contrib/forms/physician_history/report.php

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