contrib/forms/cardiology_set/Forms_Cardiology/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Forms_Cardiology");
   5 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  12 <script type="text/javascript" src="../../../library/dialog.js"></script>
  13 <script type="text/javascript" src="../../../library/textformat.js"></script>
  14 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  15 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  16 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  17 <script language='JavaScript'> var mypcc = '1'; </script>
  18
  19 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  20 <form method=post action="<?php echo $rootdir;?>/forms/Forms_Cardiology/save.php?mode=new" name="Forms_Cardiology" onSubmit="return top.restoreSession()">
  21 <hr>
  22 <h1> <?php xl("Forms_Cardiology",'e') ?> </h1>
  23 <hr>
  24 <input type="submit" name="submit form" value="submit form" />
  25
  26 <table width="100%" cellpadding="0" cellspacing="0">
  27
  28     <tr>
  29
  30         <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
  31
  32             <table width="100%" cellpadding="0" cellspacing="0">
  33
  34                 <tr>
  35
  36                     <td class='text'   colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;">
  37
  38                         <h3>
  39
  40                             PATIENT INFORMATION - PLEASE PRINT
  41
  42                         </h3>
  43                     </td>
  44                 </tr>
  45                 <tr><td class='text'   colspan="5"><b> <?php xl("FULL LEGAL NAME(FIRST NAME)",'e') ?> </b></td></tr>
  46
  47                 <tr>
  48
  49                     <td class='text'   style="border: 1px #000000 solid;">
  50
  51 <table>
  52
  53 <tr><td class='text' > first name</td> <td class='text' ><input type="text" name="_first_name"  /></td></tr>
  54
  55 </table>
  56                     </td>
  57
  58                     <td class='text'   style="border: 1px #000000 solid;">
  59
  60 <table>
  61
  62 <tr><td class='text' > middle name</td> <td class='text' ><input type="text" name="_middle_name"  /></td></tr>
  63
  64 </table>
  65                     </td>
  66
  67                      <td class='text'   style="border: 1px #000000 solid;">
  68
  69 <table>
  70
  71 <tr><td class='text' > last name</td> <td class='text' ><input type="text" name="_last_name"  /></td></tr>
  72
  73 </table>
  74                     </td>
  75
  76                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
  77
  78 <table>
  79
  80 <tr><td class='text' > nick name</td> <td class='text' ><input type="text" name="_nick_name"  /></td></tr>
  81
  82 </table>
  83                     </td>
  84                 </tr>
  85
  86
  87
  88
  89
  90                 <tr>
  91
  92
  93
  94                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
  95
  96 <table>
  97
  98 <tr><td class='text' > street address number</td> <td class='text' ><input type="text" name="_street_address_number"  /></td></tr>
  99
 100 </table>
 101                     </td>
 102
 103                     <td class='text'   style="border: 1px #000000 solid;">
 104
 105 <table>
 106
 107 <tr><td class='text' > street name</td> <td class='text' ><input type="text" name="_street_name"  /></td></tr>
 108
 109 </table>
 110                     </td>
 111
 112                      <td class='text'   style="border: 1px #000000 solid;">
 113
 114 <table>
 115
 116 <tr><td class='text' > street name apt</td> <td class='text' ><input type="text" name="_street_name_apt"  /></td></tr>
 117
 118 </table>
 119                     </td>
 120
 121                     <td class='text'   style="border: 1px #000000 solid;">
 122
 123 <table>
 124
 125 <tr><td class='text' > street name space</td> <td class='text' ><input type="text" name="_street_name_space"  /></td></tr>
 126
 127 </table>
 128                     </td>
 129                 </tr>
 130
 131                   <tr>
 132
 133
 134
 135                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 136
 137 <table>
 138
 139 <tr><td class='text' > po box address number</td> <td class='text' ><input type="text" name="_po_box_address_number"  /></td></tr>
 140
 141 </table>
 142                     </td>
 143
 144                     <td class='text'   style="border: 1px #000000 solid;">
 145
 146 <table>
 147
 148 <tr><td class='text' > po box street</td> <td class='text' ><input type="text" name="_po_box_street"  /></td></tr>
 149
 150 </table>
 151                     </td>
 152
 153                      <td class='text'   style="border: 1px #000000 solid;">
 154
 155 <table>
 156
 157 <tr><td class='text' > po box apt</td> <td class='text' ><input type="text" name="_po_box_apt"  /></td></tr>
 158
 159 </table>
 160                     </td>
 161
 162                     <td class='text'   style="border: 1px #000000 solid;">
 163
 164 <table>
 165
 166 <tr><td class='text' > po box space</td> <td class='text' ><input type="text" name="_po_box_space"  /></td></tr>
 167
 168 </table>
 169                     </td>
 170                 </tr>
 171
 172
 173
 174                  <tr>
 175
 176
 177
 178                     <td class='text'   style="border: 1px #000000 solid;">
 179
 180 <table>
 181
 182 <tr><td class='text' > city</td> <td class='text' ><input type="text" name="_city"  /></td></tr>
 183
 184 </table>
 185                     </td>
 186
 187                     <td class='text'   style="border: 1px #000000 solid;">
 188
 189 <table>
 190
 191 <tr><td class='text' > state</td> <td class='text' ><input type="text" name="_state"  /></td></tr>
 192
 193 </table>
 194                     </td>
 195
 196                      <td class='text'   style="border: 1px #000000 solid;">
 197
 198 <table>
 199
 200 <tr><td class='text' > zip code</td> <td class='text' ><input type="text" name="_zip_code"  /></td></tr>
 201
 202 </table>
 203                     </td>
 204
 205                     <td class='text'   style="border: 1px #000000 solid;">
 206
 207 <table>
 208
 209 <tr><td class='text' > social security</td> <td class='text' ><input type="text" name="_social_security"  /></td></tr>
 210
 211 </table>
 212                     </td>
 213
 214                      <td class='text'   style="border: 1px #000000 solid;">
 215
 216 <table>
 217
 218 <tr><td class='text' > home phone</td> <td class='text' ><input type="text" name="_home_phone"  /></td></tr>
 219
 220 </table>
 221                     </td>
 222                 </tr>
 223
 224
 225
 226                 <tr>
 227
 228
 229
 230                     <td class='text'    colspan="4" style="border: 1px #000000 solid; height: 10px;">
 231
 232 <table>
 233
 234 <tr><td class='text' > email address</td> <td class='text' ><input type="text" name="_email_address"  /></td></tr>
 235
 236 </table>
