after: always;">
 233   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 234     <tr>
 235       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 236         <tr align="left" valign="top">
 237           <td width="30%"   class="fibody2" id="bordR">&nbsp;</td>
 238           <td width="50" align="center"   class="ficaption2" id="bordR">Number</td>
 239           <td width="30%" align="center"   class="fibody2" id="bordR">&nbsp;</td>
 240           <td width="50" align="center"   class="ficaption2" id="bordR">Number</td>
 241           <td width="30%" align="center"   class="fibody2" id="bordR">&nbsp;</td>
 242           <td width="50" align="center"   class="ficaption2">Number</td>
 243         </tr>
 244         <tr align="left" valign="top">
 245           <td width="30%"   class="fibody2" id="bordR">Pregnancies</td>
 246           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_pregnancies'}; ?></td>
 247           <td width="30%"   class="fibody2" id="bordR">abortions</td>
 248           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_abortions'}; ?></td>
 249           <td width="30%"   class="fibody2" id="bordR">miscarriages</td>
 250           <td width="50" align="center"   class="fibody2"><? echo $fdata{'oh_miscarriages'}; ?></td>
 251         </tr>
 252         <tr align="left" valign="top">
 253           <td width="30%"   class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 254           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_premature_births'}; ?></td>
 255           <td width="30%"   class="fibody2" id="bordR">live births </td>
 256           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_live_births'}; ?></td>
 257           <td width="30%"   class="fibody2" id="bordR">living children </td>
 258           <td width="50" align="center"   class="fibody2"><? echo $fdata{'oh_living_children'}; ?></td>
 259         </tr>
 260       </table></td>
 261     </tr>
 262     <tr>
 263       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 264         <tr align="center" valign="middle">
 265           <td class="ficaption2" id="bordR">No</td>
 266           <td class="ficaption2" id="bordR">birth date </td>
 267           <td class="ficaption2" id="bordR">weight at birth </td>
 268           <td class="ficaption2" id="bordR">baby's sex </td>
 269           <td class="ficaption2" id="bordR">weeks pregnant </td>
 270           <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 271           <td class="ficaption2">physician's notes</td>
 272         </tr>
 273 <?
 274   $bi = 0;
 275   while ($bi<4) {
 276     $n = $bi+1;
 277     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 278     print <<<EOL
 279         <tr align="left" valign="top">
 280           <td   class="fibody2" id="bordR">$n.</td>
 281           <td   class="fibody2" id="bordR">${oh_ch_date}&nbsp;</td>
 282           <td   class="fibody2" id="bordR">${oh_ch_width}&nbsp;</td>
 283           <td   class="fibody2" id="bordR">${oh_ch_sex}&nbsp;</td>
 284           <td   class="fibody2" id="bordR">${oh_ch_weeks}&nbsp;</td>
 285           <td   class="fibody2" id="bordR">${oh_ch_delivery}&nbsp;</td>
 286           <td   class="fibody2">${oh_ch_notes}&nbsp;</td>
 287         </tr>
 288 EOL;
 289      $bi++;
 290   }
 291 ?>
 292       </table></td>
 293     </tr>
 294     <tr>
 295       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 296         <tr align="left" valign="top">
 297           <td width="23%" nowrap   class="fibody2">Any pregnancy complications? </td>
 298           <td class="fibody5"><? echo $fdata{'oh_complications'}; ?></td>
 299         </tr>
 300       </table></td>
 301     </tr>
 302     <tr>
 303       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 304         <tr align="left" valign="top">
 305           <td colspan="2" class="fibody2"><? echo (($fdata{'oh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 306             diabetes
 307               <? echo (($fdata{'oh_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 308               hypertension/high blood pressure
 309               <? echo (($fdata{'oh_preemclampsia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 310               preeclampsia/foxemia
 311               <? echo (($fdata{'oh_complic_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 312               other </td>
 313         </tr>
 314         <tr align="left" valign="top">
 315           <td width="472"   class="fibody2">any history of depression before or after pregnancy?
