contrib/forms/chiro_history/view.php

   1 <!-- view.php -->
   2  <?php
   3  include_once("../../globals.php");
   4  include_once("$srcdir/api.inc");
   5  formHeader("Form: chiro_history");
   6  $obj = formFetch("form_chiro_history", $_GET["id"]);  //#Use the formFetch function from api.inc to get values for existing form.
   7
   8  function chkdata_Txt(&$obj, $var) {
   9          return htmlentities($obj{"$var"});
  10  }
  11  function chkdata_Date(&$obj, $var) {
  12          return htmlentities($obj{"$var"});
  13  }
  14  function chkdata_CB(&$obj, $nam, $var) {
  15   if (preg_match("/Negative.*$var/",$obj{$nam}))
  16   {
  17    return;
  18   }
  19   else
  20   {
  21    if (preg_match("/Positive.*$var/",$obj{$nam}))
  22    {
  23      return "checked";
  24    }
  25    else
  26    {
  27      if(preg_match("/$var/",$obj{$nam}))
  28      {
  29        return "checked";
  30      }
  31      else
  32      {
  33        return;
  34      }
  35     }
  36    }
  37   }
  38
  39  function chkdata_Radio(&$obj, $nam, $var) {
  40         if (strpos($obj{$nam},$var) !== false) {return "checked";}
  41  }
  42
  43  function chkdata_PopOrScroll(&$obj, $nam, $var) {
  44  if (preg_match("/Negative.*$var/",$obj{$nam}))
  45   {
  46    return;
  47   }
  48   else
  49   {
  50    if (preg_match("/Positive.*$var/",$obj{$nam}))
  51    {
  52      return "Selected";
  53    }
  54    else
  55    {
  56      if($var==$obj{$nam})
  57      {
  58        return "Selected";
  59      }
  60      else
  61        return;
  62     }
  63   }
  64  }
  65
  66  ?>
  67  <html><head>
  68  <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  69  </head>
  70  <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  71  <style type="text/css">@import url(../../../library/dynarch_calendar.css);</style>
  72 <script type="text/javascript" src="../../../library/dialog.js"></script>
  73 <script type="text/javascript" src="../../../library/textformat.js"></script>
  74 <script type="text/javascript" src="../../../library/dynarch_calendar.js"></script>
  75 <script type="text/javascript" src="../../../library/dynarch_calendar_en.js"></script>
  76 <script type="text/javascript" src="../../../library/dynarch_calendar_setup.js"></script>
  77 <script language='JavaScript'> var mypcc = '1'; </script>
  78
  79 <form method=post action="<?php echo $rootdir;?>/forms/chiro_history/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form" onsubmit="return top.restoreSession()">
  80 <hr>
  81 <h1> <?php xl("Chiropractic History",'e') ?> </h1>
  82 <hr>
  83 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  84 <input type="submit" name="submit form" value="submit form" /><br>
  85 <br>
  86 <h3> <?php xl("History",'e') ?> </h3>
  87 <hr />
  88
  89 <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;">
  90 <tr>
  91
  92 <td><table><tbody class="data">
  93 <tr>
  94 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("General","e") ?></td>
  95 </tr>
  96 <tr>
  97 <td><input type="checkbox" name="general_condit['allergy'][0]" value = "allergy" /></td>
  98 <td><input type="checkbox" name="general_condit['allergy'][1]" value = "allergy" /></td>
  99 <td><?php xl("Allergy", "e") ?></td> </tr>
 100 <tr>
 101 <td><input type="checkbox" name="general_condit['convulsion'][0]" value = "convulsion" /></td>
 102 <td><input type="checkbox" name="general_condit['convulsion'][1]" value = "convulsion" /></td>
 103 <td><?php xl("Convulsion", "e") ?></td></tr>
 104 <tr>
 105 <td><input type="checkbox" name="general_condit['dizziness'][0]" value = "dizziness" /></td>
 106 <td><input type="checkbox" name="general_condit['dizziness'][1]" value = "dizziness" /></td>
