contrib/forms/chiro_history/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 # $patient = formNanak("patient_data", $_GET["id"]);
   5 //#Use the formnanak function from api.inc to get values for manjit
   6 formHeader("Form: chiro_history");
   7 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   8 ?>
   9 <html><head>
  10 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  11 </head>
  12 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  13 <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  14 <script type="text/javascript" src="../../../library/dialog.js"></script>
  15 <script type="text/javascript" src="../../../library/textformat.js"></script>
  16 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  17 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  18 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  19 <script language='JavaScript'> var mypcc = '1'; </script>
  20
  21 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  22 <form method=post action="<?php echo $rootdir;?>/forms/chiro_history/save.php?mode=new" name="chiro_history" onsubmit="return top.restoreSession()">
  23 <hr>
  24 <h1> <?php xl("Chiropractic History",'e') ?> </h1>
  25 <hr>
  26 <input type="submit" name="submit form" value="submit form" /><br>
  27 <br>
  28 <h3> <?php xl("History",'e') ?> </h3>
  29 <hr />
  30
  31 <table id="HIS" style="width:80%;margin-right:auto;margin-left:20px;"><tbody class="data" style="padding:2px 0px 0px 2px;margin:0px;line-height:10px;">
  32 <tr>
  33
  34 <td><table><tbody class="data">
  35 <tr>
  36 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("General","e") ?></td>
  37 </tr>
  38 <tr>
  39 <td><input type="checkbox" name="general_condit['allergy'][0]" value = "allergy" /></td>
  40 <td><input type="checkbox" name="general_condit['allergy'][1]" value = "allergy" /></td>
  41 <td><?php xl("Allergy", "e") ?></td> </tr>
  42 <tr>
  43 <td><input type="checkbox" name="general_condit['convulsion'][0]" value = "convulsion" /></td>
  44 <td><input type="checkbox" name="general_condit['convulsion'][1]" value = "convulsion" /></td>
  45 <td><?php xl("Convulsion", "e") ?></td></tr>
  46 <tr>
  47 <td><input type="checkbox" name="general_condit['dizziness'][0]" value = "dizziness" /></td>
  48 <td><input type="checkbox" name="general_condit['dizziness'][1]" value = "dizziness" /></td>
  49 <td><?php xl("Dizziness", "e") ?></td></tr>
  50 <tr>
  51 <td><input type="checkbox" name="general_condit['fainting'][0]" value = "fainting" /></td>
  52 <td><input type="checkbox" name="general_condit['fainting'][1]" value = "fainting" /></td>
  53 <td><?php xl("Fainting", "e") ?></td></tr>
  54 <tr>
  55 <td><input type="checkbox" name="general_condit['fatigue'][0]" value = "fatigue" /></td>
  56 <td><input type="checkbox" name="general_condit['fatigue'][1]" value = "fatigue" /></td>
  57 <td><?php xl("Fatigue", "e") ?></td></tr>
  58 <tr>
  59 <td><input type="checkbox" name="general_condit['depression'][0]" value = "depression" /></td>
  60 <td><input type="checkbox" name="general_condit['depression'][1]" value = "depression" /></td>
  61 <td><?php xl("Depression", "e") ?></td></tr>
  62 <tr>
  63 <td><input type="checkbox" name="general_condit['headache'][0]" value = "headache" /></td>
  64 <td><input type="checkbox" name="general_condit['headache'][1]" value = "headache" /></td>
  65 <td><?php xl("Headache", "e") ?> </td></tr>
  66 </tbody></table></td>
  67
  68 <td><table><tbody class="data">
  69 <tr>