 316             <? echo (($fdata{'oh_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 317             no
 318             <? echo (($fdata{'oh_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 319             yes, How treated </td>
 320           <td class="fibody5"><? echo $fdata{'oh_depression_treated'}; ?>&nbsp;</td>
 321         </tr>
 322       </table></td>
 323     </tr>
 324   </table>
 325 </div>
 326 <p>&nbsp;</p>
 327 <h2 align="center"><a name="ph"></a>Past history (PH)</h2>
 328 <div style="border: solid 2px black; background-color:#FFFFFF;">
 329   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 330     <tr>
 331       <td class="fibody2"><? echo (($fdata{'ph_noncontrib'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 332         Noncontributory
 333         <? echo (($fdata{'ph_nochange_since'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 334         no interval change since
 335         <? echo $fdata{'ph_nochange_since_date'}; ?></td>
 336     </tr>
 337     <tr>
 338       <td class="fibody5"><strong>Surgeries:</strong>
 339         <? echo $fdata{'ph_surgeries'}; ?></td>
 340     </tr>
 341     <tr>
 342       <td class="fibody5"><strong>Illnesses (Physical and mental):</strong>
 343         <? echo $fdata{'ph_illnesses'}; ?></td>
 344     </tr>
 345     <tr>
 346       <td class="fibody5"><strong>Injuries:</strong>
 347         <? echo $fdata{'ph_injuries'}; ?></td>
 348     </tr>
 349     <tr>
 350       <td class="fibody5"><strong>Immunizations/Tuberculosis test: </strong>
 351         <? echo $fdata{'ph_immunizations_tuberculosis'}; ?></td>
 352     </tr>
 353   </table>
 354 </div>
 355 <p>&nbsp;</p>
 356 <h2 align="center"><a name="fh"></a>Family history (FH) </h2>
 357 <div style="border: solid 2px black; background-color:#FFFFFF;">
 358   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 359     <tr align="left" valign="top">
 360       <td colspan="3" class="fibody2"><? echo (($fdata{'fh_noncontrib'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 361 Noncontributory
 362   <? echo (($fdata{'fh_nochange_since'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 363 no interval change since
 364 <? echo $fdata{'fh_nochange_since_date'}; ?></td>
 365     </tr>
 366     <tr align="left" valign="top">
 367       <td colspan="3" class="fibody2">Mother:
 368         <? echo (($fdata{'fh_mother'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> deceased'); ?>
 369         <? if ($fdata{'fh_mother'} != '0') { echo (($fdata{'fh_mother'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 370         cause:
 371         <? echo $fdata{'fh_mother_dec_cause'}; ?>
 372         , age:
 373         <? echo $fdata{'fh_mother_dec_age'}; }?>
 374 &nbsp;&nbsp;&nbsp;        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Father:
 375         <? echo (($fdata{'fh_father'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> Living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> Deceased'); ?>
 376 <? if ($fdata{'fh_father'} != '0') {  ?>
 377 deceased &mdash;  cause:
 378 <? echo $fdata{'fh_father_dec_cause'}; ?>
 379 , age:
 380 <? echo $fdata{'fh_father_dec_age'}; }?></td>
 381     </tr>
 382     <tr align="left" valign="top">
 383       <td colspan="3" class="fibody2">Siblings: number living:
 384         <? echo $fdata{'fh_sibl_living'}; ?>
 385         &nbsp;&nbsp;Number deceased:
 386         <? echo $fdata{'fh_sibl_deceased'}; ?>
 387         &nbsp;&nbsp;Cause(s) / Age(s) :<br>
 388         <? echo $fdata{'fh_sibl_cause'}; ?></td>
 389     </tr>
 390     <tr align="left" valign="top">
 391       <td colspan="3" class="fibody2">Children: number living:
 392         <? echo $fdata{'fh_children_living'}; ?>
 393 &nbsp;&nbsp;Number deceased:
 394 <? echo $fdata{'fh_children_deceased'}; ?>
 395 &nbsp;&nbsp;Cause(s) / Age(s) :<br>
 396 <? echo $fdata{'fh_children_cause'}; ?></td>
 397     </tr>
 398     <tr align="left" valign="top">
 399       <td colspan="3" class="fibody2" style="border: none">(IF YES, indicate whom, and age of diagnosis) </td>
 400     </tr>
 401     <tr align="left" valign="top">
 402       <td width="33%" class="fibody2" id="bordR"><? echo (($fdata{'fhd_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 403         diabetes
 404         <? echo $fdata{'fhd_diabetes_who'}; ?></td>
 405       <td width="33%" class="fibody2" id="bordR"><? echo (($fdata{'fhd_heart'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 406         heart disease
 407         <? echo $fdata{'fhd_heart_who'}; ?></td>
 408       <td width="33%" class="fibody2"> <? echo (($fdata{'fhd_hyperlipidemia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 409         hyperlipidemia
 410         <? echo $fdata{'fhd_hyperlipidemia_who'}; ?></td>
 411     </tr>
 412     <tr align="left" valign="top">
 413       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 414         cancer