 107 <td><?php xl("Dizziness", "e") ?></td></tr>
 108 <tr>
 109 <td><input type="checkbox" name="general_condit['fainting'][0]" value = "fainting" /></td>
 110 <td><input type="checkbox" name="general_condit['fainting'][1]" value = "fainting" /></td>
 111 <td><?php xl("Fainting", "e") ?></td></tr>
 112 <tr>
 113 <td><input type="checkbox" name="general_condit['fatigue'][0]" value = "fatigue" /></td>
 114 <td><input type="checkbox" name="general_condit['fatigue'][1]" value = "fatigue" /></td>
 115 <td><?php xl("Fatigue", "e") ?></td></tr>
 116 <tr>
 117 <td><input type="checkbox" name="general_condit['depression'][0]" value = "depression" /></td>
 118 <td><input type="checkbox" name="general_condit['depression'][1]" value = "depression" /></td>
 119 <td><?php xl("Depression", "e") ?></td></tr>
 120 <tr>
 121 <td><input type="checkbox" name="general_condit['headache'][0]" value = "headache" /></td>
 122 <td><input type="checkbox" name="general_condit['headache'][1]" value = "headache" /></td>
 123 <td><?php xl("Headache", "e") ?> </td></tr>
 124 </tbody></table></td>
 125
 126 <td><table><tbody class="data">
 127 <tr>
 128 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("Gastro-Intestinal","e") ?></td>
 129 </tr>
 130 <tr>
 131 <td><input type="checkbox" name="gastrointest['constipation'][0]" value = "constipation" /></td>
 132 <td><input type="checkbox" name="gastrointest['constipation'][1]" value = "constipation" /></td>
 133 <td><?php xl("Constipation", "e") ?></td> </tr>
 134 <tr>
 135 <td><input type="checkbox" name="gastrointest['diarrhea'][0]" value = "diarrhea" /></td>
 136 <td><input type="checkbox" name="gastrointest['diarrhea'][1]" value = "diarrhea" /></td>
 137 <td><?php xl("Diarrhea", "e") ?></td></tr>
 138 <tr>
 139 <td><input type="checkbox" name="gastrointest['digestion_trouble'][0]" value = "digestion_trouble" /></td>
 140 <td><input type="checkbox" name="gastrointest['digestion_trouble'][1]" value = "digestion_trouble" /></td>
 141 <td><?php xl("Difficult/Painful Digestion", "e") ?></td></tr>
 142 <tr>
 143 <td><input type="checkbox" name="gastrointest['post_meal_short_breath'][0]" value = "post_meal_short_breath" /></td>
 144 <td><input type="checkbox" name="gastrointest['post_meal_short_breath'][1]" value = "post_meal_short_breath" /></td>
 145 <td><?php xl("Shortness of Breathing after Meals", "e") ?></td></tr>
 146 <tr>
 147 <td><input type="checkbox" name="gastrointest['ulcers'][0]" value = "ulcers" /></td>
 148 <td><input type="checkbox" name="gastrointest['ulcers'][1]" value = "ulcers" /></td>
 149 <td><?php xl("Ulcers", "e") ?></td></tr>
 150 <tr>
 151 <td><input type="checkbox" name="gastrointest['intestinal_gas'][0]" value = "intestinal_gas" /></td>
 152 <td><input type="checkbox" name="gastrointest['intestinal_gas'][1]" value = "intestinal_gas" /></td>
 153 <td><?php xl("Intestinal Gas", "e") ?></td></tr>
 154 <tr>
 155 <td><input type="checkbox" name="gastrointest['hemorrhoids'][0]" value = "hemorrhoids" /></td>
 156 <td><input type="checkbox" name="gastrointest['hemorrhoids'][1]" value = "hemorrhoids" /></td>
 157 <td><?php xl("Hemorrhoids", "e") ?> </td></tr>
 158 <tr>
 159 <td><input type="checkbox" name="gastrointest['heartburn'][0]" value = "heartburn" /></td>
 160 <td><input type="checkbox" name="gastrointest['heartburn'][1]" value = "heartburn" /></td>
 161 <td><?php xl("Heartburn", "e") ?></td></tr>
 162 <tr>
 163 <td><input type="checkbox" name="gastrointest['histal_hernia'][0]" value = "histal_hernia" /></td>
 164 <td><input type="checkbox" name="gastrointest['histal_hernia'][1]" value = "histal_hernia" /></td>
 165 <td><?php xl("Histal Hernia", "e") ?> </td></tr>