  70 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("Gastro-Intestinal","e") ?></td>
  71 </tr>
  72 <tr>
  73 <td><input type="checkbox" name="gastrointest['constipation'][0]" value = "constipation" /></td>
  74 <td><input type="checkbox" name="gastrointest['constipation'][1]" value = "constipation" /></td>
  75 <td><?php xl("Constipation", "e") ?></td> </tr>
  76 <tr>
  77 <td><input type="checkbox" name="gastrointest['diarrhea'][0]" value = "diarrhea" /></td>
  78 <td><input type="checkbox" name="gastrointest['diarrhea'][1]" value = "diarrhea" /></td>
  79 <td><?php xl("Diarrhea", "e") ?></td></tr>
  80 <tr>
  81 <td><input type="checkbox" name="gastrointest['digestion_trouble'][0]" value = "digestion_trouble" /></td>
  82 <td><input type="checkbox" name="gastrointest['digestion_trouble'][1]" value = "digestion_trouble" /></td>
  83 <td><?php xl("Difficult/Painful Digestion", "e") ?></td></tr>
  84 <tr>
  85 <td><input type="checkbox" name="gastrointest['post_meal_short_breath'][0]" value = "post_meal_short_breath" /></td>
  86 <td><input type="checkbox" name="gastrointest['post_meal_short_breath'][1]" value = "post_meal_short_breath" /></td>
  87 <td><?php xl("Shortness of Breathing after Meals", "e") ?></td></tr>
  88 <tr>
  89 <td><input type="checkbox" name="gastrointest['ulcers'][0]" value = "ulcers" /></td>
  90 <td><input type="checkbox" name="gastrointest['ulcers'][1]" value = "ulcers" /></td>
  91 <td><?php xl("Ulcers", "e") ?></td></tr>
  92 <tr>
  93 <td><input type="checkbox" name="gastrointest['intestinal_gas'][0]" value = "intestinal_gas" /></td>
  94 <td><input type="checkbox" name="gastrointest['intestinal_gas'][1]" value = "intestinal_gas" /></td>
  95 <td><?php xl("Intestinal Gas", "e") ?></td></tr>
  96 <tr>
  97 <td><input type="checkbox" name="gastrointest['hemorrhoids'][0]" value = "hemorrhoids" /></td>
  98 <td><input type="checkbox" name="gastrointest['hemorrhoids'][1]" value = "hemorrhoids" /></td>
  99 <td><?php xl("Hemorrhoids", "e") ?> </td></tr>
 100 <tr>
 101 <td><input type="checkbox" name="gastrointest['heartburn'][0]" value = "heartburn" /></td>
 102 <td><input type="checkbox" name="gastrointest['heartburn'][1]" value = "heartburn" /></td>
 103 <td><?php xl("Heartburn", "e") ?></td></tr>
 104 <tr>
 105 <td><input type="checkbox" name="gastrointest['histal_hernia'][0]" value = "histal_hernia" /></td>
 106 <td><input type="checkbox" name="gastrointest['histal_hernia'][1]" value = "histal_hernia" /></td>
 107 <td><?php xl("Histal Hernia", "e") ?> </td></tr>
 108 </tbody></table></td>
 109
 110 <td><table><tbody class="data">
 111 <tr>
 112 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("Eyes,Ears,Nose&ampThroat","e") ?></td>
 113 </tr>
 114 <tr>
 115 <td><input type="checkbox" name="head_neck['eye_pain'][0]" value = "eye_pain" /></td>
 116 <td><input type="checkbox" name="head_neck['eye_pain'][1]" value = "eye_pain" /></td>
 117 <td><?php xl("Eye Pain", "e") ?></td> </tr>
 118 <tr>
 119 <td><input type="checkbox" name="head_neck['nearorfar_sighted'][0]" value = "nearorfar_sighted" /></td>
 120 <td><input type="checkbox" name="head_neck['nearorfar_sighted'][1]" value = "nearorfar_sighted" /></td>
 121 <td><?php xl("Near or Far Sighted", "e") ?></td></tr>
 122 <tr>
 123 <td><input type="checkbox" name="head_neck['light_sensitivity'][0]" value = "light_sensitivity" /></td>
 124 <td><input type="checkbox" name="head_neck['light_sensitivity'][1]" value = "light_sensitivity" /></td>
 125 <td><?php xl("Light Bothers Eyes", "e") ?></td></tr>
