contrib/forms/progressnotes/new.php

   1 <?php
   2 #######################################################
   3 # Progress Notes Form created by Kam Sharifi          #
   4 # kam@sharmen.com                                     #
   5 #######################################################
   6 include_once("../../globals.php");
   7 include_once("$srcdir/api.inc");
   8 formHeader("Form: progressnotes");
   9 ?>
  10 <html><head>
  11 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  12 </head>
  13 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  14 <form method=post action="<?echo $rootdir;?>/forms/progressnotes/save.php?mode=new" name="my_form">
  15 <span class="title">Progress Notes</span><br><br>
  16
  17 <table width=100%>
  18 <b>
  19 <span class=text>P: </span><input size=3 type=entry name="prog_p" value="" >
  20 <span class=text>R: </span><input size=3 type=entry name="prog_r" value="" >
  21 <span class=text>BP: </span><input size=3 type=entry name="prog_bp" value="" >
  22 <span class=text>HT: </span><input size=3 type=entry name="prog_ht" value="" >
  23 <span class=text>WT: </span><input size=3 type=entry name="prog_wt" value="" >
  24 <span class=text>TEMP: </span><input size=3 type=entry name="prog_temp" value="" >
  25 <span class=text>LMP: </span><input size=3 type=entry name="prog_lmp" value="" >
  26 <br><span class=text>Last Pap Smear: </span><input size=3 type=entry name="prog_last_pap_smear" value="" >
  27 <span class=text>Last Td. Booster: </span><input size=3 type=entry name="prog_last_td_booster" value="" >
  28 <span class=text>Allergies: </span><input size=3 type=entry name="prog_allergies" value="" >
  29 <span class=text>Last Mammogram: </span><input size=3 type=entry name="prog_last_mammogram" value="" >
  30 </b>
  31 </table>
  32 <br>
  33
  34 <span class=text><b>Present Complaint*:</b> </span><br><textarea cols=40 rows=8 wrap=virtual name="prog_present_complaint" ></textarea>
  35
  36 <br><br>
  37 <b>Past Medical History</b>
  38
  39     <TABLE ID="Table1" BORDER=1 CELLSPACING=2 CELLPADDING=1 WIDTH="100%" >
  40         <TR>
  41             <TD WIDTH=53>
  42                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
  43             </TD>
  44             <TD WIDTH=40>
  45                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>ABN</B></FONT><B></B></P>
  46             </TD>
  47             <TD WIDTH=34>
  48                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NE</B></FONT><B></B></P>
  49             </TD>
  50             <TD WIDTH=324>
  51                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>PHYSICAL EXAMINATION -Comments</B></FONT><B></B></P>
  52             </TD>
  53         </TR>
  54         <TR>
  55             <TD HEIGHT=14>
  56                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
  57             </TD>
  58             <TD WIDTH=40>
  59                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
  60                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
  61                         <TR>
  62                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox2" TYPE=CHECKBOX NAME="prog_skin_abn" VALUE=""></TD>
  63                         </TR>
  64                     </TABLE>
  65                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
  66             <TD WIDTH=34>
  67                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
  68                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
  69                         <TR>
  70                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox8" TYPE=CHECKBOX NAME="prog_skin_ne" VALUE=""></TD>
  71                         </TR>
  72                     </TABLE>
  73                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
  74             <TD WIDTH=324>
  75                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>SKIN: no significant lesions</B></FONT><B></B></P>
  76             </TD>
  77         </TR>
  78         <TR>
  79             <TD HEIGHT=14>
  80                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
  81             </TD>
  82             <TD WIDTH=40>
  83                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
  84                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
  85                         <TR>
  86                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox7" TYPE=CHECKBOX NAME="prog_head_abn" VALUE=""></TD>
  87                         </TR>
  88                     </TABLE>
  89                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
  90             <TD WIDTH=34>
  91                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
  92                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
  93                         <TR>
  94                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox9" TYPE=CHECKBOX NAME="prog_head_ne" VALUE=""></TD>
  95                         </TR>
  96                     </TABLE>
  97                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
  98             <TD WIDTH=324>
  99                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>HEAD: normocephalic. no headache</B></FONT><B></B></P>
 100             </TD>
 101         </TR>
 102         <TR>
 103             <TD HEIGHT=11>
 104                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 105             </TD>
 106             <TD WIDTH=40>
 107                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 108                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 109                         <TR>
 110                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox10" TYPE=CHECKBOX NAME="prog_eyes_abn" VALUE=""></TD>
 111                         </TR>
 112                     </TABLE>
 113                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 114             <TD WIDTH=34>
 115                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 116                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 117                         <TR>
 118                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox11" TYPE=CHECKBOX NAME="prog_eyes_ne" VALUE=""></TD>
 119                         </TR>
 120                     </TABLE>
 121                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 122             <TD WIDTH=324>
 123                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EYES: perla. eom satisfactory</B></FONT><B></B></P>
 124             </TD>
 125         </TR>
 126         <TR>
 127             <TD>
 128                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 129             </TD>
 130             <TD WIDTH=40>
 131                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 132                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 133                         <TR>
 134                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox12" TYPE=CHECKBOX NAME="prog_ears_abn" VALUE=""></TD>
 135                         </TR>
 136                     </TABLE>
 137                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 138             <TD WIDTH=34>