 166 </tbody></table></td>
 167
 168 <td><table><tbody class="data">
 169 <tr>
 170 <td><?php xl("Past","e") ?><br /></td><td colspan=2><?php xl("Present","e") ?><br /><?php xl("Eyes,Ears,Nose&ampThroat","e") ?></td>
 171 </tr>
 172 <tr>
 173 <td><input type="checkbox" name="head_neck['eye_pain'][0]" value = "eye_pain" /></td>
 174 <td><input type="checkbox" name="head_neck['eye_pain'][1]" value = "eye_pain" /></td>
 175 <td><?php xl("Eye Pain", "e") ?></td> </tr>
 176 <tr>
 177 <td><input type="checkbox" name="head_neck['nearorfar_sighted'][0]" value = "nearorfar_sighted" /></td>
 178 <td><input type="checkbox" name="head_neck['nearorfar_sighted'][1]" value = "nearorfar_sighted" /></td>
 179 <td><?php xl("Near or Far Sighted", "e") ?></td></tr>
 180 <tr>
 181 <td><input type="checkbox" name="head_neck['light_sensitivity'][0]" value = "light_sensitivity" /></td>
 182 <td><input type="checkbox" name="head_neck['light_sensitivity'][1]" value = "light_sensitivity" /></td>
 183 <td><?php xl("Light Bothers Eyes", "e") ?></td></tr>
 184 <tr>
 185 <td><input type="checkbox" name="head_neck['deafness'][0]" value = "deafness" /></td>
 186 <td><input type="checkbox" name="head_neck['deafness'][1]" value = "deafness" /></td>
 187 <td><?php xl("Deafness", "e") ?></td></tr>
 188 <tr>
 189 <td><input type="checkbox" name="head_neck['earaches'][0]" value = "earaches" /></td>
 190 <td><input type="checkbox" name="head_neck['earaches'][1]" value = "earaches" /></td>
 191 <td><?php xl("Earaches", "e") ?></td></tr>
 192 <tr>
 193 <td><input type="checkbox" name="head_neck['ear_noises'][0]" value = "ear_noises" /></td>
 194 <td><input type="checkbox" name="head_neck['ear_noises'][1]" value = "ear_noises" /></td>
 195 <td><?php xl("Ear Noises", "e") ?></td></tr>
 196 <tr>
 197 <td><input type="checkbox" name="head_neck['sinus'][0]" value = "sinus" /></td>
 198 <td><input type="checkbox" name="head_neck['sinus'][1]" value = "sinus" /></td>
 199 <td><?php xl("Sinus", "e") ?> </td></tr>
 200 </tbody></table></td>
 201
 202 </tr>
 203 <tr>
 204
 205 <td><table><tbody class="data">
 206 <tr>
 207 <td /><td colspan=2><?php xl("Muscle &amp Joints","e") ?></td>
 208 </tr>
 209 <tr>
 210 <td><input type="checkbox" name="muscle_joint['jaw_problems'][0]" value = "jaw_problems" /></td>
 211 <td><input type="checkbox" name="muscle_joint['jaw_problems'][1]" value = "jaw_problems" /></td>
 212 <td><?php xl("Jaw Problems", "e") ?></td> </tr>
 213 <tr>
 214 <td><input type="checkbox" name="muscle_joint['grindclench_teeth'][0]" value = "grindclench_teeth" /></td>
 215 <td><input type="checkbox" name="muscle_joint['grindclench_teeth'][1]" value = "grindclench_teeth" /></td>
 216 <td><?php xl("Grinding or Clenching Teeth", "e") ?></td></tr>
 217 <tr>
 218 <td><input type="checkbox" name="muscle_joint['lowback_pain'][0]" value = "lowback_pain" /></td>
 219 <td><input type="checkbox" name="muscle_joint['lowback_pain'][1]" value = "lowback_pain" /></td>
 220 <td><?php xl("Lower Back Pain", "e") ?></td></tr>
 221 <tr>
 222 <td><input type="checkbox" name="muscle_joint['betweenshoulder_pain'][0]" value = "betweenshoulder_pain" /></td>
 223 <td><input type="checkbox" name="muscle_joint['betweenshoulder_pain'][1]" value = "betweenshoulder_pain" /></td>
 224 <td><?php xl("Pain Between Shoulders", "e") ?></td></tr>
 225 </tbody></table></td>
 226
 227 <td><table><tbody class="data">
 228 <tr>
 229 <td /><td colspan=2><?php xl("Genito-Urinary","e") ?></td>
 230 </tr>
 231 <tr>
 232 <td><input type="checkbox" name="genitouro['bed_wetting'][0]" value = "bed_wetting" /></td>
 233 <td><input type="checkbox" name="genitouro['bed_wetting'][1]" value = "bed_wetting" /></td>