 126 <tr>
 127 <td><input type="checkbox" name="head_neck['deafness'][0]" value = "deafness" /></td>
 128 <td><input type="checkbox" name="head_neck['deafness'][1]" value = "deafness" /></td>
 129 <td><?php xl("Deafness", "e") ?></td></tr>
 130 <tr>
 131 <td><input type="checkbox" name="head_neck['earaches'][0]" value = "earaches" /></td>
 132 <td><input type="checkbox" name="head_neck['earaches'][1]" value = "earaches" /></td>
 133 <td><?php xl("Earaches", "e") ?></td></tr>
 134 <tr>
 135 <td><input type="checkbox" name="head_neck['ear_noises'][0]" value = "ear_noises" /></td>
 136 <td><input type="checkbox" name="head_neck['ear_noises'][1]" value = "ear_noises" /></td>
 137 <td><?php xl("Ear Noises", "e") ?></td></tr>
 138 <tr>
 139 <td><input type="checkbox" name="head_neck['sinus'][0]" value = "sinus" /></td>
 140 <td><input type="checkbox" name="head_neck['sinus'][1]" value = "sinus" /></td>
 141 <td><?php xl("Sinus", "e") ?> </td></tr>
 142 </tbody></table></td>
 143
 144 </tr>
 145 <tr>
 146
 147 <td><table><tbody class="data">
 148 <tr>
 149 <td /><td colspan=2><?php xl("Muscle &amp Joints","e") ?></td>
 150 </tr>
 151 <tr>
 152 <td><input type="checkbox" name="muscle_joint['jaw_problems'][0]" value = "jaw_problems" /></td>
 153 <td><input type="checkbox" name="muscle_joint['jaw_problems'][1]" value = "jaw_problems" /></td>
 154 <td><?php xl("Jaw Problems", "e") ?></td> </tr>
 155 <tr>
 156 <td><input type="checkbox" name="muscle_joint['grindclench_teeth'][0]" value = "grindclench_teeth" /></td>
 157 <td><input type="checkbox" name="muscle_joint['grindclench_teeth'][1]" value = "grindclench_teeth" /></td>
 158 <td><?php xl("Grinding or Clenching Teeth", "e") ?></td></tr>
 159 <tr>
 160 <td><input type="checkbox" name="muscle_joint['lowback_pain'][0]" value = "lowback_pain" /></td>
 161 <td><input type="checkbox" name="muscle_joint['lowback_pain'][1]" value = "lowback_pain" /></td>
 162 <td><?php xl("Lower Back Pain", "e") ?></td></tr>
 163 <tr>
 164 <td><input type="checkbox" name="muscle_joint['betweenshoulder_pain'][0]" value = "betweenshoulder_pain" /></td>
 165 <td><input type="checkbox" name="muscle_joint['betweenshoulder_pain'][1]" value = "betweenshoulder_pain" /></td>
 166 <td><?php xl("Pain Between Shoulders", "e") ?></td></tr>
 167 </tbody></table></td>
 168
 169 <td><table><tbody class="data">
 170 <tr>
 171 <td /><td colspan=2><?php xl("Genito-Urinary","e") ?></td>
 172 </tr>
 173 <tr>
 174 <td><input type="checkbox" name="genitouro['bed_wetting'][0]" value = "bed_wetting" /></td>
 175 <td><input type="checkbox" name="genitouro['bed_wetting'][1]" value = "bed_wetting" /></td>
 176 <td><?php xl("Bed Wetting", "e") ?></td> </tr>
 177 <tr>
 178 <td><input type="checkbox" name="genitouro['blood_urine'][0]" value = "blood_urine" /></td>
 179 <td><input type="checkbox" name="genitouro['blood_urine'][1]" value = "blood_urine" /></td>
 180 <td><?php xl("Blood in Urine", "e") ?></td></tr>
 181 <tr>
 182 <td><input type="checkbox" name="genitouro['frequent_urine'][0]" value = "frequent_urine" /></td>
 183 <td><input type="checkbox" name="genitouro['frequent_urine'][1]" value = "frequent_urine" /></td>
 184 <td><?php xl("Frequent Urination", "e") ?></td></tr>
 185 <tr>
 186 <td><input type="checkbox" name="genitouro['no_kidney_control'][0]" value = "no_kidney_control" /></td>
 187 <td><input type="checkbox" name="genitouro['no_kidney_control'][1]" value = "no_kidney_control" /></td>
 188 <td><?php xl("Inability to Control Kidneys", "e") ?></td></tr>