 415         <? echo $fdata{'fhd_cancer_who'}; ?></td>
 416       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 417         Hypertension
 418         <? echo $fdata{'fhd_hipertension_who'}; ?></td>
 419       <td rowspan="2" valign="middle" class="fibody2"><? echo (($fdata{'fhd_deepvenous'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 420         deep venous tromboembolIsm / Pulmonary embolism
 421         <? echo $fdata{'fhd_deepvenous_who'}; ?></td>
 422     </tr>
 423     <tr align="left" valign="top">
 424       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_osteoporosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 425         osteoporosis
 426         <? echo $fdata{'fhd_osteoporosis_who'}; ?></td>
 427       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 428         other illnesses
 429         <? echo $fdata{'fhd_other_who'}; ?></td>
 430       </tr>
 431   </table>
 432 </div>
 433 <p></p>
 434 <p>&nbsp;</p>
 435 <h2 align="center"><a name="sh"></a>Social history (SH) </h2>
 436 <div style="border: solid 2px black; background-color:#FFFFFF;">
 437   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 438     <tr>
 439       <td align="left" valign="top" class="fibody2"> <? echo (($fdata{'sh_noncontrib'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 440 Noncontributory
 441 <? echo (($fdata{'sh_nochange_since'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 442 no interval change since
 443 <? echo $fdata{'sh_nochange_since_date'}; ?>&nbsp; </td>
 444     </tr>
 445     <tr>
 446       <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 447         <tr align="center" valign="top">
 448           <td width="190" class="ficaption2">&nbsp;</td>
 449           <td width="30" class="ficaption2">yes</td>
 450           <td width="30" class="ficaption2" id="bordR">no</td>
 451           <td class="ficaption2" id="bordR">notes</td>
 452           <td width="190" class="ficaption2">&nbsp;</td>
 453           <td width="30" class="ficaption2">yes</td>
 454           <td width="30" class="ficaption2" id="bordR">no</td>
 455           <td class="ficaption2">notes</td>
 456         </tr>
 457         <tr align="left" valign="top">
 458           <td   class="fibody2">Tobacco use </td>
 459           <td class="fibody2"><? echo (($fdata{'sh_tobacco'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 460           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_tobacco'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 461           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_1'}; ?>&nbsp;</td>
 462           <td   class="fibody2">diet discussed </td>
 463           <td class="fibody2"><? echo (($fdata{'sh_diet'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 464           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_diet'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 465           <td class="fibody2">
 466             <? echo $fdata{'sh_notes_9'}; ?>&nbsp;</td>
 467         </tr>
 468         <tr align="left" valign="top">
 469           <td rowspan="2"   class="fibody2">Alcohol use<br>
 470             specify amount and type<br>
 471             <small style="font-size:6pt;">12 OZ beer = 5 oz wine = 1 1/2 oz liquor</small> </td>
 472           <td rowspan="2" class="fibody2"><? echo (($fdata{'sh_alcohol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 473           <td rowspan="2" class="fibody2" id="bordR"><? echo (($fdata{'sh_alcohol'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 474           <td rowspan="2" class="fibody2" id="bordR"><? echo $fdata{'sh_notes_2'}; ?>&nbsp;</td>
 475           <td   class="fibody2">folic acid intake </td>
 476           <td class="fibody2"><? echo (($fdata{'sh_folic_acid'} == '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{'sh_folic_acid'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 478           <td class="fibody2"><? echo $fdata{'sh_notes_10'}; ?>&nbsp;</td>
 479         </tr>
 480         <tr align="left" valign="top">
 481           <td   class="fibody2">calcium intake </td>
 482           <td class="fibody2"><? echo (($fdata{'sh_calcium'} == '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{'sh_calcium'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 484           <td class="fibody2"><? echo $fdata{'sh_notes_11'}; ?>&nbsp;</td>
 485         </tr>
 486         <tr align="left" valign="top">
 487           <td   class="fibody2">Illegal/Street drug use </td>
 488           <td class="fibody2"><? echo (($fdata{'sh_drugs'} == '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{'sh_drugs'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 490           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_3'}; ?>&nbsp;</td>
 491           <td   class="fibody2">regular exercise </td>