 237                     </td>
 238
 239
 240
 241                      <td class='text'   style="border: 1px #000000 solid; height: 10px;">
 242
 243 <table>
 244
 245 <tr><td class='text' > cell phone</td> <td class='text' ><input type="text" name="_cell_phone"  /></td></tr>
 246
 247 </table>
 248                     </td>
 249                 </tr>
 250
 251
 252
 253                  <tr>
 254
 255
 256
 257                     <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 258
 259 <table>
 260
 261 <tr><td class='text' >
 262 <span ><?php xl(' date of birth (yyyy-mm-dd): ','e') ?></span>
 263 </td><td class='text' >
 264 <input type='text' size='10' name='_date_of_birth' id='_date_of_birth' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 265 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 266 id='img__date_of_birth' border='0' alt='[?]' style='cursor:pointer'
 267 title='Click here to choose a date'>
 268 <script>
 269 Calendar.setup({inputField:'_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__date_of_birth'});
 270 </script>
 271 </td></tr>
 272
 273 </table>
 274                     </td>
 275
 276                     <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 277
 278 <table>
 279
 280 <tr><td class='text' > age</td> <td class='text' ><input type="text" name="_age"  /></td></tr>
 281
 282 </table>
 283                     </td>
 284
 285                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 286
 287 <table>
 288
 289 <tr><td class='text' > sex</td> <td class='text' ><label><input type="checkbox" name="_sex[]" value="MALE" /> <?php xl("MALE",'e') ?> </label>
 290     <label><input type="checkbox" name="_sex[]" value="FEMALE" /> <?php xl("FEMALE",'e') ?> </label></td></tr>
 291
 292 </table>
 293                     </td>
 294
 295                     <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 296
 297 <table>
 298
 299 <tr><td class='text' > marital status</td> <td class='text' ><label><input type="checkbox" name="_marital_status[]" value="MARRIED" /> <?php xl("MARRIED",'e') ?> </label>
 300     <label><input type="checkbox" name="_marital_status[]" value="SINGLE" />
 301     <?php xl("SINGLE",'e') ?>
 302     </label></td></tr>
 303 </table>
 304                     </td>
 305
 306                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 307
 308 <table>
 309
 310 <tr><td class='text' > occupation</td> <td class='text' ><input type="text" name="_occupation"  /></td></tr>
 311
 312 </table>
 313                     </td>
 314                 </tr>
 315
 316                 <tr>
 317
 318                     <td class='text'     style="border: 1px #000000 solid; height: 15px;">
 319
 320 <table>
 321
 322 <tr><td class='text' > employer name</td> <td class='text' ><input type="text" name="_employer_name"  /></td></tr>
 323
 324 </table>
 325                     </td>
 326
 327                     <td class='text'   colspan="4" style="border: 1px #000000 solid;;">
 328
 329                         <table>
 330
 331                             <tr>
 332
 333                                 <td class='text'  >
 334
 335 <table>
 336
 337 <tr><td class='text' > employer street address</td> <td class='text' ><input type="text" name="_employer_street_address"  /></td></tr>
 338
 339 </table>
 340                                 </td>
 341
 342                                 <td class='text'  >
 343
 344 <table>
 345
 346 <tr><td class='text' > employer city</td> <td class='text' ><input type="text" name="_employer_city"  /></td></tr>
 347
 348 </table>
 349                                 </td>
 350
 351                                 <td class='text'  >
 352
 353 <table>
 354
 355 <tr><td class='text' > employer state</td> <td class='text' ><input type="text" name="_employer_state"  /></td></tr>
 356
 357 </table>
 358                                 </td>
 359
 360                                 <td class='text'  >
 361
 362 <table>
 363
 364 <tr><td class='text' > employer zip code</td> <td class='text' ><input type="text" name="_employer_zip_code"  /></td></tr>
 365
 366 </table>
 367                                 </td>
 368                             </tr>
 369
 370                         </table>
 371                     </td>
 372                 </tr>
 373
 374                  <tr>
 375
 376
 377
 378                     <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 379
 380 <table>
 381
 382 <tr><td class='text' > business phone</td> <td class='text' ><input type="text" name="_business_phone"  /></td></tr>
 383
 384 </table>
 385                     </td>
 386
 387                     <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 388
 389 <table>
 390
 391 <tr><td class='text' > extension</td> <td class='text' ><input type="text" name="_extension"  /></td></tr>
 392
 393 </table>
 394                     </td>
 395
 396                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 397
 398 <table>
 399
 400 <tr><td class='text' > drivers license</td> <td class='text' ><input type="text" name="_drivers_license"  /></td></tr>
 401
 402 </table>
 403                     </td>
 404
 405                     <td class='text'   colspan="2" style="border: 1px #000000 solid; height: 15px;">
 406
 407 <table>
 408
 409 <tr><td class='text' > drivers license state</td> <td class='text' ><input type="text" name="_drivers_license_state"  /></td></tr>
 410
 411 </table>
 412                     </td>
 413
 414
 415                 </tr>
 416
 417
 418
 419
 420
 421             </table>
 422         </td>
 423     </tr>
 424
 425
 426
 427
 428
 429
 430
 431
 432
 433     <tr>
 434
 435          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 436
 437             <table width="100%" cellpadding="0" cellspacing="0">
 438
 439                 <tr>
 440
 441                     <td class='text'   colspan="7" align="center" style="border: 1px #000000 solid; height: 15px;">
 442
 443                         <h3>
 444
 445                             SPOUSE'S, PARENT'S, AND / OR GUARANTER'S INFORMATION
 446
 447                         </h3>
 448                     </td>
 449                 </tr>
 450
 451                 <tr><td class='text'   colspan="7">
 452
 453 <table>
 454
 455 <tr><td class='text' > spg refers to spouse/parents/guarantors</td> <td class='text' ><input type="text" name="_spg_refers_to_spouse_parents_guarantors"  /></td></tr>
 456
 457 </table>
 458                 </td></tr>
 459
 460                 <tr>
 461
 462
 463
 464                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 465
 466 <table>
 467
 468 <tr><td class='text' > spg first name</td> <td class='text' ><input type="text" name="_spg_first_name"  /></td></tr>
 469
 470 </table>
 471                     </td>
 472
 473                     <td class='text'   style="border: 1px #000000 solid;">
 474
 475 <table>
 476