 189 <tr>
 190 <td><input type="checkbox" name="genitouro['kidney_infectionorstones'][0]" value = "kidney_infectionorstones" /></td>
 191 <td><input type="checkbox" name="genitouro['kidney_infectionorstones'][1]" value = "kidney_infectionorstones" /></td>
 192 <td><?php xl("Kidney Infection or Stones", "e") ?></td></tr>
 193 <tr>
 194 <td><input type="checkbox" name="genitouro['painful_urination'][0]" value = "painful_urination" /></td>
 195 <td><input type="checkbox" name="genitouro['painful_urination'][1]" value = "painful_urination" /></td>
 196 <td><?php xl("Painful Urination", "e") ?></td></tr>
 197 <tr>
 198 <td><input type="checkbox" name="genitouro['prostate_trouble'][0]" value = "prostate_trouble" /></td>
 199 <td><input type="checkbox" name="genitouro['prostate_trouble'][1]" value = "prostate_trouble" /></td>
 200 <td><?php xl("Prostate Trouble", "e") ?> </td></tr>
 201 <tr>
 202 <td><input type="checkbox" name="genitouro['urine_pus'][0]" value = "urine_pus" /></td>
 203 <td><input type="checkbox" name="genitouro['urine_pus'][1]" value = "urine_pus" /></td>
 204 <td><?php xl("Pus in Urine", "e") ?></td></tr>
 205 <tr>
 206 <td><input type="checkbox" name="genitouro['bladder_infection'][0]" value = "bladder_infection" /></td>
 207 <td><input type="checkbox" name="genitouro['bladder_infection'][1]" value = "bladder_infection" /></td>
 208 <td><?php xl("Bladder Infection", "e") ?> </td></tr>
 209 </tbody></table></td>
 210
 211 <td><table><tbody class="data">
 212 <tr>
 213 <td /><td colspan=2><?php xl("Cardiovascular","e") ?></td>
 214 </tr>
 215 <tr>
 216 <td><input type="checkbox" name="cardiovascular['high_bpressure'][0]" value = "high_bpressure" /></td>
 217 <td><input type="checkbox" name="cardiovascular['high_bpressure'][1]" value = "high_bpressure" /></td>
 218 <td><?php xl("High Blood Pressure", "e") ?></td> </tr>
 219 <tr>
 220 <td><input type="checkbox" name="cardiovascular['low_bpressure'][0]" value = "low_bpressure" /></td>
 221 <td><input type="checkbox" name="cardiovascular['low_bpressure'][1]" value = "low_bpressure" /></td>
 222 <td><?php xl("Low Blood Pressure", "e") ?></td></tr>
 223 <tr>
 224 <td><input type="checkbox" name="cardiovascular['poor_circulation'][0]" value = "poor_circulation" /></td>
 225 <td><input type="checkbox" name="cardiovascular['poor_circulation'][1]" value = "poor_circulation" /></td>
 226 <td><?php xl("Poor Circulation", "e") ?></td></tr>
 227 <tr>
 228 <td><input type="checkbox" name="cardiovascular['rapid_heartbeat'][0]" value = "rapid_heartbeat" /></td>
 229 <td><input type="checkbox" name="cardiovascular['rapid_heartbeat'][1]" value = "rapid_heartbeat" /></td>
 230 <td><?php xl("Rapid Heartbeat", "e") ?></td></tr>
 231 <tr>
 232 <td><input type="checkbox" name="cardiovascular['slow_heartbeat'][0]" value = "slow_heartbeat" /></td>
 233 <td><input type="checkbox" name="cardiovascular['slow_heartbeat'][1]" value = "slow_heartbeat" /></td>
 234 <td><?php xl("Slow Heartbeat", "e") ?></td></tr>
 235 </tbody></table></td>
 236
 237 </tr>
 238 <tr>
 239
 240 <td><table><tbody class="data">
 241 <tr>
 242 <td /><td colspan=2><?php xl("Pain or Numbness In:","e") ?></td>
 243 </tr>
 244 <tr>
 245 <td><input type="checkbox" name="pain_numb_locat['neck'][0]" value = "neck" /></td>
 246 <td><input type="checkbox" name="pain_numb_locat['neck'][1]" value = "neck" /></td>
 247 <td><?php xl("Neck", "e") ?></td> </tr>
 248 <tr>
 249 <td><input type="checkbox" name="pain_numb_locat['shoulder'][0]" value = "shoulder" /></td>