 492           <td class="fibody2"><? echo (($fdata{'sh_reg_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 493           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_reg_exercise'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 494           <td class="fibody2"><? echo $fdata{'sh_notes_12'}; ?>&nbsp;</td>
 495         </tr>
 496         <tr align="left" valign="top">
 497           <td   class="fibody2">misuse of prescription drugs </td>
 498           <td class="fibody2"><? echo (($fdata{'sh_misuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 499           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_misuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 500           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_4'}; ?>&nbsp;</td>
 501           <td   class="fibody2">caffeine intake </td>
 502           <td class="fibody2"><? echo (($fdata{'sh_caffeine'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 503           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_caffeine'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 504           <td class="fibody2"><? echo $fdata{'sh_notes_13'}; ?>&nbsp;</td>
 505         </tr>
 506         <tr align="left" valign="top">
 507           <td   class="fibody2">intimate partner violence </td>
 508           <td class="fibody2"><? echo (($fdata{'sh_partner_violence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 509           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_partner_violence'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 510           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_5'}; ?>&nbsp;</td>
 511           <td   class="fibody2">advance directive (living will) </td>
 512           <td class="fibody2"><? echo (($fdata{'sh_advance'} == '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{'sh_advance'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 514           <td class="fibody2"><? echo $fdata{'sh_notes_14'}; ?>&nbsp;</td>
 515         </tr>
 516         <tr align="left" valign="top">
 517           <td   class="fibody2">sexual abuse </td>
 518           <td class="fibody2"><? echo (($fdata{'sh_sexual_abuse'} == '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{'sh_sexual_abuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 520           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_6'}; ?>&nbsp;</td>
 521           <td   class="fibody2">organ donation </td>
 522           <td class="fibody2"><? echo (($fdata{'sh_organ_donation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 523           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_organ_donation'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 524           <td class="fibody2"><? echo $fdata{'sh_notes_15'}; ?>&nbsp;</td>
 525         </tr>
 526         <tr align="left" valign="top">
 527           <td   class="fibody2">health hazards at home/work </td>
 528           <td class="fibody2"><? echo (($fdata{'sh_health_hazards'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 529           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_health_hazards'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 530           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_7'}; ?>&nbsp;</td>
 531           <td   class="fibody2">other</td>
 532           <td class="fibody2"><? echo (($fdata{'sh_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 533           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_other'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 534           <td class="fibody2"><? echo $fdata{'sh_notes_16'}; ?>&nbsp;</td>
 535         </tr>
 536         <tr align="left" valign="top">
 537           <td   class="fibody2">seat belt use </td>
 538           <td class="fibody2"><? echo (($fdata{'sh_seat_belt'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 539           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_seat_belt'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 540           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_8'}; ?>&nbsp;</td>
 541           <td   class="fibody2"><? echo (($fdata{'sh_nochanges_since2'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 542             no changes since              <? echo $fdata{'sh_nochanges_since2_date'}; ?>&nbsp; </td>
 543           <td class="fibody2">&nbsp;</td>
 544           <td class="fibody2">&nbsp;</td>
 545           <td class="fibody2">&nbsp;</td>
 546         </tr>
 547       </table></td>
 548     </tr>
 549   </table>
 550 </div>
 551 <p>&nbsp;  </p>
 552 <h2 align="center"><a name="ros"></a>Review of systems (ROS)</h2>
 553 <div style="border: solid 2px black; background-color:#FFFFFF;">
 554 <table width="100%"  border="0" cellspacing="0" cellpadding="2" class="fitable">
 555   <tr>
 556     <td width="190" align="left" valign="top" class="ficaption">1. Constitutional </td>
 557     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 558       <tr align="left" valign="baseline">