 477 <tr><td class='text' > spg middle name</td> <td class='text' ><input type="text" name="_spg_middle_name"  /></td></tr>
 478
 479 </table>
 480                     </td>
 481
 482                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 483
 484 <table>
 485
 486 <tr><td class='text' > spg last name</td> <td class='text' ><input type="text" name="_spg_last_name"  /></td></tr>
 487
 488 </table>
 489                     </td>
 490
 491                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 492
 493 <table>
 494
 495 <tr><td class='text' > spg occupation</td> <td class='text' ><input type="text" name="_spg_occupation"  /></td></tr>
 496
 497 </table>
 498                     </td>
 499                 </tr>
 500
 501
 502
 503                  <tr>
 504
 505
 506
 507                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 508
 509 <table>
 510
 511 <tr><td class='text' > spg address if different than above</td> <td class='text' ><input type="text" name="_spg_address_if_different_than_above"  /></td></tr>
 512
 513 </table>
 514                     </td>
 515
 516                     <td class='text'   style="border: 1px #000000 solid;">
 517
 518 <table>
 519
 520 <tr><td class='text' > spg city</td> <td class='text' ><input type="text" name="_spg_city"  /></td></tr>
 521
 522 </table>
 523                     </td>
 524
 525                      <td class='text'   style="border: 1px #000000 solid;">
 526
 527 <table>
 528
 529 <tr><td class='text' > spg state</td> <td class='text' ><input type="text" name="_spg_state"  /></td></tr>
 530
 531 </table>
 532                     </td>
 533
 534                     <td class='text'   style="border: 1px #000000 solid;">
 535
 536 <table>
 537
 538 <tr><td class='text' > spg zip code</td> <td class='text' ><input type="text" name="_spg_zip_code"  /></td></tr>
 539
 540 </table>
 541                     </td>
 542
 543                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 544
 545 <table>
 546
 547 <tr><td class='text' > spg home phone</td> <td class='text' ><input type="text" name="_spg_home_phone"  /></td></tr>
 548
 549 </table>
 550                     </td>
 551                 </tr>
 552
 553
 554
 555                   <tr>
 556
 557
 558
 559                     <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 560
 561 <table>
 562
 563 <tr><td class='text' > spg employer street address</td> <td class='text' ><input type="text" name="_spg_employer_street_address"  /></td></tr>
 564
 565 </table>
 566                     </td>
 567
 568                    <td class='text'   style="border: 1px #000000 solid;">
 569
 570 <table>
 571
 572 <tr><td class='text' > spg employer city</td> <td class='text' ><input type="text" name="_spg_employer_city"  /></td></tr>
 573
 574 </table>
 575                     </td>
 576
 577                      <td class='text'   style="border: 1px #000000 solid;">
 578
 579 <table>
 580
 581 <tr><td class='text' > spg employer state</td> <td class='text' ><input type="text" name="_spg_employer_state"  /></td></tr>
 582
 583 </table>
 584                     </td>
 585
 586                     <td class='text'   style="border: 1px #000000 solid;">
 587
 588 <table>
 589
 590 <tr><td class='text' > spg employer zip code</td> <td class='text' ><input type="text" name="_spg_employer_zip_code"  /></td></tr>
 591
 592 </table>
 593                     </td>
 594
 595                      <td class='text'   style="border: 1px #000000 solid;">
 596
 597 <table>
 598
 599 <tr><td class='text' > spg employer business phone</td> <td class='text' ><input type="text" name="_spg_employer_business_phone"  /></td></tr>
 600
 601 </table>
 602                     </td>
 603
 604                     <td class='text'    style="border: 1px #000000 solid;">
 605
 606 <table>
 607
 608 <tr><td class='text' > spg employer extension</td> <td class='text' ><input type="text" name="_spg_employer_extension"  /></td></tr>
 609
 610 </table>
 611                     </td>
 612                 </tr>
 613
 614
 615
 616             </table>
 617         </td>
 618     </tr>
 619
 620
 621
 622      <tr>
 623
 624          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 625
 626             <table width="100%" cellpadding="0" cellspacing="0">
 627
 628                 <tr>
 629
 630                     <td class='text'   colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
 631
 632                         <h3>
 633
 634                             CONCERNING INSURANCE
 635
 636                         </h3>
 637                     </td>
 638                 </tr>
 639
 640                 <tr>
 641
 642
 643
 644                     <td class='text'   colspan="3" style="border: 1px #000000 solid;">
 645
 646 <table>
 647
 648 <tr><td class='text' > concerning insurance deatils</td> <td class='text' ><label><input type="checkbox" name="_concerning_insurance_deatils[]" value="SPOUCE IS POLICY HOLDER" /> <?php xl("SPOUCE IS POLICY HOLDER",'e') ?></label>
 649   <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="MEDICARE" /> <?php xl("MEDICARE",'e') ?></label>
 650   <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="MEDICAL" /> <?php xl("MEDICAL",'e') ?></label>
 651   <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="HMO" /> <?php xl("HMO",'e') ?></label>
 652   <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="WORK COMP" /> <?php xl("WORK COMP",'e') ?></label></td></tr>
 653
 654 </table>
 655                     </td>
 656
 657
 658                 </tr>
 659
 660                 <tr>
 661
 662
 663
 664                     <td class='text'   colspan="3" align="right" >
 665
 666 <table>
 667
 668 <tr><td class='text' >
 669 <span ><?php xl(' date of injury (yyyy-mm-dd): ','e') ?></span>
 670 </td><td class='text' >
 671 <input type='text' size='10' name='_date_of_injury' id='_date_of_injury' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 672 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 673 id='img__date_of_injury' border='0' alt='[?]' style='cursor:pointer'
 674 title='Click here to choose a date'>
 675 <script>
 676 Calendar.setup({inputField:'_date_of_injury', ifFormat:'%Y-%m-%d', button:'img__date_of_injury'});
 677 </script>
 678 </td></tr>
 679
 680 </table>
 681                     </td>
 682
 683
 684                 </tr>
 685
 686
 687
 688                  <tr>
 689
 690
 691
 692                     <td class='text'   style="border: 1px #000000 solid;">
 693
 694 <table>
 695
 696 <tr><td class='text' > primary insurance co here</td> <td class='text' ><input type="text" name="_primary_insurance_co_here"  /></td></tr>
 697
 698 </table>
 699                     </td>
 700
 701                     <td class='text'   style="border: 1px #000000 solid;">
 702
 703 <table>
 704
 705 <tr><td class='text' > primary insurance group number</td> <td class='text' ><input type="text" name="_primary_insurance_group_number"  /></td></tr>