 250 <td><input type="checkbox" name="pain_numb_locat['shoulder'][1]" value = "shoulder" /></td>
 251 <td><?php xl("Shoulder", "e") ?></td></tr>
 252 <tr>
 253 <td><input type="checkbox" name="pain_numb_locat['arm'][0]" value = "arm" /></td>
 254 <td><input type="checkbox" name="pain_numb_locat['arm'][1]" value = "arm" /></td>
 255 <td><?php xl("Arm", "e") ?></td></tr>
 256 <tr>
 257 <td><input type="checkbox" name="pain_numb_locat['elbow'][0]" value = "elbow" /></td>
 258 <td><input type="checkbox" name="pain_numb_locat['elbow'][1]" value = "elbow" /></td>
 259 <td><?php xl("Elbow", "e") ?></td></tr>
 260 <tr>
 261 <td><input type="checkbox" name="pain_numb_locat['hands'][0]" value = "hands" /></td>
 262 <td><input type="checkbox" name="pain_numb_locat['hands'][1]" value = "hands" /></td>
 263 <td><?php xl("Hands", "e") ?></td> </tr>
 264 <tr>
 265 <td><input type="checkbox" name="pain_numb_locat['hip'][0]" value = "hip" /></td>
 266 <td><input type="checkbox" name="pain_numb_locat['hip'][1]" value = "hip" /></td>
 267 <td><?php xl("Hip", "e") ?></td></tr>
 268 <tr>
 269 <td><input type="checkbox" name="pain_numb_locat['legs'][0]" value = "legs" /></td>
 270 <td><input type="checkbox" name="pain_numb_locat['legs'][1]" value = "legs" /></td>
 271 <td><?php xl("Legs", "e") ?></td></tr>
 272 <tr>
 273 <td><input type="checkbox" name="pain_numb_locat['knees'][0]" value = "knees" /></td>
 274 <td><input type="checkbox" name="pain_numb_locat['knees'][1]" value = "knees" /></td>
 275 <td><?php xl("Knees", "e") ?></td></tr>
 276 <tr>
 277 <td><input type="checkbox" name="pain_numb_locat['feet'][0]" value = "feet" /></td>
 278 <td><input type="checkbox" name="pain_numb_locat['feet'][1]" value = "feet" /></td>
 279 <td><?php xl("Feet", "e") ?></td></tr>
 280 </tbody></table></td>
 281
 282 <td><table><tbody class="data">
 283 <tr>
 284 <td /><td colspan=2><?php xl("Respiratory","e") ?></td>
 285 </tr>
 286 <tr>
 287 <td><input type="checkbox" name="respiratory['chronic_cough'][0]" value = "chronic_cough" /></td>
 288 <td><input type="checkbox" name="respiratory['chronic_cough'][1]" value = "chronic_cough" /></td>
 289 <td><?php xl("Chronic Cough", "e") ?></td> </tr>
 290 <tr>
 291 <td><input type="checkbox" name="respiratory['chest_pain'][0]" value = "chest_pain" /></td>
 292 <td><input type="checkbox" name="respiratory['chest_pain'][1]" value = "chest_pain" /></td>
 293 <td><?php xl("Chest Pain", "e") ?></td></tr>
 294 <tr>
 295 <td><input type="checkbox" name="respiratory['difficulty_breathing'][0]" value = "difficulty_breathing" /></td>
 296 <td><input type="checkbox" name="respiratory['difficulty_breathing'][1]" value = "difficulty_breathing" /></td>
 297 <td><?php xl("Difficulty Breathing", "e") ?></td></tr>
 298 <tr>
 299 <td><input type="checkbox" name="respiratory['blood_spitting'][0]" value = "blood_spitting" /></td>
 300 <td><input type="checkbox" name="respiratory['blood_spitting'][1]" value = "blood_spitting" /></td>
 301 <td><?php xl("Spitting up Blood", "e") ?></td></tr>
 302 <tr>
 303 <td><input type="checkbox" name="respiratory['wheezing'][0]" value = "wheezing" /></td>
 304 <td><input type="checkbox" name="respiratory['wheezing'][1]" value = "wheezing" /></td>
 305 <td><?php xl("Wheezing", "e") ?></td></tr>
 306 <tr>
 307 <td><input type="checkbox" name="respiratory['asthma'][0]" value = "asthma" /></td>
 308 <td><input type="checkbox" name="respiratory['asthma'][1]" value = "asthma" /></td>
 309 <td><?php xl("Asthma", "e") ?></td></tr>