 139                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 140                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 141                         <TR>
 142                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox13" TYPE=CHECKBOX NAME="prog_ears_ne" VALUE=""></TD>
 143                         </TR>
 144                     </TABLE>
 145                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 146             <TD WIDTH=324>
 147                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EARS: drums intact</B></FONT><B></B></P>
 148             </TD>
 149         </TR>
 150         <TR>
 151             <TD HEIGHT=19>
 152                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 153             </TD>
 154             <TD WIDTH=40>
 155                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 156                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 157                         <TR>
 158                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox14" TYPE=CHECKBOX NAME="prog_nose_abn" VALUE=""></TD>
 159                         </TR>
 160                     </TABLE>
 161                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 162             <TD WIDTH=34>
 163                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 164                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 165                         <TR>
 166                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox16" TYPE=CHECKBOX NAME="prog_nose_ne" VALUE=""></TD>
 167                         </TR>
 168                     </TABLE>
 169                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 170             <TD WIDTH=324>
 171                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NOSE: no abnormality</B></FONT><B></B></P>
 172             </TD>
 173         </TR>
 174         <TR>
 175             <TD>
 176                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 177             </TD>
 178             <TD WIDTH=40>
 179                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 180                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 181                         <TR>
 182                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox17" TYPE=CHECKBOX NAME="prog_throat_abn" VALUE=""></TD>
 183                         </TR>
 184                     </TABLE>
 185                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 186             <TD WIDTH=34>
 187                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 188                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 189                         <TR>
 190                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox15" TYPE=CHECKBOX NAME="prog_throat_ne" VALUE=""></TD>
 191                         </TR>
 192                     </TABLE>
 193                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 194             <TD WIDTH=324>
 195                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>THROAT: dear, no infection</B></FONT><B></B></P>
 196             </TD>
 197         </TR>
 198         <TR>
 199             <TD HEIGHT=18>
 200                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 201             </TD>
 202             <TD WIDTH=40>
 203                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 204                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 205                         <TR>
 206                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox19" TYPE=CHECKBOX NAME="prog_teeth_abn" VALUE=""></TD>
 207                         </TR>
 208                     </TABLE>
 209                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 210             <TD WIDTH=34>
 211                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 212                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 213                         <TR>
 214                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox20" TYPE=CHECKBOX NAME="prog_teeth_ne" VALUE=""></TD>
 215                         </TR>
 216                     </TABLE>
 217                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 218             <TD WIDTH=324>
 219                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>TEETH: good repair, no dentures</B></FONT><B></B></P>
 220             </TD>
 221         </TR>
 222         <TR>
 223             <TD>
 224                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 225             </TD>
 226             <TD WIDTH=40>
 227                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 228                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 229                         <TR>
 230                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox18" TYPE=CHECKBOX NAME="prog_neck_abn" VALUE=""></TD>
 231                         </TR>
 232                     </TABLE>
 233                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 234             <TD WIDTH=34>
 235                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 236                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 237                         <TR>
 238                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox21" TYPE=CHECKBOX NAME="prog_neck_ne" VALUE=""></TD>
 239                         </TR>
 240                     </TABLE>
 241                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 242             <TD WIDTH=324>
 243                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NECK: supple, no adenopathy</B></FONT><B></B></P>
 244             </TD>
 245         </TR>
 246         <TR>
 247             <TD>
 248                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 249             </TD>
 250             <TD WIDTH=40>
 251                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 252                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 253                         <TR>
 254                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox22" TYPE=CHECKBOX NAME="prog_chest_abn" VALUE=""></TD>
 255                         </TR>
 256                     </TABLE>
 257                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 258             <TD WIDTH=34>
 259                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 260                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 261                         <TR>
 262                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox23" TYPE=CHECKBOX NAME="prog_chest_ne" VALUE=""></TD>
 263                         </TR>
 264                     </TABLE>
 265                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 266             <TD WIDTH=324>
 267                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>CHEST: symmetrical, no pain</B></FONT><B></B></P>
 268             </TD>
 269         </TR>
 270         <TR>
 271             <TD>
 272                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 273             </TD>
 274             <TD WIDTH=40>