 706
 707 </table>
 708                     </td>
 709
 710                      <td class='text'   style="border: 1px #000000 solid;">
 711
 712 <table>
 713
 714 <tr><td class='text' > primary insurance id number</td> <td class='text' ><input type="text" name="_primary_insurance_id_number"  /></td></tr>
 715
 716 </table>
 717                     </td>
 718
 719
 720                 </tr>
 721
 722
 723
 724                  <tr>
 725
 726
 727
 728                     <td class='text'   style="border: 1px #000000 solid;">
 729
 730 <table>
 731
 732 <tr><td class='text' > primary insurance insured name</td> <td class='text' ><input type="text" name="_primary_insurance_insured_name"  /></td></tr>
 733
 734 </table>
 735                     </td>
 736
 737                     <td class='text'   style="border: 1px #000000 solid;">
 738
 739 <table>
 740
 741 <tr><td class='text' >
 742 <span ><?php xl(' primary insurance insured date of birth (yyyy-mm-dd): ','e') ?></span>
 743 </td><td class='text' >
 744 <input type='text' size='10' name='_primary_insurance_insured_date_of_birth' id='_primary_insurance_insured_date_of_birth' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 745 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 746 id='img__primary_insurance_insured_date_of_birth' border='0' alt='[?]' style='cursor:pointer'
 747 title='Click here to choose a date'>
 748 <script>
 749 Calendar.setup({inputField:'_primary_insurance_insured_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__primary_insurance_insured_date_of_birth'});
 750 </script>
 751 </td></tr>
 752
 753 </table>
 754                     </td>
 755
 756                      <td class='text'   style="border: 1px #000000 solid;">
 757
 758 <table>
 759
 760 <tr><td class='text' > primary insurance insured address</td> <td class='text' ><input type="text" name="_primary_insurance_insured_address"  /></td></tr>
 761
 762 </table>
 763                     </td>
 764
 765
 766                 </tr>
 767
 768
 769
 770                   <tr>
 771
 772
 773
 774                     <td class='text'   style="border: 1px #000000 solid;">
 775
 776 <table>
 777
 778 <tr><td class='text' > secondary insurance co name</td> <td class='text' ><input type="text" name="_secondary_insurance_co_name"  /></td></tr>
 779
 780 </table>
 781                     </td>
 782
 783                     <td class='text'   style="border: 1px #000000 solid;">
 784
 785 <table>
 786
 787 <tr><td class='text' > secondary insurance group number</td> <td class='text' ><input type="text" name="_secondary_insurance_group_number"  /></td></tr>
 788
 789 </table>
 790                     </td>
 791
 792                      <td class='text'   style="border: 1px #000000 solid;">
 793
 794 <table>
 795
 796 <tr><td class='text' > secondary insurance id number</td> <td class='text' ><input type="text" name="_secondary_insurance_id_number"  /></td></tr>
 797
 798 </table>
 799                     </td>
 800
 801
 802                 </tr>
 803
 804
 805
 806                   <tr>
 807
 808
 809
 810                     <td class='text'   style="border: 1px #000000 solid;">
 811
 812 <table>
 813
 814 <tr><td class='text' > secondary insurance insureds name</td> <td class='text' ><input type="text" name="_secondary_insurance_insureds_name"  /></td></tr>
 815
 816 </table>
 817                     </td>
 818
 819                     <td class='text'   style="border: 1px #000000 solid;">
 820
 821 <table>
 822
 823 <tr><td class='text' >
 824 <span ><?php xl(' secondary insurance insureds date of birth (yyyy-mm-dd): ','e') ?></span>
 825 </td><td class='text' >
 826 <input type='text' size='10' name='_secondary_insurance_insureds_date_of_birth' id='_secondary_insurance_insureds_date_of_birth' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 827 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 828 id='img__secondary_insurance_insureds_date_of_birth' border='0' alt='[?]' style='cursor:pointer'
 829 title='Click here to choose a date'>
 830 <script>
 831 Calendar.setup({inputField:'_secondary_insurance_insureds_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__secondary_insurance_insureds_date_of_birth'});
 832 </script>
 833 </td></tr>
 834
 835 </table>
 836                     </td>
 837
 838                      <td class='text'   style="border: 1px #000000 solid;">
 839
 840 <table>
 841
 842 <tr><td class='text' > secondary insurance insureds col address</td> <td class='text' ><input type="text" name="_secondary_insurance_insureds_col_address"  /></td></tr>
 843
 844 </table>
 845                     </td>
 846
 847
 848                 </tr>
 849
 850
 851
 852
 853
 854
 855
 856             </table>
 857         </td>
 858     </tr>
 859
 860
 861
 862
 863
 864       <tr>
 865
 866          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 867
 868             <table width="100%" cellpadding="0" cellspacing="0">
 869
 870                 <tr>
 871
 872                     <td class='text'   colspan="4" align="center" style="border: 1px #000000 solid; height: 15px;">
 873
 874                         <h3>
 875
 876                             EMERGENCY INFORMATION
 877
 878                         </h3>
 879                     </td>
 880                 </tr>
 881
 882
 883
 884
 885
 886                  <tr>
 887
 888
 889
 890                     <td class='text'   colspan="3" style="border: 1px #000000 solid;">
 891
 892 <table>
 893
 894 <tr><td class='text' > person to notify in case of emergency not leaving with you</td> <td class='text' ><input type="text" name="_person_to_notify_in_case_of_emergency_not_leaving_with_you"  /></td></tr>
 895
 896 </table>
 897                     </td>
 898
 899                     <td class='text'   style="border: 1px #000000 solid;">
 900
 901 <table>
 902
 903 <tr><td class='text' > relationship</td> <td class='text' ><input type="text" name="_relationship"  /></td></tr>
 904
 905 </table>
 906                     </td>
 907
 908
 909                 </tr>
 910
 911
 912
 913                  <tr>
 914
 915
 916
 917                     <td class='text'   style="border: 1px #000000 solid;">
 918
 919 <table>
 920
 921 <tr><td class='text' > person address</td> <td class='text' ><input type="text" name="_person_address"  /></td></tr>
 922
 923 </table>
 924                     </td>
 925
 926                     <td class='text'   style="border: 1px #000000 solid;">
 927
 928 <table>
 929
 930 <tr><td class='text' > person street</td> <td class='text' ><input type="text" name="_person_street"  /></td></tr>
 931
 932 </table>
 933                     </td>
 934
 935                      <td class='text'   style="border: 1px #000000 solid;">
 936
 937 <table>
 938
 939 <tr><td class='text' > person apt</td> <td class='text' ><input type="text" name="_person_apt"  /></td></tr>