 310 </tbody></table></td>
 311
 312 <td><table><tbody class="data">
 313 <tr>
 314 <td /><td colspan=2><?php xl("Women Only","e") ?></td>
 315 </tr>
 316 <tr>
 317 <td><input type="checkbox" name="women_health['congested_breasts'][0]" value = "congested_breasts" /></td>
 318 <td><input type="checkbox" name="women_health['congested_breasts'][1]" value = "congested_breasts" /></td>
 319 <td><?php xl("Congested Breasts", "e") ?></td> </tr>
 320 <tr>
 321 <td><input type="checkbox" name="women_health['cramps_backache'][0]" value = "cramps_backache" /></td>
 322 <td><input type="checkbox" name="women_health['cramps_backache'][1]" value = "cramps_backache" /></td>
 323 <td><?php xl("Cramps or Backache", "e") ?></td></tr>
 324 <tr>
 325 <td><input type="checkbox" name="women_health['excessive_menses'][0]" value = "excessive_menses" /></td>
 326 <td><input type="checkbox" name="women_health['excessive_menses'][1]" value = "excessive_menses" /></td>
 327 <td><?php xl("Excessive Menstruation", "e") ?></td></tr>
 328 <tr>
 329 <td><input type="checkbox" name="women_health['menopausal_signs'][0]" value = "menopausal_signs" /></td>
 330 <td><input type="checkbox" name="women_health['menopausal_signs'][1]" value = "menopausal_signs" /></td>
 331 <td><?php xl("Menopausal Symptoms", "e") ?></td></tr>
 332 <tr>
 333 <td><input type="checkbox" name="women_health['irregular_cycle'][0]" value = "irregular_cycle" /></td>
 334 <td><input type="checkbox" name="women_health['irregular_cycle'][1]" value = "irregular_cycle" /></td>
 335 <td><?php xl("Irregular Cycle", "e") ?></td></tr>
 336 <tr>
 337 <td><input type="checkbox" name="women_health['lumps'][0]" value = "lumps" /></td>
 338 <td><input type="checkbox" name="women_health['lumps'][1]" value = "lumps" /></td>
 339 <td><?php xl("Lumps in Breasts", "e") ?></td> </tr>
 340 <tr>
 341 <td><input type="checkbox" name="women_health['painful_menses'][0]" value = "painful_menses" /></td>
 342 <td><input type="checkbox" name="women_health['painful_menses'][1]" value = "painful_menses" /></td>
 343 <td><?php xl("Painful Menstruation", "e") ?></td></tr>
 344 <tr>
 345 <td><input type="checkbox" name="women_health['vaginal_discharge'][0]" value = "vaginal_discharge" /></td>
 346 <td><input type="checkbox" name="women_health['vaginal_discharge'][1]" value = "vaginal_discharge" /></td>
 347 <td><?php xl("Vaginal Discharge", "e") ?></td></tr>
 348 <tr>
 349 <td><input type="checkbox" name="women_health['endometriosis'][0]" value = "endometriosis" /></td>
 350 <td><input type="checkbox" name="women_health['endometriosis'][1]" value = "endometriosis" /></td>
 351 <td><?php xl("Endometriosis", "e") ?></td></tr>
 352 <tr>
 353 <td><input type="checkbox" name="women_health['premenstrual_syndrome'][0]" value = "premenstrual_syndrome" /></td>
 354 <td><input type="checkbox" name="women_health['premenstrual_syndrome'][1]" value = "premenstrual_syndrome" /></td>
 355 <td><?php xl("Premenstrual Syndrome", "e") ?></td></tr>
 356 </tbody></table></td>
 357
 358 </tr>
 359 <tr>
 360 <td colspan=3><hr /><table style="width:100%;"><tbody class="data"><tr>
 361 <td><input type="checkbox" name="alcoholism" value = "alcoholism" /> <?php xl("Alcoholism", "e") ?><br />
 362 <input type="checkbox" name="anemia" value = "anemia" /> <?php xl("Anemia", "e") ?><br />
 363 <input type="checkbox" name="arthritis" value = "arthritis" /> <?php xl("Arthritis", "e") ?><br />
 364 <input type="checkbox" name="cancer" value = "cancer" /> <?php xl("Cancer", "e") ?><br />
