contrib/forms/physician_history/report.php

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