 940
 941 </table>
 942                     </td>
 943
 944
 945
 946                       <td class='text'   style="border: 1px #000000 solid;">
 947
 948 <table>
 949
 950 <tr><td class='text' > person space</td> <td class='text' ><input type="text" name="_person_space"  /></td></tr>
 951
 952 </table>
 953                     </td>
 954
 955
 956                 </tr>
 957
 958                   <tr>
 959
 960
 961
 962                     <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 963
 964 <table>
 965
 966 <tr><td class='text' > person city</td> <td class='text' ><input type="text" name="_person_city"  /></td></tr>
 967
 968 </table>
 969                     </td>
 970
 971                     <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 972
 973 <table>
 974
 975 <tr><td class='text' > person state</td> <td class='text' ><input type="text" name="_person_state"  /></td></tr>
 976
 977 </table>
 978                     </td>
 979
 980                      <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 981
 982 <table>
 983
 984 <tr><td class='text' > person zip code</td> <td class='text' ><input type="text" name="_person_zip_code"  /></td></tr>
 985
 986 </table>
 987                     </td>
 988
 989
 990
 991                      <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 992
 993 <table>
 994
 995 <tr><td class='text' > person home phone</td> <td class='text' ><input type="text" name="_person_home_phone"  /></td></tr>
 996
 997 </table>
 998                     </td>
 999                 </tr>
1000
1001
1002
1003
1004
1005
1006
1007
1008
1009
1010
1011             </table>
1012         </td>
1013     </tr>
1014
1015 </table>
1016 <table width="100%"><tr><td class='text'   colspan="3"><h3> <?php xl("Health History (Confidential)",'e') ?> </h3></td></tr>
1017
1018 <tr>
1019 <td class='text'   colspan="3" style="border: 1px #000000 solid"><h3> <?php xl("History and Physical",'e') ?> </h3></td></tr>
1020
1021 <tr><td class='text'    valign="top">
1022
1023  <?php xl("Heart problems",'e') ?><br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Attack" /> <?php xl("Heart Attack",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Angina" /> <?php xl("Angina",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Murmur" /> <?php xl("Heart Murmur",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Rheumatic Fever" /> <?php xl("Rheumatic Fever",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Abnormal Rhythm-arrhythmia" /> <?php xl("Abnormal Rhythm(arrhythmia)",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Palpitations and irregular heartbeats" /> <?php xl("Palpitations and irregular heartbeats",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Fainting" /> <?php xl("Fainting",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Enlarge Heart" /> <?php xl("Enlarge Heart",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Chest Pains or Pressure" /> <?php xl("Chest Pains or Pressure",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Shortness of Breath" /> <?php xl("Shortness of Breath",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Dizziness" /> <?php xl("Dizziness",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Swollen Legs" /> <?php xl("Swollen Legs",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Failure" /> <?php xl("Heart Failure",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Blue Lips or Fingernails" /> <?php xl("Blue Lips or Fingernails",'e') ?> </label> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Leg Cramps when you walk" /> <?php xl("Leg Cramps when you walk",'e') ?> </label></td>
1024
1025 <td class='text'    valign="top">
1026
1027  <?php xl("Have you ever had",'e') ?><br> <label><input type="checkbox" name="have_you_ever_had[]" value="A Stress Test" /> <?php xl("A Stress Test",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="An Echocardiogram" /> <?php xl("An Echocardiogram",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Cardiac Catheterization" /> <?php xl("Cardiac Catheterization",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Coronary Angioplasty" /> <?php xl("Coronary Angioplasty",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Coronary Bypass Surgery" /> <?php xl("Coronary Bypass Surgery",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Valve Surgery" /> <?php xl("Valve Surgery",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Electrophysiology Study or Proc" /> <?php xl("Electrophysiology Study or Proc",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="A Pacemaker" /> <?php xl("A Pacemaker",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Implanted Defibrillator" /> <?php xl("Implanted Defibrillator",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="ECG" /> <?php xl("ECG",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="24 Holter Monitor" /> <?php xl("24 Holter Monitor",'e') ?> </label> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Event Recorder " /> <?php xl("Event Recorder ",'e') ?> </label>
1028 </td>
1029
1030 <td class='text'    valign="top">
1031 <?php xl("Check if you have",'e') ?><br> <label><input type="checkbox" name="check_if_you_have[]" value="High Blood Pressure" /> <?php xl("High Blood Pressure",'e') ?> </label> <br> <label><input type="checkbox" name="check_if_you_have[]" value="High Cholestrol" /> <?php xl("High Cholestrol",'e') ?> </label> <br> <label><input type="checkbox" name="check_if_you_have[]" value="Ever Smoked" /> <?php xl("Ever Smoked",'e') ?> </label> <br> <label><input type="checkbox" name="check_if_you_have[]" value="Diabetes" /> <?php xl("Diabetes",'e') ?> </label> <br> <label><input type="checkbox" name="check_if_you_have[]" value="Do You Exercise" /> <?php xl("Do You Exercise",'e') ?> </label><br><?php xl("Close family member with",'e') ?><br> <label><input type="checkbox" name="close_family_member_with[]" value="Heart Attack" /> <?php xl("Heart Attack",'e') ?> </label> <br> <label><input type="checkbox" name="close_family_member_with[]" value="Angina" /> <?php xl("Angina",'e') ?> </label><br><?php xl("If a woman have you",'e') ?><br> <label><input type="checkbox" name="if_a_woman_have_you[]" value="Passed Menopause" /> <?php xl("Passed Menopause",'e') ?> </label><br><?php xl("Menopause passed on what age",'e') ?><input type="text" name="menopause_passed_on_what_age"  /><br><label><input type="checkbox" name="have_you_take_estrogen_replacement" value="yes" /></label>  <?php xl("Have you take estrogen replacement",'e') ?></td></tr>
1032
1033
1034 </td>
1035 </tr>
1036
1037
1038
1039 <tr><td class='text'  colspan="3"> <?php xl("Please tell us anything else about heart",'e') ?><textarea name="please_tell_us_anything_else_about_heart"  rows="4" cols="40"></textarea>
1040 <tr><td class='text'   colspan="3" style="border: 1px #000000 solid; height: 28px;"><h3> <?php xl("Current Medications",'e') ?> </h3></td></tr>