 559         <td width="20%" nowrap><? echo (($fdata{'ros_const_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 560         Negative</td>
 561         <td width="20%" nowrap><? echo (($fdata{'ros_const_weight_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 562           weight loss</td>
 563         <td width="20%" nowrap><? echo (($fdata{'ros_const_weight_gain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 564           weight gain
 565 </td>
 566         <td>&nbsp;</td>
 567         <td width="20%">&nbsp;</td>
 568       </tr>
 569       <tr align="left" valign="baseline">
 570         <td width="20%" nowrap><? echo (($fdata{'ros_const_fever'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 571           fever</td>
 572         <td width="20%" nowrap><? echo (($fdata{'ros_const_fatigue'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 573           fatigue</td>
 574         <td nowrap><? echo (($fdata{'ros_const_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 575           other</td>
 576         <td align="right" nowrap>tallest height&nbsp; </td>
 577         <td><? echo $fdata{'ros_const_tallest_height'}; ?></td>
 578       </tr>
 579     </table></td>
 580   </tr>
 581   <tr>
 582     <td width="190" align="left" valign="top" class="ficaption">2. Eyes </td>
 583     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 584       <tr align="left" valign="baseline">
 585         <td width="20%" nowrap><? echo (($fdata{'ros_eyes_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 586       Negative</td>
 587         <td colspan="2" nowrap><? echo (($fdata{'ros_eyes_vision_change'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 588       Vision change </td>
 589         <td colspan="2" nowrap><? echo (($fdata{'ros_eyes_glasses'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 590 Glasses/contacts</td>
 591         </tr>
 592       <tr align="left" valign="baseline">
 593         <td width="20%" nowrap><? echo (($fdata{'ros_eyes_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 594       Other</td>
 595         <td width="20%" nowrap>&nbsp;</td>
 596         <td width="20%" nowrap>&nbsp;</td>
 597         <td align="right" nowrap>&nbsp; </td>
 598         <td width="20%">&nbsp;</td>
 599       </tr>
 600     </table></td>
 601   </tr>
 602   <tr>
 603     <td width="190" align="left" valign="top" class="ficaption">3. Ear, nose and throat </td>
 604     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 605       <tr align="left" valign="baseline">
 606         <td width="20%" nowrap><? echo (($fdata{'ros_ear_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 607       Negative</td>
 608         <td width="20%" nowrap><? echo (($fdata{'ros_ear_ulcers'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 609       Ulcers</td>
 610         <td width="20%" nowrap><? echo (($fdata{'ros_ear_sinusitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 611       sinusitis</td>
 612         <td width="20%">&nbsp;</td>
 613         <td width="20%">&nbsp;</td>
 614       </tr>
 615       <tr align="left" valign="baseline">
 616         <td nowrap><? echo (($fdata{'ros_ear_headache'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 617       Headache</td>
 618         <td nowrap><? echo (($fdata{'ros_ear_hearing_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 619       Hearing loss </td>
 620         <td nowrap><? echo (($fdata{'ros_ear_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 621       other</td>
 622         <td width="20%" align="right" nowrap>&nbsp;</td>
 623         <td>&nbsp;</td>
 624       </tr>
 625     </table></td>
 626   </tr>
 627   <tr>
 628     <td width="190" align="left" valign="top" class="ficaption">4. Cardiovascular </td>
 629     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 630       <tr align="left" valign="baseline">
 631         <td width="20%" nowrap><? echo (($fdata{'ros_cv_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 632       Negative</td>
 633         <td width="20%" nowrap><? echo (($fdata{'ros_cv_orthopnea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 634       Orthopnea</td>
 635         <td width="20%" nowrap><? echo (($fdata{'ros_cv_chest_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 636       Chest pain </td>
 637         <td colspan="2" rowspan="2"><? echo (($fdata{'ros_cv_difficulty_breathing'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 638           Difficulty breathing on exertion
 639 </td>
 640         </tr>
 641       <tr align="left" valign="baseline">
 642         <td nowrap><? echo (($fdata{'ros_cv_edema'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 643       Edema</td>
 644         <td nowrap><? echo (($fdata{'ros_cv_palpitation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 645       Palpitation</td>
 646         <td nowrap><? echo (($fdata{'ros_cv_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 647       other</td>