 234 <td><?php xl("Bed Wetting", "e") ?></td> </tr>
 235 <tr>
 236 <td><input type="checkbox" name="genitouro['blood_urine'][0]" value = "blood_urine" /></td>
 237 <td><input type="checkbox" name="genitouro['blood_urine'][1]" value = "blood_urine" /></td>
 238 <td><?php xl("Blood in Urine", "e") ?></td></tr>
 239 <tr>
 240 <td><input type="checkbox" name="genitouro['frequent_urine'][0]" value = "frequent_urine" /></td>
 241 <td><input type="checkbox" name="genitouro['frequent_urine'][1]" value = "frequent_urine" /></td>
 242 <td><?php xl("Frequent Urination", "e") ?></td></tr>
 243 <tr>
 244 <td><input type="checkbox" name="genitouro['no_kidney_control'][0]" value = "no_kidney_control" /></td>
 245 <td><input type="checkbox" name="genitouro['no_kidney_control'][1]" value = "no_kidney_control" /></td>
 246 <td><?php xl("Inability to Control Kidneys", "e") ?></td></tr>
 247 <tr>
 248 <td><input type="checkbox" name="genitouro['kidney_infectionorstones'][0]" value = "kidney_infectionorstones" /></td>
 249 <td><input type="checkbox" name="genitouro['kidney_infectionorstones'][1]" value = "kidney_infectionorstones" /></td>
 250 <td><?php xl("Kidney Infection or Stones", "e") ?></td></tr>
 251 <tr>
 252 <td><input type="checkbox" name="genitouro['painful_urination'][0]" value = "painful_urination" /></td>
 253 <td><input type="checkbox" name="genitouro['painful_urination'][1]" value = "painful_urination" /></td>
 254 <td><?php xl("Painful Urination", "e") ?></td></tr>
 255 <tr>
 256 <td><input type="checkbox" name="genitouro['prostate_trouble'][0]" value = "prostate_trouble" /></td>
 257 <td><input type="checkbox" name="genitouro['prostate_trouble'][1]" value = "prostate_trouble" /></td>
 258 <td><?php xl("Prostate Trouble", "e") ?> </td></tr>
 259 <tr>
 260 <td><input type="checkbox" name="genitouro['urine_pus'][0]" value = "urine_pus" /></td>
 261 <td><input type="checkbox" name="genitouro['urine_pus'][1]" value = "urine_pus" /></td>
 262 <td><?php xl("Pus in Urine", "e") ?></td></tr>
 263 <tr>
 264 <td><input type="checkbox" name="genitouro['bladder_infection'][0]" value = "bladder_infection" /></td>
 265 <td><input type="checkbox" name="genitouro['bladder_infection'][1]" value = "bladder_infection" /></td>
 266 <td><?php xl("Bladder Infection", "e") ?> </td></tr>
 267 </tbody></table></td>
 268
 269 <td><table><tbody class="data">
 270 <tr>
 271 <td /><td colspan=2><?php xl("Cardiovascular","e") ?></td>
 272 </tr>
 273 <tr>
 274 <td><input type="checkbox" name="cardiovascular['high_bpressure'][0]" value = "high_bpressure" /></td>
 275 <td><input type="checkbox" name="cardiovascular['high_bpressure'][1]" value = "high_bpressure" /></td>
 276 <td><?php xl("High Blood Pressure", "e") ?></td> </tr>
 277 <tr>
 278 <td><input type="checkbox" name="cardiovascular['low_bpressure'][0]" value = "low_bpressure" /></td>
 279 <td><input type="checkbox" name="cardiovascular['low_bpressure'][1]" value = "low_bpressure" /></td>
 280 <td><?php xl("Low Blood Pressure", "e") ?></td></tr>
 281 <tr>
 282 <td><input type="checkbox" name="cardiovascular['poor_circulation'][0]" value = "poor_circulation" /></td>
 283 <td><input type="checkbox" name="cardiovascular['poor_circulation'][1]" value = "poor_circulation" /></td>
 284 <td><?php xl("Poor Circulation", "e") ?></td></tr>
 285 <tr>
 286 <td><input type="checkbox" name="cardiovascular['rapid_heartbeat'][0]" value = "rapid_heartbeat" /></td>
 287 <td><input type="checkbox" name="cardiovascular['rapid_heartbeat'][1]" value = "rapid_heartbeat" /></td>
 288 <td><?php xl("Rapid Heartbeat", "e") ?></td></tr>
 289 <tr>
 290 <td><input type="checkbox" name="cardiovascular['slow_heartbeat'][0]" value = "slow_heartbeat" /></td>