1041
1042 <tr>
1043
1044 <td class='text'   colspan="3">
1045     <strong> <?php xl("Please tell us about medicines(name,dose or strength,how many times a day).Include over the counter medictaions:",'e') ?> </strong></td></tr>
1046
1047 <tr><td class='text'   colspan="3">
1048
1049 <table>
1050
1051 <tr><td class='text' > <?php xl("Medicine detail1",'e') ?><textarea name="medicine_detail1"  rows="4" cols="40"></textarea></td></tr>
1052
1053 </table>
1054 </td></tr>
1055
1056 <tr><td class='text'   colspan="3">
1057
1058 <table>
1059
1060 <tr><td class='text' > <?php xl("Medicine detail2",'e') ?><textarea name="medicine_detail2"  rows="4" cols="40"></textarea></td></tr>
1061
1062 </table>
1063 </td></tr>
1064
1065 <tr><td class='text'   colspan="3">
1066
1067 <table>
1068
1069 <tr><td class='text' > <?php xl("Medicine detail3",'e') ?><textarea name="medicine_detail3"  rows="4" cols="40"></textarea></td></tr>
1070
1071 </table>
1072 </td></tr>
1073
1074 <tr><td class='text'   colspan="3">
1075
1076 <table>
1077
1078 <tr><td class='text' > <?php xl("Medicine detail4",'e') ?><textarea name="medicine_detail4"  rows="4" cols="40"></textarea></td></tr>
1079
1080 </table>
1081 </td></tr>
1082
1083 <tr><td class='text'   colspan="3">
1084
1085 <table>
1086
1087 <tr><td class='text' > <?php xl("Medicine detail5",'e') ?><textarea name="medicine_detail5"  rows="4" cols="40"></textarea></td></tr>
1088
1089 </table>
1090 </td></tr>
1091
1092 <tr><td class='text'   colspan="3">
1093
1094 <table>
1095
1096 <tr><td class='text' > <?php xl("Medicine detail6",'e') ?><textarea name="medicine_detail6"  rows="4" cols="40"></textarea></td></tr>
1097
1098 </table>
1099 </td></tr>
1100
1101 <tr><td class='text'   colspan="3">
1102
1103 <table>
1104
1105 <tr><td class='text' > <?php xl("Medicine detail7",'e') ?><textarea name="medicine_detail7"  rows="4" cols="40"></textarea></td></tr>
1106
1107 </table>
1108 </td></tr>
1109
1110 <tr><td class='text'   colspan="3">
1111
1112 <table>
1113
1114 <tr><td class='text' > <?php xl("Medicine detail8",'e') ?><textarea name="medicine_detail8"  rows="4" cols="40"></textarea></td></tr>
1115
1116 </table>
1117 </td></tr>
1118
1119 <tr>
1120 <td class='text'   colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Allergies",'e') ?> </h3></td></tr>
1121
1122 <tr><td class='text'   colspan="3">
1123
1124 <table>
1125
1126 <tr><td class='text' > <?php xl("Are you allergic to any medications",'e') ?>
1127   <label><input type="checkbox" name="are_you_allergic_to_any_medications[]" value="Yes" /> <?php xl("Yes",'e') ?> </label>
1128   <label><input type="checkbox" name="are_you_allergic_to_any_medications[]" value="No" /> <?php xl("No",'e') ?> </label></td></tr>
1129
1130 </table>
1131 </td></tr>
1132
1133 <tr><td class='text'   colspan="3">
1134
1135 <table>
1136
1137 <tr><td class='text' > <?php xl("Lis medicine to which you are allergic",'e') ?><input type="text" name="lis_medicine_to_which_you_are_allergic"  /></td></tr>
1138
1139 </table>
1140 </td></tr>
1141
1142 <tr><td class='text'   colspan="3">
1143
1144 <table>
1145
1146 <tr><td class='text' > <?php xl("What kind of reaction did you have",'e') ?><input type="text" name="what_kind_of_reaction_did_you_have"  /></td></tr>
1147
1148 </table>
1149 </td></tr>
1150
1151 <tr>
1152
1153 <td class='text'   valign="top">
1154
1155 <?php xl("Constitutional",'e') ?><br> <label><input type="checkbox" name="constitutional[]" value="Lack of energy" /> <?php xl("Lack of energy",'e') ?> </label> <br> <label><input type="checkbox" name="constitutional[]" value="Trouble sleeping" /> <?php xl("Trouble sleeping",'e') ?> </label><BR><label><input type="checkbox" name="constitutional[]" value="Loss of appetite" /> <?php xl("Loss of appetite",'e') ?> </label> <br> <label><input type="checkbox" name="constitutional[]" value="Weight changes" /> <?php xl("Weight changes",'e') ?></label><br><label><input type="checkbox" name="constitutional[]" value="Fever" /> <?php xl("Fever",'e') ?> </label>
1156 </td>
1157
1158 <td class='text'    valign="top">
1159
1160  <?php xl("Heent",'e') ?><br> <label><input type="checkbox" name="heent[]" value="Blurred vision" /> <?php xl("Blurred vision",'e') ?> </label> <br> <label><input type="checkbox" name="heent[]" value="Glaucoma" /> <?php xl("Glaucoma",'e') ?> </label> <br> <label><input type="checkbox" name="heent[]" value="Cataracts" /> <?php xl("Cataracts",'e') ?> </label> <br> <label><input type="checkbox" name="heent[]" value="Buzzing or ringing in ears" /> <?php xl("Buzzing or ringing in ears",'e') ?> </label> <br> <label><input type="checkbox" name="heent[]" value="Hay fever" /> <?php xl("Hay fever",'e') ?> </label> <br> <label><input type="checkbox" name="heent[]" value="Sinus problem" /> <?php xl("Sinus problem",'e') ?> </label>
1161 </td>
1162
1163 <td class='text'    valign="top">
1164
1165 <?php xl("Respiratory",'e') ?><br> <label><input type="checkbox" name="respiratory[]" value="Wheezing" /> <?php xl("Wheezing",'e') ?> </label> <br> <label><input type="checkbox" name="respiratory[]" value="Cough" /> <?php xl("Cough",'e') ?> </label> <br> <label><input type="checkbox" name="respiratory[]" value="Coughing Blood" /> <?php xl("Coughing Blood",'e') ?> </label> <br> <label><input type="checkbox" name="respiratory[]" value="Asthma" /> <?php xl("Asthma",'e') ?> </label> <br> <label><input type="checkbox" name="respiratory[]" value="Tuberculosis" /> <?php xl("Tuberculosis",'e') ?> </label>
1166 </td>
1167 </tr>
1168
1169 <tr>
1170
1171 <td class='text'    valign="top">
1172
1173  <?php xl("Digestive",'e') ?><br> <label><input type="checkbox" name="digestive[]" value="Indigestion" /> <?php xl("Indigestion",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Change in bowel habits" /> <?php xl("Change in bowel habits",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Bloody or tarry stools" /> <?php xl("Bloody or tarry stools",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Jaundice" /> <?php xl("Jaundice",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Liver problems" /> <?php xl("Liver problems",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Ulcers" /> <?php xl("Ulcers",'e') ?> </label> <br> <label><input type="checkbox" name="digestive[]" value="Gallstone" /> <?php xl("Gallstone",'e') ?> </label>
1174 </td>
1175
1176 <td class='text'    valign="top">
1177
1178  <?php xl("Urinary",'e') ?><br> <label><input type="checkbox" name="urinary[]" value="Frequency" /> <?php xl("Frequency",'e') ?> </label> <br> <label><input type="checkbox" name="urinary[]" value="Infections" /> <?php xl("Infections",'e') ?> </label> <br> <label><input type="checkbox" name="urinary[]" value="Stones" /> <?php xl("Stones",'e') ?> </label> <br> <label><input type="checkbox" name="urinary[]" value="Bladder incontinence" /> <?php xl("Bladder incontinence",'e') ?> </label>
1179 </td>
1180
1181 <td class='text'    valign="top">