 648         </tr>
 649     </table></td>
 650   </tr>
 651   <tr>
 652     <td width="190" align="left" valign="top" class="ficaption">5. Respiratory </td>
 653     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 654       <tr align="left" valign="baseline">
 655         <td width="20%" nowrap><? echo (($fdata{'ros_resp_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 656       Negative</td>
 657         <td width="20%" nowrap><? echo (($fdata{'ros_resp_wheezing'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 658       Wheezing</td>
 659         <td width="20%" nowrap><? echo (($fdata{'ros_hemoptysis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 660       Hemoptysis</td>
 661         <td width="20%">&nbsp;</td>
 662         <td width="20%">&nbsp;</td>
 663       </tr>
 664       <tr align="left" valign="baseline">
 665         <td colspan="2" nowrap><? echo (($fdata{'ros_resp_shortness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 666       Shortness of breath </td>
 667         <td nowrap><? echo (($fdata{'ros_resp_cough'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 668       Cough</td>
 669         <td colspan="2" align="left" nowrap><? echo (($fdata{'ros_resp_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 670           Other
 671 </td>
 672         </tr>
 673     </table></td>
 674   </tr>
 675   <tr>
 676     <td width="190" align="left" valign="top" class="ficaption">6. Gastrointestinal </td>
 677     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 678       <tr align="left" valign="baseline">
 679         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 680       Negative</td>
 681         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_diarrhea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 682       Diarrhea</td>
 683         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_bloody_stool'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 684       Bloody stool </td>
 685         <td colspan="2"><? echo (($fdata{'ros_gastr_nausea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 686           Nausea/Vomiting/Indigestion
 687 </td>
 688         </tr>
 689       <tr align="left" valign="baseline">
 690         <td nowrap><? echo (($fdata{'ros_gastr_constipation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 691       Constipation</td>
 692         <td nowrap><? echo (($fdata{'ros_gastr_flatulence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 693       Flatulence</td>
 694         <td nowrap><? echo (($fdata{'ros_gastr_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 695       pain</td>
 696         <td align="left" nowrap><? echo (($fdata{'ros_gastr_fecal'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 697           Fecal incontinence</td>
 698         <td nowrap><? echo (($fdata{'ros_gastr_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 699           Other</td>
 700       </tr>
 701     </table></td>
 702   </tr>
 703   <tr>
 704     <td width="190" align="left" valign="top" class="ficaption">7. Genitourinary </td>
 705     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 706       <tr align="left" valign="baseline">
 707         <td width="20%" nowrap><? echo (($fdata{'ros_genit_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 708       Negative</td>
 709         <td width="20%" nowrap><? echo (($fdata{'ros_genit_hematuria'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 710       Hematuria</td>
 711         <td nowrap><? echo (($fdata{'ros_genit_dysuria'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 712       Dysuria</td>
 713         <td align="left" nowrap><? echo (($fdata{'ros_genit_urgency'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 714           Urgency</td>
 715         <td align="left" nowrap>&nbsp;</td>
 716       </tr>
 717       <tr align="left" valign="baseline">
 718         <td width="20%" nowrap><? echo (($fdata{'ros_genit_frequency'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 719       Frequency</td>
 720         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_incomplete_emptying'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 721       Incomplete emptying </td>
 722         <td align="left" nowrap><? echo (($fdata{'ros_genit_incontinence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 723           Incontinence</td>
 724         <td align="left" nowrap>&nbsp;</td>
 725       </tr>
 726       <tr align="left" valign="baseline">
 727         <td width="20%" nowrap><? echo (($fdata{'ros_genit_dyspareunia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 728   Dyspareunia</td>
 729         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_abnormal_periods'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 730           Abnormal or painful periods </td>
 731         <td nowrap><? echo (($fdata{'ros_genit_pms'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 732   PMS</td>