 291 <td><input type="checkbox" name="cardiovascular['slow_heartbeat'][1]" value = "slow_heartbeat" /></td>
 292 <td><?php xl("Slow Heartbeat", "e") ?></td></tr>
 293 </tbody></table></td>
 294
 295 </tr>
 296 <tr>
 297
 298 <td><table><tbody class="data">
 299 <tr>
 300 <td /><td colspan=2><?php xl("Pain or Numbness In:","e") ?></td>
 301 </tr>
 302 <tr>
 303 <td><input type="checkbox" name="pain_numb_locat['neck'][0]" value = "neck" /></td>
 304 <td><input type="checkbox" name="pain_numb_locat['neck'][1]" value = "neck" /></td>
 305 <td><?php xl("Neck", "e") ?></td> </tr>
 306 <tr>
 307 <td><input type="checkbox" name="pain_numb_locat['shoulder'][0]" value = "shoulder" /></td>
 308 <td><input type="checkbox" name="pain_numb_locat['shoulder'][1]" value = "shoulder" /></td>
 309 <td><?php xl("Shoulder", "e") ?></td></tr>
 310 <tr>
 311 <td><input type="checkbox" name="pain_numb_locat['arm'][0]" value = "arm" /></td>
 312 <td><input type="checkbox" name="pain_numb_locat['arm'][1]" value = "arm" /></td>
 313 <td><?php xl("Arm", "e") ?></td></tr>
 314 <tr>
 315 <td><input type="checkbox" name="pain_numb_locat['elbow'][0]" value = "elbow" /></td>
 316 <td><input type="checkbox" name="pain_numb_locat['elbow'][1]" value = "elbow" /></td>
 317 <td><?php xl("Elbow", "e") ?></td></tr>
 318 <tr>
 319 <td><input type="checkbox" name="pain_numb_locat['hands'][0]" value = "hands" /></td>
 320 <td><input type="checkbox" name="pain_numb_locat['hands'][1]" value = "hands" /></td>
 321 <td><?php xl("Hands", "e") ?></td> </tr>
 322 <tr>
 323 <td><input type="checkbox" name="pain_numb_locat['hip'][0]" value = "hip" /></td>
 324 <td><input type="checkbox" name="pain_numb_locat['hip'][1]" value = "hip" /></td>
 325 <td><?php xl("Hip", "e") ?></td></tr>
 326 <tr>
 327 <td><input type="checkbox" name="pain_numb_locat['legs'][0]" value = "legs" /></td>
 328 <td><input type="checkbox" name="pain_numb_locat['legs'][1]" value = "legs" /></td>
 329 <td><?php xl("Legs", "e") ?></td></tr>
 330 <tr>
 331 <td><input type="checkbox" name="pain_numb_locat['knees'][0]" value = "knees" /></td>
 332 <td><input type="checkbox" name="pain_numb_locat['knees'][1]" value = "knees" /></td>
 333 <td><?php xl("Knees", "e") ?></td></tr>
 334 <tr>
 335 <td><input type="checkbox" name="pain_numb_locat['feet'][0]" value = "feet" /></td>
 336 <td><input type="checkbox" name="pain_numb_locat['feet'][1]" value = "feet" /></td>
 337 <td><?php xl("Feet", "e") ?></td></tr>
 338 </tbody></table></td>
 339
 340 <td><table><tbody class="data">
 341 <tr>
 342 <td /><td colspan=2><?php xl("Respiratory","e") ?></td>
 343 </tr>
 344 <tr>
 345 <td><input type="checkbox" name="respiratory['chronic_cough'][0]" value = "chronic_cough" /></td>
 346 <td><input type="checkbox" name="respiratory['chronic_cough'][1]" value = "chronic_cough" /></td>
 347 <td><?php xl("Chronic Cough", "e") ?></td> </tr>
 348 <tr>
 349 <td><input type="checkbox" name="respiratory['chest_pain'][0]" value = "chest_pain" /></td>
 350 <td><input type="checkbox" name="respiratory['chest_pain'][1]" value = "chest_pain" /></td>
 351 <td><?php xl("Chest Pain", "e") ?></td></tr>
 352 <tr>
 353 <td><input type="checkbox" name="respiratory['difficulty_breathing'][0]" value = "difficulty_breathing" /></td>
 354 <td><input type="checkbox" name="respiratory['difficulty_breathing'][1]" value = "difficulty_breathing" /></td>
 355 <td><?php xl("Difficulty Breathing", "e") ?></td></tr>
 356 <tr>
 357 <td><input type="checkbox" name="respiratory['blood_spitting'][0]" value = "blood_spitting" /></td>
 358 <td><input type="checkbox" name="respiratory['blood_spitting'][1]" value = "blood_spitting" /></td>