 275                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 276                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 277                         <TR>
 278                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox24" TYPE=CHECKBOX NAME="prog_breast_abn" VALUE=""></TD>
 279                         </TR>
 280                     </TABLE>
 281                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 282             <TD WIDTH=34>
 283                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 284                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 285                         <TR>
 286                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox25" TYPE=CHECKBOX NAME="prog_breast_ne" VALUE=""></TD>
 287                         </TR>
 288                     </TABLE>
 289                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 290             <TD WIDTH=324>
 291                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>BREAST: no masses</B></FONT><B></B></P>
 292             </TD>
 293         </TR>
 294         <TR>
 295             <TD>
 296                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 297             </TD>
 298             <TD WIDTH=40>
 299                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 300                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 301                         <TR>
 302                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox26" TYPE=CHECKBOX NAME="prog_lungs_abn" VALUE=""></TD>
 303                         </TR>
 304                     </TABLE>
 305                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 306             <TD WIDTH=34>
 307                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 308                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 309                         <TR>
 310                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox27" TYPE=CHECKBOX NAME="prog_lungs_ne" VALUE=""></TD>
 311                         </TR>
 312                     </TABLE>
 313                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 314             <TD WIDTH=324>
 315                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>LUNGS: dear to P&amp;a. no mono, no rales</B></FONT><B></B></P>
 316             </TD>
 317         </TR>
 318         <TR>
 319             <TD>
 320                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 321             </TD>
 322             <TD WIDTH=40>
 323                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 324                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 325                         <TR>
 326                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox28" TYPE=CHECKBOX NAME="prog_heart_abn" VALUE=""></TD>
 327                         </TR>
 328                     </TABLE>
 329                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 330             <TD WIDTH=34>
 331                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 332                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 333                         <TR>
 334                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox29" TYPE=CHECKBOX NAME="prog_heart_ne" VALUE=""></TD>
 335                         </TR>
 336                     </TABLE>
 337                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 338             <TD WIDTH=324>
 339                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>HEART: rsr. no cardiomegaly</B></FONT><B></B></P>
 340             </TD>
 341         </TR>
 342         <TR>
 343             <TD>
 344                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 345             </TD>
 346             <TD WIDTH=40>
 347                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 348                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 349                         <TR>
 350                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox30" TYPE=CHECKBOX NAME="prog_abdomen_abn" VALUE=""></TD>
 351                         </TR>
 352                     </TABLE>
 353                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 354             <TD WIDTH=34>
 355                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 356                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 357                         <TR>
 358                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox31" TYPE=CHECKBOX NAME="prog_abdomen_ne" VALUE=""></TD>
 359                         </TR>
 360                     </TABLE>
 361                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 362             <TD WIDTH=324>
 363                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>ABDOMEN: non-tender, soft, no masses</B></FONT><B></B></P>
 364             </TD>
 365         </TR>
 366         <TR>
 367             <TD>
 368                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 369             </TD>
 370             <TD WIDTH=40>
 371                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 372                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 373                         <TR>
 374                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox32" TYPE=CHECKBOX NAME="prog_spine_abn" VALUE=""></TD>
 375                         </TR>
 376                     </TABLE>
 377                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 378             <TD WIDTH=34>
 379                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 380                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 381                         <TR>
 382                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox33" TYPE=CHECKBOX NAME="prog_spine_ne" VALUE=""></TD>
 383                         </TR>
 384                     </TABLE>
 385                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 386             <TD WIDTH=324>
 387                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>SPINE: no abnormalities</B></FONT><B></B></P>
 388             </TD>
 389         </TR>
 390         <TR>
 391             <TD>
 392                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 393             </TD>
 394             <TD WIDTH=40>
 395                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 396                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 397                         <TR>
 398                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox34" TYPE=CHECKBOX NAME="prog_extremeities_abn" VALUE=""></TD>
 399                         </TR>
 400                     </TABLE>
 401                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 402             <TD WIDTH=34>
 403                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 404                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 405                         <TR>
 406                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox35" TYPE=CHECKBOX NAME="prog_extremeities_ne" VALUE=""></TD>