 733         <td align="left" nowrap>&nbsp;</td>
 734       </tr>
 735       <tr align="left" valign="baseline">
 736         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_abnormal_bleeding'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 737   Abnormal vaginal bleeding </td>
 738         <td nowrap><? echo (($fdata{'ros_genit_abnormal_discharge'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 739   Abnormal vaginal discharge </td>
 740         <td nowrap><? echo (($fdata{'ros_genit_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 741   other</td>
 742         <td align="left" nowrap>&nbsp;</td>
 743       </tr>
 744     </table></td>
 745   </tr>
 746   <tr>
 747     <td width="190" align="left" valign="top" class="ficaption">8. Musculoskeletal </td>
 748     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 749       <tr align="left" valign="baseline">
 750         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 751       Negative</td>
 752         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_weakness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 753       Muscle weakness </td>
 754         <td nowrap>&nbsp;</td>
 755         <td width="10%">&nbsp;</td>
 756         <td width="10%">&nbsp;</td>
 757       </tr>
 758       <tr align="left" valign="baseline">
 759         <td nowrap><? echo (($fdata{'ros_muscul_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 760       Muscle or joint pain </td>
 761         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 762 other</td>
 763         <td nowrap>&nbsp;</td>
 764         <td width="10%" align="left" nowrap>&nbsp;</td>
 765         <td width="10%">&nbsp;</td>
 766       </tr>
 767     </table></td>
 768   </tr>
 769   <tr>
 770     <td width="190" align="left" valign="top" class="ficaption">9a. Skin </td>
 771     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 772       <tr align="left" valign="baseline">
 773         <td width="20%" nowrap><? echo (($fdata{'ros_skin_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 774       Negative</td>
 775         <td width="20%" nowrap><? echo (($fdata{'ros_skin_rash'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 776       Rash</td>
 777         <td width="20%" nowrap><? echo (($fdata{'ros_skin_ulcers'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 778       Ulcers</td>
 779         <td width="20%">&nbsp;</td>
 780         <td width="20%">&nbsp;</td>
 781       </tr>
 782       <tr align="left" valign="baseline">
 783         <td nowrap><? echo (($fdata{'ros_skin_dry'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 784       Dry skin </td>
 785         <td colspan="2" nowrap><? echo (($fdata{'ros_skin_pigmented'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 786       Pigmented lesions </td>
 787         <td align="left" nowrap><? echo (($fdata{'ros_skin_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 788 other</td>
 789         <td>&nbsp;</td>
 790       </tr>
 791     </table></td>
 792   </tr>
 793   <tr>
 794     <td width="190" align="left" valign="top" class="ficaption">9b. Breast </td>
 795     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 796       <tr align="left" valign="baseline">
 797         <td width="20%" nowrap><? echo (($fdata{'ros_breast_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 798       Negative</td>
 799         <td width="20%" nowrap><? echo (($fdata{'ros_breast_mastalgia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 800       Mastalgia</td>
 801         <td width="20%" nowrap>&nbsp;</td>
 802         <td width="20%">&nbsp;</td>
 803         <td width="20%">&nbsp;</td>
 804       </tr>
 805       <tr align="left" valign="baseline">
 806         <td nowrap><? echo (($fdata{'ros_breast_discharge'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 807       Discharge</td>
 808         <td nowrap><? echo (($fdata{'ros_breast_masses'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 809       Masses</td>
 810         <td nowrap><? echo (($fdata{'ros_breast_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 811       other</td>
 812         <td align="right" nowrap>&nbsp;</td>
 813         <td width="20%">&nbsp;</td>
 814       </tr>
 815     </table></td>
 816   </tr>
 817   <tr>
 818     <td width="190" align="left" valign="top" class="ficaption">10. Neurologic </td>
 819     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 820       <tr align="left" valign="baseline">
 821         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 822       Negative</td>
 823         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_syncope'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 824       Syncope</td>
 825         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_seizures'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 826       Seizures</td>