 359 <td><?php xl("Spitting up Blood", "e") ?></td></tr>
 360 <tr>
 361 <td><input type="checkbox" name="respiratory['wheezing'][0]" value = "wheezing" /></td>
 362 <td><input type="checkbox" name="respiratory['wheezing'][1]" value = "wheezing" /></td>
 363 <td><?php xl("Wheezing", "e") ?></td></tr>
 364 <tr>
 365 <td><input type="checkbox" name="respiratory['asthma'][0]" value = "asthma" /></td>
 366 <td><input type="checkbox" name="respiratory['asthma'][1]" value = "asthma" /></td>
 367 <td><?php xl("Asthma", "e") ?></td></tr>
 368 </tbody></table></td>
 369
 370 <td><table><tbody class="data">
 371 <tr>
 372 <td /><td colspan=2><?php xl("Women Only","e") ?></td>
 373 </tr>
 374 <tr>
 375 <td><input type="checkbox" name="women_health['congested_breasts'][0]" value = "congested_breasts" /></td>
 376 <td><input type="checkbox" name="women_health['congested_breasts'][1]" value = "congested_breasts" /></td>
 377 <td><?php xl("Congested Breasts", "e") ?></td> </tr>
 378 <tr>
 379 <td><input type="checkbox" name="women_health['cramps_backache'][0]" value = "cramps_backache" /></td>
 380 <td><input type="checkbox" name="women_health['cramps_backache'][1]" value = "cramps_backache" /></td>
 381 <td><?php xl("Cramps or Backache", "e") ?></td></tr>
 382 <tr>
 383 <td><input type="checkbox" name="women_health['excessive_menses'][0]" value = "excessive_menses" /></td>
 384 <td><input type="checkbox" name="women_health['excessive_menses'][1]" value = "excessive_menses" /></td>
 385 <td><?php xl("Excessive Menstruation", "e") ?></td></tr>
 386 <tr>
 387 <td><input type="checkbox" name="women_health['menopausal_signs'][0]" value = "menopausal_signs" /></td>
 388 <td><input type="checkbox" name="women_health['menopausal_signs'][1]" value = "menopausal_signs" /></td>
 389 <td><?php xl("Menopausal Symptoms", "e") ?></td></tr>
 390 <tr>
 391 <td><input type="checkbox" name="women_health['irregular_cycle'][0]" value = "irregular_cycle" /></td>
 392 <td><input type="checkbox" name="women_health['irregular_cycle'][1]" value = "irregular_cycle" /></td>
 393 <td><?php xl("Irregular Cycle", "e") ?></td></tr>
 394 <tr>
 395 <td><input type="checkbox" name="women_health['lumps'][0]" value = "lumps" /></td>
 396 <td><input type="checkbox" name="women_health['lumps'][1]" value = "lumps" /></td>
 397 <td><?php xl("Lumps in Breasts", "e") ?></td> </tr>
 398 <tr>
 399 <td><input type="checkbox" name="women_health['painful_menses'][0]" value = "painful_menses" /></td>
 400 <td><input type="checkbox" name="women_health['painful_menses'][1]" value = "painful_menses" /></td>
 401 <td><?php xl("Painful Menstruation", "e") ?></td></tr>
 402 <tr>
 403 <td><input type="checkbox" name="women_health['vaginal_discharge'][0]" value = "vaginal_discharge" /></td>
 404 <td><input type="checkbox" name="women_health['vaginal_discharge'][1]" value = "vaginal_discharge" /></td>
 405 <td><?php xl("Vaginal Discharge", "e") ?></td></tr>
 406 <tr>
 407 <td><input type="checkbox" name="women_health['endometriosis'][0]" value = "endometriosis" /></td>
 408 <td><input type="checkbox" name="women_health['endometriosis'][1]" value = "endometriosis" /></td>
 409 <td><?php xl("Endometriosis", "e") ?></td></tr>
 410 <tr>
 411 <td><input type="checkbox" name="women_health['premenstrual_syndrome'][0]" value = "premenstrual_syndrome" /></td>
 412 <td><input type="checkbox" name="women_health['premenstrual_syndrome'][1]" value = "premenstrual_syndrome" /></td>
 413 <td><?php xl("Premenstrual Syndrome", "e") ?></td></tr>
 414 </tbody></table></td>
 415
 416 </tr>
 417 <tr>
 418 <td colspan=3><hr /><table style="width:100%;"><tbody class="data"><tr>
 419 <td><input type="checkbox" name="alcoholism" value = "alcoholism" /> <?php xl("Alcoholism", "e") ?><br />