1182
1183  <?php xl("Musculoskeletal",'e') ?><br> <label><input type="checkbox" name="musculoskeletal[]" value="Joint pain swelling or redness" /> <?php xl("Joint pain swelling or redness",'e') ?> </label> <br> <label><input type="checkbox" name="musculoskeletal[]" value="arthritis" /> <?php xl("arthritis",'e') ?> </label> <br> <label><input type="checkbox" name="musculoskeletal[]" value="back pain" /> <?php xl("back pain",'e') ?> </label> <br> <label><input type="checkbox" name="musculoskeletal[]" value="muscle aches" /> <?php xl("muscle aches",'e') ?> </label> <br> <label><input type="checkbox" name="musculoskeletal[]" value="muscle tenderness" /> <?php xl("muscle tenderness",'e') ?> </label> <br> <label><input type="checkbox" name="musculoskeletal[]" value="gout" /> <?php xl("gout",'e') ?> </label>
1184 </td>
1185 </tr>
1186
1187 <tr>
1188
1189 <td class='text'    valign="top">
1190  <?php xl("Dermatological",'e') ?><br> <label><input type="checkbox" name="dermatological[]" value="Rash" /> <?php xl("Rash",'e') ?> </label> <br> <label><input type="checkbox" name="dermatological[]" value="Itching" /> <?php xl("Itching",'e') ?> </label> <br> <label><input type="checkbox" name="dermatological[]" value="other skin problems" /> <?php xl("other skin problems",'e') ?> </label>
1191 </td>
1192
1193 <td class='text'    valign="top">
1194
1195 <?php xl("Men",'e') ?><br> <label><input type="checkbox" name="men[]" value="Prostate problems" /> <?php xl("Prostate problems",'e') ?> </label> <br> <label><input type="checkbox" name="men[]" value="night time urination" /> <?php xl("night time urination",'e') ?> </label>
1196 </td>
1197
1198 <td class='text'    valign="top">
1199
1200  <?php xl("Women",'e') ?><br> <label><input type="checkbox" name="women[]" value="Abnormal Menstrua periods" /> <?php xl("Abnormal Menstrua periods",'e') ?> </label> <br> <label><input type="checkbox" name="women[]" value="could you be pregnant" /> <?php xl("could you be pregnant",'e') ?> </label>
1201 </td>
1202 </tr>
1203
1204 <tr>
1205
1206 <td class='text'    valign="top">
1207
1208  <?php xl("Female reproductive",'e') ?><br> <label><input type="checkbox" name="female_reproductive[]" value="breast lumps" /> <?php xl("breast lumps",'e') ?> </label> <br> <label><input type="checkbox" name="female_reproductive[]" value="recent mamogram" /> <?php xl("recent mamogram",'e') ?> </label> <br> <label><input type="checkbox" name="female_reproductive[]" value="pap smear or pelvic exam" /> <?php xl("pap smear or pelvic exam",'e') ?> </label>
1209 </td>
1210
1211 <td class='text'    valign="top">
1212
1213  <?php xl("Neurological",'e') ?><br> <label><input type="checkbox" name="neurological[]" value="Paralysis-even temporary" /> <?php xl("Paralysis-even temporary",'e') ?> </label> <br> <label><input type="checkbox" name="neurological[]" value="stroke" /> <?php xl("stroke",'e') ?> </label> <br> <label><input type="checkbox" name="neurological[]" value="numbness" /> <?php xl("numbness",'e') ?> </label> <br> <label><input type="checkbox" name="neurological[]" value="loss of balance" /> <?php xl("loss of balance",'e') ?> </label> <br> <label><input type="checkbox" name="neurological[]" value="dizziness" /> <?php xl("dizziness",'e') ?> </label>
1214 </td>
1215
1216 <td class='text'    valign="top">
1217
1218  <?php xl("Psychiatric",'e') ?><br> <label><input type="checkbox" name="psychiatric[]" value="Unusual thoughts" /> <?php xl("Unusual thoughts",'e') ?> </label> <br> <label><input type="checkbox" name="psychiatric[]" value="Nervousness" /> <?php xl("Nervousness",'e') ?> </label> <br> <label><input type="checkbox" name="psychiatric[]" value="crying or sadness" /> <?php xl("crying or sadness",'e') ?> </label> <br> <label><input type="checkbox" name="psychiatric[]" value="depression" /> <?php xl("depression",'e') ?> </label> <br> <label><input type="checkbox" name="psychiatric[]" value="suicide attempts" /> <?php xl("suicide attempts",'e') ?> </label>
1219 </td>
1220 </tr>
1221
1222 <tr>
1223
1224 <td class='text'    valign="top">
1225
1226  <?php xl("Endocrinology",'e') ?><br> <label><input type="checkbox" name="endocrinology[]" value="Thyroid disorder" /> <?php xl("Thyroid disorder",'e') ?> </label> <br> <label><input type="checkbox" name="endocrinology[]" value="Diabetes" /><?php xl("Diabetes",'e') ?> </label> <br> <label><input type="checkbox" name="endocrinology[]" value="Excess thirst" /><?php xl("Excess thirst",'e') ?> </label> <br> <label><input type="checkbox" name="endocrinology[]" value="Excess hunger" /> <?php xl("Excess hunger",'e') ?> </label> <br> <label><input type="checkbox" name="endocrinology[]" value="excess urination" /> <?php xl("excess urination",'e') ?> </label>
1227 </td>
1228
1229 <td class='text'    valign="top">
1230
1231  <?php xl("Hematological",'e') ?><br> <label><input type="checkbox" name="hematological[]" value="Bleeding" /> <?php xl("Bleeding",'e') ?> </label> <br> <label><input type="checkbox" name="hematological[]" value="Easy bruising" /> <?php xl("Easy bruising",'e') ?> </label> <br> <label><input type="checkbox" name="hematological[]" value="risk factors for hiv" /> <?php xl("risk factors for hiv",'e') ?> </label> <br> <label><input type="checkbox" name="hematological[]" value="Anemia" /> <?php xl("Anemia",'e') ?> </label> <br> <label><input type="checkbox" name="hematological[]" value="Cancer" /> <?php xl("Cancer",'e') ?> </label>
1232 </td>
1233
1234 <td class='text'    valign="top">&nbsp;
1235
1236
1237 </td>
1238 </tr>
1239
1240 <tr><td class='text'   colspan="3">
1241
1242 <table>
1243
1244 <tr><td class='text' > <?php xl("Have you had any operations",'e') ?><textarea name="have_you_had_any_operations"  rows="4" cols="40"></textarea></td></tr>
1245
1246 </table>
1247 </td></tr>
1248
1249 <tr><td class='text'   colspan="3">
1250
1251 <table>
1252
1253 <tr><td class='text' > <?php xl("Are you being treated now or have been treated for any illness",'e') ?><textarea name="are_you_being_treated_now_or_have_been_treated_for_any_illness"  rows="4" cols="40"></textarea></td></tr>
1254
1255 </table>
1256 </td></tr>
1257
1258 <tr><td class='text'   colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Social History
1259 ",'e') ?></h3> </td></tr>
1260
1261 <tr>
1262
1263 <td class='text'  colspan="2" ><strong>
1264
1265 Marital</strong></td>
1266
1267 <td class='text'   valign="top" ><strong>
1268
1269 Health Habits:</strong></td>
1270 </tr>
1271
1272 <tr>
1273
1274 <td class='text'   colspan="2">
1275
1276 <table>
1277
1278 <tr><td class='text' > <?php xl("Marital status",'e') ?>
1279   <label><input type="checkbox" name="marital_status[]" value="single" /> <?php xl("single",'e') ?> </label>
1280   <label><input type="checkbox" name="marital_status[]" value="married" /> <?php xl("married",'e') ?> </label>
1281   <label><input type="checkbox" name="marital_status[]" value="widowed" /> <?php xl("widowed",'e') ?> </label>