 827         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_numbness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 828           Numbness</td>
 829         <td width="20%">&nbsp;</td>
 830       </tr>
 831       <tr align="left" valign="baseline">
 832         <td colspan="2" nowrap><? echo (($fdata{'ros_neuro_trouble_walking'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 833       Trouble walking </td>
 834         <td colspan="2" nowrap><? echo (($fdata{'ros_neuro_memory'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 835 Severe memory problems </td>
 836         <td><? echo (($fdata{'ros_neuro_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 837 other</td>
 838       </tr>
 839     </table></td>
 840   </tr>
 841   <tr>
 842     <td width="190" align="left" valign="top" class="ficaption">11. Psychiatric</td>
 843     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 844       <tr align="left" valign="baseline">
 845         <td nowrap><? echo (($fdata{'ros_psych_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 846       Negative</td>
 847         <td width="20%" nowrap><? echo (($fdata{'ros_psych_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 848       Depression</td>
 849         <td width="20%" nowrap><? echo (($fdata{'ros_psych_crying'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 850       Crying</td>
 851         <td width="20%">&nbsp;</td>
 852         <td width="20%">&nbsp;</td>
 853       </tr>
 854       <tr align="left" valign="baseline">
 855         <td colspan="2" nowrap><? echo (($fdata{'ros_psych_anxiety'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 856       Severe anxiety </td>
 857         <td width="20%" nowrap><? echo (($fdata{'ros_psych_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 858 Other</td>
 859         <td align="right" nowrap>&nbsp;</td>
 860         <td>&nbsp;</td>
 861       </tr>
 862     </table></td>
 863   </tr>
 864   <tr>
 865     <td width="190" align="left" valign="top" class="ficaption">12. Endocrine </td>
 866     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 867       <tr align="left" valign="baseline">
 868         <td width="20%" nowrap><? echo (($fdata{'ros_endo_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 869       Negative</td>
 870         <td width="20%" nowrap><? echo (($fdata{'ros_endo_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 871         Diabetes</td>
 872         <td nowrap><? echo (($fdata{'ros_endo_hipothyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 873       Hypothyroid</td>
 874         <td nowrap><? echo (($fdata{'ros_endo_hiperthyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 875 Hyperthyroid</td>
 876       </tr>
 877       <tr align="left" valign="baseline">
 878         <td nowrap><? echo (($fdata{'ros_endo_flashes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 879       Hot flashes </td>
 880         <td nowrap><? echo (($fdata{'ros_endo_hair_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 881       Hair loss </td>
 882         <td nowrap><? echo (($fdata{'ros_endo_intolerance'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 883       Heat/cold intolerance </td>
 884         <td><? echo (($fdata{'ros_endo_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 885           Other
 886 </td>
 887       </tr>
 888     </table></td>
 889   </tr>
 890   <tr>
 891     <td width="190" align="left" valign="top" class="ficaption">13. Hematologic/Lymphatic</td>
 892     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 893       <tr align="left" valign="baseline">
 894         <td width="20%" nowrap><? echo (($fdata{'ros_hemato_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 895       Negative</td>
 896         <td width="20%" nowrap><? echo (($fdata{'ros_hemato_bruises'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 897       Bruises</td>
 898         <td width="20%" nowrap>&nbsp;</td>
 899         <td width="20%">&nbsp;</td>
 900         <td width="20%">&nbsp;</td>
 901       </tr>
 902       <tr align="left" valign="baseline">
 903         <td nowrap><? echo (($fdata{'ros_hemato_bleeding'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 904       Bleeding</td>
 905         <td nowrap><? echo (($fdata{'ros_hemato_adenopathy'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 906       Adenopathy</td>
 907         <td nowrap><? echo (($fdata{'ros_hemato_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 908       other</td>
 909         <td align="right" nowrap>&nbsp;</td>
 910         <td>&nbsp;</td>
 911       </tr>
 912     </table></td>
 913   </tr>
 914   <tr>
 915     <td width="190" align="left" valign="top" class="ficaption">14. Allergic/Immunologic </td>
 916     <td align="center" valign="middle" class="fibody"><a href="#allergies">See above (Page 1 of PH) </a></td>
 917   </tr>
 918 </table>
 919 </div>
 920 </body>
 921 </html>