 420 <input type="checkbox" name="anemia" value = "anemia" /> <?php xl("Anemia", "e") ?><br />
 421 <input type="checkbox" name="arthritis" value = "arthritis" /> <?php xl("Arthritis", "e") ?><br />
 422 <input type="checkbox" name="cancer" value = "cancer" /> <?php xl("Cancer", "e") ?><br />
 423 <input type="checkbox" name="herpes" value = "herpes" /> <?php xl("Herpes", "e") ?><br />
 424 <input type="checkbox" name="hypoglycemia" value = "hypoglycemia" /> <?php xl("Hypoglycemia", "e") ?><br />
 425 </td>
 426 <td><input type="checkbox" name="diabetes" value = "diabetes" /> <?php xl("Diabetes", "e") ?><br />
 427 <input type="checkbox" name="eczema" value = "eczema" /> <?php xl("Eczema", "e") ?><br />
 428 <input type="checkbox" name="emphysema" value = "emphysema" /> <?php xl("Emphysema", "e") ?><br />
 429 <input type="checkbox" name="goiter" value = "goiter" /> <?php xl("Goiter", "e") ?><br />
 430 <input type="checkbox" name="ulcers" value = "ulcers" /> <?php xl("Ulcers", "e") ?><br />
 431 </td>
 432 <td><input type="checkbox" name="gout" value = "gout" /> <?php xl("Gout", "e") ?><br />
 433 <input type="checkbox" name="heart_disease" value = "heart_disease" /> <?php xl("Heart Disease/Attack", "e") ?><br />
 434 <input type="checkbox" name="rheumetic_fever" value = "rheumetic_fever" /> <?php xl("Rheumatic Fever", "e") ?><br />
 435 <input type="checkbox" name="miscarriage" value = "miscarriage" /> <?php xl("Miscarriage", "e") ?><br />
 436 <input type="checkbox" name="polio" value = "polio" /> <?php xl("Polio", "e") ?><br />
 437 </td>
 438 <td><input type="checkbox" name="pneumonia" value = "pneumonia" /> <?php xl("Pneumonia", "e") ?><br />
 439 <input type="checkbox" name="atherosclerosis" value = "atherosclerosis" /> <?php xl("Atherosclerosis", "e") ?><br />
 440 <input type="checkbox" name="multiple_sclerosis" value = "multiple_sclerosis" /> <?php xl("Multiple Sclerosis", "e") ?><br />
 441 <input type="checkbox" name="stroke" value = "stroke" /> <?php xl("Stroke", "e") ?><br />
 442 <input type="checkbox" name="tuberculosis" value = "tuberculosis" /> <?php xl("Tuberculosis", "e") ?><br />
 443 </td>
 444 <td><input type="checkbox" name="epilepsy" value = "epilepsy" /> <?php xl("Epilepsy", "e") ?><br />
 445 <input type="checkbox" name="measles" value = "measles" /> <?php xl("Measles", "e") ?><br />
 446 <input type="checkbox" name="mumps" value = "mumps" /> <?php xl("Mumps", "e") ?><br />
 447 <input type="checkbox" name="chicken_pox" value = "chicken_pox" /> <?php xl("Chicken Pox", "e") ?><br />
 448 <input type="checkbox" name="venereal_disease" value = "venereal_disease" /> <?php xl("Venereal Disease", "e") ?><br />
 449 </td>
 450 </tr></tbody></table><hr /></td>
 451 </tr>
 452
 453 <tr>
 454 <td colspan=3><table><tbody class="data">
 455 <tr>
 456 <td colspan=2><?php xl("Please Indicate If You Have/Had Trouble With Any Glands/Organs", "e")?><br />
 457 </td>
 458 <td colspan=2><?php xl("Family History: Have Your Mother or Father Had Any of These Disorders?", "e")?><br />
 459 </td>
 460 </tr>
 461 <tr>
 462
 463 <td><label><input type="checkbox" name="organ_gland[]" value="pituitary" /><?php xl("Pituitary", "e") ?></lable><br />
 464 <label><input type="checkbox" name="organ_gland[]" value="thyroid" /><?php xl("Thyroid", "e") ?></lable><br />
 465 <label><input type="checkbox" name="organ_gland[]" value="pancreas" /><?php xl("Pancreas", "e") ?></lable><br />
 466 <label><input type="checkbox" name="organ_gland[]" value="adrenal" /><?php xl("Adrenal", "e") ?></lable><br />
 467 <label><input type="checkbox" name="organ_gland[]" value="ovary_teste" /><?php xl("Ovary/Teste", "e") ?></lable><br />