 365 <input type="checkbox" name="herpes" value = "herpes" /> <?php xl("Herpes", "e") ?><br />
 366 <input type="checkbox" name="hypoglycemia" value = "hypoglycemia" /> <?php xl("Hypoglycemia", "e") ?><br />
 367 </td>
 368 <td><input type="checkbox" name="diabetes" value = "diabetes" /> <?php xl("Diabetes", "e") ?><br />
 369 <input type="checkbox" name="eczema" value = "eczema" /> <?php xl("Eczema", "e") ?><br />
 370 <input type="checkbox" name="emphysema" value = "emphysema" /> <?php xl("Emphysema", "e") ?><br />
 371 <input type="checkbox" name="goiter" value = "goiter" /> <?php xl("Goiter", "e") ?><br />
 372 <input type="checkbox" name="ulcers" value = "ulcers" /> <?php xl("Ulcers", "e") ?><br />
 373 </td>
 374 <td><input type="checkbox" name="gout" value = "gout" /> <?php xl("Gout", "e") ?><br />
 375 <input type="checkbox" name="heart_disease" value = "heart_disease" /> <?php xl("Heart Disease/Attack", "e") ?><br />
 376 <input type="checkbox" name="rheumetic_fever" value = "rheumetic_fever" /> <?php xl("Rheumatic Fever", "e") ?><br />
 377 <input type="checkbox" name="miscarriage" value = "miscarriage" /> <?php xl("Miscarriage", "e") ?><br />
 378 <input type="checkbox" name="polio" value = "polio" /> <?php xl("Polio", "e") ?><br />
 379 </td>
 380 <td><input type="checkbox" name="pneumonia" value = "pneumonia" /> <?php xl("Pneumonia", "e") ?><br />
 381 <input type="checkbox" name="atherosclerosis" value = "atherosclerosis" /> <?php xl("Atherosclerosis", "e") ?><br />
 382 <input type="checkbox" name="multiple_sclerosis" value = "multiple_sclerosis" /> <?php xl("Multiple Sclerosis", "e") ?><br />
 383 <input type="checkbox" name="stroke" value = "stroke" /> <?php xl("Stroke", "e") ?><br />
 384 <input type="checkbox" name="tuberculosis" value = "tuberculosis" /> <?php xl("Tuberculosis", "e") ?><br />
 385 </td>
 386 <td><input type="checkbox" name="epilepsy" value = "epilepsy" /> <?php xl("Epilepsy", "e") ?><br />
 387 <input type="checkbox" name="measles" value = "measles" /> <?php xl("Measles", "e") ?><br />
 388 <input type="checkbox" name="mumps" value = "mumps" /> <?php xl("Mumps", "e") ?><br />
 389 <input type="checkbox" name="chicken_pox" value = "chicken_pox" /> <?php xl("Chicken Pox", "e") ?><br />
 390 <input type="checkbox" name="venereal_disease" value = "venereal_disease" /> <?php xl("Venereal Disease", "e") ?><br />
 391 </td>
 392 </tr></tbody></table><hr /></td>
 393 </tr>
 394
 395 <tr>
 396 <td colspan=3><table><tbody class="data">
 397 <tr>
 398 <td colspan=2><?php xl("Please Indicate If You Have/Had Trouble With Any Glands/Organs", "e")?><br />
 399 </td>
 400 <td colspan=2><?php xl("Family History: Have Your Mother or Father Had Any of These Disorders?", "e")?><br />
 401 </td>
 402 </tr>
 403 <tr>
 404
 405 <td><label><input type="checkbox" name="organ_gland[]" value="pituitary" /><?php xl("Pituitary", "e") ?></lable><br />
 406 <label><input type="checkbox" name="organ_gland[]" value="thyroid" /><?php xl("Thyroid", "e") ?></lable><br />
 407 <label><input type="checkbox" name="organ_gland[]" value="pancreas" /><?php xl("Pancreas", "e") ?></lable><br />
 408 <label><input type="checkbox" name="organ_gland[]" value="adrenal" /><?php xl("Adrenal", "e") ?></lable><br />
 409 <label><input type="checkbox" name="organ_gland[]" value="ovary_teste" /><?php xl("Ovary/Teste", "e") ?></lable><br />
 410 <label><input type="checkbox" name="organ_gland[]" value="liver" /><?php xl("Liver", "e") ?></lable><br />