 407                         </TR>
 408                     </TABLE>
 409                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 410             <TD WIDTH=324>
 411                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>EXTREMEITIES: no abnormalities</B></FONT><B></B></P>
 412             </TD>
 413         </TR>
 414         <TR>
 415             <TD>
 416                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 417             </TD>
 418             <TD WIDTH=40>
 419                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 420                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 421                         <TR>
 422                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox36" TYPE=CHECKBOX NAME="prog_lowback_abn" VALUE=""></TD>
 423                         </TR>
 424                     </TABLE>
 425                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 426             <TD WIDTH=34>
 427                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 428                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 429                         <TR>
 430                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox37" TYPE=CHECKBOX NAME="prog_lowback_ne" VALUE=""></TD>
 431                         </TR>
 432                     </TABLE>
 433                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 434             <TD WIDTH=324>
 435                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>LOW BACK: rom normal</B></FONT><B></B></P>
 436             </TD>
 437         </TR>
 438         <TR>
 439             <TD>
 440                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 441             </TD>
 442             <TD WIDTH=40>
 443                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 444                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 445                         <TR>
 446                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox38" TYPE=CHECKBOX NAME="prog_neuro_abn" VALUE=""></TD>
 447                         </TR>
 448                     </TABLE>
 449                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 450             <TD WIDTH=34>
 451                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 452                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 453                         <TR>
 454                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox39" TYPE=CHECKBOX NAME="prog_neuro_ne" VALUE=""></TD>
 455                         </TR>
 456                     </TABLE>
 457                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 458             <TD WIDTH=324>
 459                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>NEURO: d(r&gt;&gt;2&gt;&gt;. no abnormal findings</B></FONT><B></B></P>
 460             </TD>
 461         </TR>
 462         <TR>
 463             <TD>
 464                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 465             </TD>
 466             <TD WIDTH=40>
 467                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 468                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 469                         <TR>
 470                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox40" TYPE=CHECKBOX NAME="prog_rectal_abn" VALUE=""></TD>
 471                         </TR>
 472                     </TABLE>
 473                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 474             <TD WIDTH=34>
 475                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 476                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 477                         <TR>
 478                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox41" TYPE=CHECKBOX NAME="prog_rectal_ne" VALUE=""></TD>
 479                         </TR>
 480                     </TABLE>
 481                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 482             <TD WIDTH=324>
 483                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>RECTAL: no abnormalities</B></FONT><B></B></P>
 484             </TD>
 485         </TR>
 486         <TR>
 487             <TD>
 488                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif">&nbsp;</FONT></P>
 489             </TD>
 490             <TD WIDTH=40>
 491                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 492                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 493                         <TR>
 494                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox42" TYPE=CHECKBOX NAME="prog_pelvic_abn" VALUE=""></TD>
 495                         </TR>
 496                     </TABLE>
 497                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 498             <TD WIDTH=34>
 499                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT>
 500                     <TABLE WIDTH="100%" BORDER=0 CELLSPACING=0 CELLPADDING=0 NOF=TE>
 501                         <TR>
 502                             <TD ALIGN="CENTER"><INPUT ID="Forms Checkbox43" TYPE=CHECKBOX NAME="prog_pelvic_ne" VALUE=""></TD>
 503                         </TR>
 504                     </TABLE>
 505                     <FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT></TD>
 506             <TD WIDTH=324>
 507                 <P><FONT FACE="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B>PELVIC:</B></FONT><B></B></P>
 508             </TD>
 509         </TR>
 510     </TABLE>
 511
 512 <br>
 513
 514
 515 <span class=text><b>HEALTH EDUCATION PROVIDED<br>ASSESSMENT:</b></span><br><textarea cols=40 rows=8 wrap=virtual name="prog_assessment" ></textarea>
 516
 517 <br><br>
 518
 519 <span class=text><b>Plan:</b></span><br><textarea cols=40 rows=8 wrap=virtual name="prog_plan" ></textarea>
 520
 521 <br><br>
 522 <td><input size=3 type=entry name="prog_breast_se" value="" >&nbsp;<span class=text><b>Breast Self Examination </span></td><br></b>
 523 <td><input size=3 type=entry name="prog_dental_h" value="" >&nbsp;<span class=text><b>Dental Health </span></td><br></b>
 524 <td><input size=3 type=entry name="prog_diagnosis" value="" >&nbsp;<span class=text><b>Diagnosis/Prognosis </span></td><br></b>
 525 <td><input size=3 type:entry name="prog_injur_p" value="" >&nbsp;<span class=text><b>Injury Prevention </span></td><br></b>
 526 <td><input size=3 type=entry name="prog_new_treat" value="" >&nbsp;<span class=text><b>New Treatment/Medication </span></td><br></b>
 527 <td><input size=3 type=entry name="prog_nutrition_e" value="" >&nbsp;<span class=text><b>Nutrition/Exercise </span></td><br></b>
 528 <td><input size=3 type=entry name="prog_sexual_p" value="" >&nbsp;<span class=text><b>Sexual Practice </span></td><br></b>
 529 <td><input size=3 type=entry name="prog_substance_a" value="" >&nbsp;<span class=text><b>Substance Abuse </span></td><br></b>
 530
 531
 532 <br>
 533 <a href="javascript:document.my_form.submit();" class="link_submit">[Save]</a>
 534 &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
 535 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link">[Don't Save]</a>
 536 </form>
 537 <?php
 538 formFooter();
 539 ?>