1282   <label><input type="checkbox" name="marital_status[]" value="divorced" />
1283   <?php xl("divorced",'e') ?></label></td></tr>
1284
1285 </table>
1286 </td>
1287
1288 <td class='text'    valign="top">
1289
1290 <table>
1291
1292 <tr><td class='text' > <?php xl("Do you smoke",'e') ?>
1293   <label><input type="checkbox" name="do_you_smoke[]" value="Yes" /> <?php xl("Yes",'e') ?> </label>
1294   <label><input type="checkbox" name="do_you_smoke[]" value="No" /> <?php xl("No",'e') ?> </label></td></tr>
1295
1296 </table>
1297 </td>
1298 </tr>
1299
1300 <tr>
1301
1302 <td class='text'   colspan="2">
1303
1304 <table>
1305
1306 <tr><td class='text' > <?php xl("Occupation",'e') ?><input type="text" name="occupation"  /></td></tr>
1307
1308 </table>
1309 </td>
1310
1311 <td class='text'    valign="top">
1312
1313 <table>
1314
1315 <tr><td class='text' > <?php xl("How many packs per day",'e') ?><input type="text" name="how_many_packs_per_day"  /></td></tr>
1316
1317 </table>
1318 </td>
1319 </tr>
1320
1321 <tr>
1322
1323 <td class='text'   colspan="2">
1324
1325 <table>
1326
1327 <tr><td class='text' > <?php xl("Leisure activities",'e') ?><input type="text" name="leisure_activities"  /></td></tr>
1328
1329 </table>
1330 </td>
1331
1332 <td class='text'    valign="top">
1333
1334 <table>
1335
1336 <tr><td class='text' > <?php xl("For how many years",'e') ?><input type="text" name="for_how_many_years"  /></td></tr>
1337
1338 </table>
1339 </td>
1340 </tr>
1341
1342 <tr>
1343
1344 <td class='text'   colspan="2">
1345
1346 <table>
1347
1348 <tr><td class='text' > <?php xl("Educational level",'e') ?><input type="text" name="educational_level"  /></td></tr>
1349
1350 </table>
1351 </td>
1352
1353 <td class='text'    valign="top">
1354
1355 <table>
1356
1357 <tr><td class='text' > <?php xl("How much alcohol do you drink",'e') ?><input type="text" name="how_much_alcohol_do_you_drink"  /></td></tr>
1358
1359 </table>
1360 </td>
1361 </tr>
1362
1363 <tr>
1364
1365 <td class='text'   colspan="2">&nbsp;
1366
1367
1368 </td>
1369
1370 <td class='text'    valign="top">
1371
1372 <table>
1373
1374 <tr><td class='text' > <?php xl("Do you use any drugs",'e') ?><input type="text" name="do_you_use_any_drugs"  /></td></tr>
1375
1376 </table>
1377 </td>
1378 </tr>
1379
1380 <tr><td class='text'   colspan="3"  style="border: 1px #000000 solid;">
1381 <H3>Family History:</H3>
1382
1383 </td></tr>
1384 <tr><td class='text'   colspan="3"> <?php xl("Check if any close family members(parents,brothers and sisters,children) have:",'e') ?> </td></tr>
1385
1386 <tr><td class='text'   colspan="3">
1387
1388 <table>
1389
1390 <tr><td class='text' > <?php xl("Heart problems",'e') ?>
1391   <label><input type="checkbox" name="heart_problems[]" value="Mother" /> <?php xl("Mother",'e') ?> </label>
1392   <label><input type="checkbox" name="heart_problems[]" value="Father" /> <?php xl("Father",'e') ?> </label>
1393   <label><input type="checkbox" name="heart_problems[]" value="Brother" /> <?php xl("Brother",'e') ?> </label>
1394   <label><input type="checkbox" name="heart_problems[]" value="Sister" /> <?php xl("Sister",'e') ?> </label>
1395   <label><input type="checkbox" name="heart_problems[]" value="Child" /> <?php xl("Child",'e') ?> </label>
1396   <label><input type="checkbox" name="heart_problems[]" value="None" /> <?php xl("None",'e') ?> </label></td></tr>
1397
1398 </table>
1399 </td></tr>
1400
1401 <tr><td class='text'   colspan="3">
1402
1403 <table>
1404
1405 <tr><td class='text' > <?php xl("High blood pressure",'e') ?>
1406   <label><input type="checkbox" name="high_blood_pressure[]" value="Mother" /> <?php xl("Mother",'e') ?> </label>
1407   <label><input type="checkbox" name="high_blood_pressure[]" value="Father" /> <?php xl("Father",'e') ?> </label>
1408   <label><input type="checkbox" name="high_blood_pressure[]" value="Brother" /> <?php xl("Brother",'e') ?> </label>
1409   <label><input type="checkbox" name="high_blood_pressure[]" value="Sister" /> <?php xl("Sister",'e') ?> </label>
1410   <label><input type="checkbox" name="high_blood_pressure[]" value="Child" /> <?php xl("Child",'e') ?> </label>
1411   <label><input type="checkbox" name="high_blood_pressure[]" value="None" />
1412   <?php xl("None",'e') ?></label></td></tr>
1413
1414 </table>
1415 </td></tr>
1416
1417 <tr><td class='text'   colspan="3">
1418
1419 <table>
1420
1421 <tr><td class='text' > <?php xl("Diabetes",'e') ?>
1422   <label><input type="checkbox" name="diabetes[]" value="Mother" /> <?php xl("Mother",'e') ?> </label>
1423   <label><input type="checkbox" name="diabetes[]" value="Father" /> <?php xl("Father",'e') ?> </label>
1424   <label><input type="checkbox" name="diabetes[]" value="Brother" /> <?php xl("Brother",'e') ?> </label>
1425   <label><input type="checkbox" name="diabetes[]" value="Sister" /> <?php xl("Sister",'e') ?> </label>
1426   <label><input type="checkbox" name="diabetes[]" value="Child" /> <?php xl("Child",'e') ?> </label>
1427   <label><input type="checkbox" name="diabetes[]" value="None" />
1428   <?php xl("None",'e') ?></label></td></tr>
1429
1430 </table>
1431 </td></tr>
1432
1433 <tr><td class='text'   colspan="3">
1434
1435 <table>
1436
1437 <tr><td class='text' > cancer</td> <td class='text' ><label><input type="checkbox" name="_cancer[]" value="Mother" /> <?php xl("Mother",'e') ?> </label>
1438     <label><input type="checkbox" name="_cancer[]" value="Father" /> <?php xl("Father",'e') ?> </label>
1439     <label><input type="checkbox" name="_cancer[]" value="Brother" /> <?php xl("Brother",'e') ?> </label>
1440     <label><input type="checkbox" name="_cancer[]" value="Sister" /> <?php xl("Sister",'e') ?> </label>
1441     <label><input type="checkbox" name="_cancer[]" value="Child" /> <?php xl("Child",'e') ?> </label>
1442     <label><input type="checkbox" name="_cancer[]" value="None" />
1443     <?php xl("None",'e') ?></label></td></tr>
1444
1445 </table>
1446     </td></tr>
1447
1448 <tr>
1449
1450 <td class='text'   colspan="3" style="border: 1px #000000 solid;">
1451 <h3>
1452 Hospitalizations:</h3>
1453 </td></tr>
1454
1455 <tr>
1456
1457 <td class='text'    valign="top">
1458
1459 <table>
1460
1461 <tr><td class='text' > <?php xl("Year",'e') ?><input type="text" name="year"  /></td></tr>
1462
1463 </table>
1464 </td>
1465
1466 <td class='text'    valign="top">
1467
1468 <table>
1469
1470 <tr><td class='text' > <?php xl("Hospital",'e') ?><input type="text" name="hospital"  /></td></tr>
1471
1472 </table>
1473 </td>
1474
1475 <td class='text'    valign="top">
1476
1477 <table>
1478
1479 <tr><td class='text' > <?php xl("Reason",'e') ?><input type="text" name="reason"  /></td></tr>
1480
1481 </table>
1482 </td>
1483 </tr>
1484
1485 </table>
1486 <table></table><input type="submit" name="submit form" value="submit form" />
1487 </form>
1488 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
1489 <?php
1490 formFooter();
1491 ?>