 411 <label><input type="checkbox" name="organ_gland[]" value="gall_bladder" /><?php xl("Gall Bladder", "e") ?></label></td>
 412
 413 <td><label><input type="checkbox" name="organ_gland[]" value="stomach" /><?php xl("Stomach", "e") ?></lable><br />
 414 <label><input type="checkbox" name="organ_gland[]" value="small_intestine" /><?php xl("Small Intestine", "e") ?></lable><br />
 415 <label><input type="checkbox" name="organ_gland[]" value="large_intestine" /><?php xl("Large Intestine", "e") ?></lable><br />
 416 <label><input type="checkbox" name="organ_gland[]" value="bladder" /><?php xl("Bladder", "e") ?></lable><br />
 417 <label><input type="checkbox" name="organ_gland[]" value="lungs" /><?php xl("Lungs", "e") ?></lable><br />
 418 <label><input type="checkbox" name="organ_gland[]" value="prostate_uterus" /><?php xl("Prostate/Uterus", "e") ?></label></td>
 419
 420 <td><label><input type="checkbox" name="family_history[]" value="arthritis" /><?php xl("Arthritis", "e") ?></lable><br />
 421 <label><input type="checkbox" name="family_history[]" value="atherosclerosis" /><?php xl("Atherosclerosis", "e") ?></lable><br />
 422 <label><input type="checkbox" name="family_history[]" value="osteoprosis" /><?php xl("Osteoporosis", "e") ?></lable><br />
 423 <label><input type="checkbox" name="family_history[]" value="allergies" /><?php xl("Allergies", "e") ?></lable><br />
 424 <label><input type="checkbox" name="family_history[]" value="cancer" /><?php xl("Cancer", "e") ?></lable><br />
 425 <label><input type="checkbox" name="family_history[]" value="obesity" /><?php xl("Obesity", "e") ?></lable><br />
 426 <label><input type="checkbox" name="family_history[]" value="hemorrhoids" /><?php xl("Hemorrhoids", "e") ?></label></td>
 427
 428 <td><label><input type="checkbox" name="family_history[]" value="stroke" /><?php xl("Stroke", "e") ?></lable><br />
 429 <label><input type="checkbox" name="family_history[]" value="alcoholism" /><?php xl("Alcoholism", "e") ?></lable><br />
 430 <label><input type="checkbox" name="family_history[]" value="high_bpressure" /><?php xl("High Blood Pressure", "e") ?></lable><br />
 431 <label><input type="checkbox" name="family_history[]" value="heart_disease" /><?php xl("Heart Trouble", "e") ?></lable><br />
 432 <label><input type="checkbox" name="family_history[]" value="kidney_disease" /><?php xl("Kidney Disorders", "e") ?></lable><br />
 433 <label><input type="checkbox" name="family_history[]" value="nervous_disorder" /><?php xl("Other Nervous Systems", "e") ?></lable><br />
 434 <label><input type="checkbox" name="family_history[]" value="spinal_disorder" /><?php xl("Spinal Problems", "e") ?></label></td>
 435
 436 </tr>
 437 </tbody></table></td>
 438 </tr>
 439
 440 <tr><td colspan=3><hr />
 441 <?php xl("Check Which Meals That You Eat Regularly: ", "e")?>
 442 <input type="checkbox" name="regular_meals" value="breakfast" /><?php xl(" Breakfast", "e")?>
 443 <input type="checkbox" name="regular_meals" value="lunch" /><?php xl(" Lunch", "e")?>
 444 <input type="checkbox" name="regular_meals" value="dinner" /><?php xl(" Dinner", "e")?>
 445 <input type="checkbox" name="regular_meals" value="between_meals" /><?php xl(" Between Meals", "e")?>
 446 <input type="checkbox" name="regular_meals" value="before_bed" /><?php xl(" Before Bed", "e")?>
 447 </td></tr>
 448 </tbody></table>
 449
 450 <input type="submit" name="submit form" value="submit form" />
 451 </form>
 452 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 453 <?php
 454 formFooter();
 455 ?>