 468 <label><input type="checkbox" name="organ_gland[]" value="liver" /><?php xl("Liver", "e") ?></lable><br />
 469 <label><input type="checkbox" name="organ_gland[]" value="gall_bladder" /><?php xl("Gall Bladder", "e") ?></label></td>
 470
 471 <td><label><input type="checkbox" name="organ_gland[]" value="stomach" /><?php xl("Stomach", "e") ?></lable><br />
 472 <label><input type="checkbox" name="organ_gland[]" value="small_intestine" /><?php xl("Small Intestine", "e") ?></lable><br />
 473 <label><input type="checkbox" name="organ_gland[]" value="large_intestine" /><?php xl("Large Intestine", "e") ?></lable><br />
 474 <label><input type="checkbox" name="organ_gland[]" value="bladder" /><?php xl("Bladder", "e") ?></lable><br />
 475 <label><input type="checkbox" name="organ_gland[]" value="lungs" /><?php xl("Lungs", "e") ?></lable><br />
 476 <label><input type="checkbox" name="organ_gland[]" value="prostate_uterus" /><?php xl("Prostate/Uterus", "e") ?></label></td>
 477
 478 <td><label><input type="checkbox" name="family_history[]" value="arthritis" /><?php xl("Arthritis", "e") ?></lable><br />
 479 <label><input type="checkbox" name="family_history[]" value="atherosclerosis" /><?php xl("Atherosclerosis", "e") ?></lable><br />
 480 <label><input type="checkbox" name="family_history[]" value="osteoprosis" /><?php xl("Osteoporosis", "e") ?></lable><br />
 481 <label><input type="checkbox" name="family_history[]" value="allergies" /><?php xl("Allergies", "e") ?></lable><br />
 482 <label><input type="checkbox" name="family_history[]" value="cancer" /><?php xl("Cancer", "e") ?></lable><br />
 483 <label><input type="checkbox" name="family_history[]" value="obesity" /><?php xl("Obesity", "e") ?></lable><br />
 484 <label><input type="checkbox" name="family_history[]" value="hemorrhoids" /><?php xl("Hemorrhoids", "e") ?></label></td>
 485
 486 <td><label><input type="checkbox" name="family_history[]" value="stroke" /><?php xl("Stroke", "e") ?></lable><br />
 487 <label><input type="checkbox" name="family_history[]" value="alcoholism" /><?php xl("Alcoholism", "e") ?></lable><br />
 488 <label><input type="checkbox" name="family_history[]" value="high_bpressure" /><?php xl("High Blood Pressure", "e") ?></lable><br />
 489 <label><input type="checkbox" name="family_history[]" value="heart_disease" /><?php xl("Heart Trouble", "e") ?></lable><br />
 490 <label><input type="checkbox" name="family_history[]" value="kidney_disease" /><?php xl("Kidney Disorders", "e") ?></lable><br />
 491 <label><input type="checkbox" name="family_history[]" value="nervous_disorder" /><?php xl("Other Nervous Systems", "e") ?></lable><br />
 492 <label><input type="checkbox" name="family_history[]" value="spinal_disorder" /><?php xl("Spinal Problems", "e") ?></label></td>
 493
 494 </tr>
 495 </tbody></table></td>
 496 </tr>
 497
 498 <tr><td colspan=3><hr />
 499 <?php xl("Check Which Meals That You Eat Regularly: ", "e")?>
 500 <input type="checkbox" name="regular_meals" value="breakfast" /><?php xl(" Breakfast", "e")?>
 501 <input type="checkbox" name="regular_meals" value="lunch" /><?php xl(" Lunch", "e")?>
 502 <input type="checkbox" name="regular_meals" value="dinner" /><?php xl(" Dinner", "e")?>
 503 <input type="checkbox" name="regular_meals" value="between_meals" /><?php xl(" Between Meals", "e")?>
 504 <input type="checkbox" name="regular_meals" value="before_bed" /><?php xl(" Before Bed", "e")?>
 505 </td></tr>
 506 </tbody></table>
 507
 508 <input type="submit" name="submit form" value="submit form" />
 509 </form>
 510 <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
 511 <?php
 512  formFooter();
 513  ?>