contrib/forms/patient_intake_history/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_patient_intake_history';
   7 $ftitle = 'Patient intake history';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $linked = $dt['linked_ros_id'];
  17   $oldros = sqlStatement("select * from form_patient_intake_history_ros where id=$linked");
  18   $dtros = sqlFetchArray($oldros);
  19   //$dtros = formFetch("form_patient_intake_history_ros", $linked);
  20   $newid = formSubmit("form_patient_intake_history_ros", array_slice($dtros,7), $id, $userauthorized);
  21   $dt['linked_ros_id'] = $newid;
  22   $newid = formSubmit("form_patient_intake_history", array_slice($dt,7), $id, $userauthorized);
  23   addForm($encounter, "Patient intake history", $newid, "patient_intake_history", $pid, $userauthorized);
  24   $id = $newid;
  25   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  26   exit;
  27   }
  28 }
  29 ?>
  30 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  31 "http://www.w3.org/TR/html4/loose.dtd">
  32
  33 <html>
  34 <head>
  35 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  36 <link rel=stylesheet href="../../acog.css" type="text/css">
  37 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  38 <script language="JavaScript" type="text/JavaScript">
  39 window.onload = initialize;
  40 </script>
  41 </head>
  42
  43 <body <?echo $top_bg_line;?>>
  44
  45 <?
  46    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  47    if ($fres){
  48      $patient = sqlFetchArray($fres);
  49    }
  50 ?>
  51 <form action="<?echo $rootdir;?>/forms/patient_intake_history/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  52 <?
  53 $addmenu = <<<EOL
  54 <blockquote>
  55   <small><strong>Local sections: </strong><br>
  56   <a href="#gh">Gynecologic history</a>  |
  57   <a href="#oh">Obstetric history</a> | <a href="#cm">Current medications</a> |
  58   <a href="#fh">Family history</a> | <a href="#sh">Social history</a> |
  59   <a href="#pp">Personal profile</a> |
  60   <a href="#ih">Personal past history of illnesses</a> | <a href="#op">Operations/Hospitalizations</a> |
  61   <a href="#ii">Injuries/Illnesses</a> | <a href="#im">Immunizations/Test</a> |
  62   <a href="#ros">Review of systems</a></small>
  63 </blockquote>
  64 EOL;
  65 ?>
  66 <? include("../../acog_menu.inc"); ?>
  67   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  68     <tr>
  69       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  70     </tr>
  71     <tr>
  72       <td align="left" valign="bottom" nowrap class="fibody3"> <input name="pih_patient" type="radio" value="0" checked>
  73       New patient </td>
  74     </tr>
  75     <tr>
  76       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_patient" type="radio" value="1">
  77       Established patient </td>
  78     </tr>
  79     <tr>
  80       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_consultation" type="checkbox" id="pih_consultation" value="1">
  81       Consultation</td>
  82     </tr>
  83     <tr>
  84       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_report_sent" type="checkbox" id="pih_report_sent" value="1">
  85       Report sent
  86       <input name="pih_report_sent_date" type="text" class="fullin" id="pih_report_sent_date" style="width:90px" value="YYYY-MM-DD"></td>
  87     </tr>
  88 </table>
  89 <?
  90 $tip1 = <<<EOL
  91 <strong>Patient Intake History</strong> is an optional form
  92 giving practices the flexibility to have patients complete
  93 their own history at or before the visit. It uses language
  94 that a patient is likely to understand and includes ample
  95 space for physician notes. Space at the end of the form
  96 allows physicians to review the history and sign off for 4
  97 years. At year 5, the patient should be asked to complete
  98 a new Patient Intake History.
  99 EOL;
 100 $tip1 = strtr($tip1, "\n\r", "  ");
 101 ?>
 102 <div class="srvChapter">Patient Intake history <a href="#" onMouseOver="toolTip('<? echo $tip1; ?>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
 103 <div style="border: solid 2px black; background-color: white;">
 104 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 105   <tr>
 106     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
 107       <tr align="left" valign="bottom" class="fibody">
 108         <td width="40%" class="bordR">Patient name <br>
 109           <input name="pname" type="text" class="fullin" id="pname" value="<?
 110           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
 111           ?>"></td>
 112         <td width="20%" class="bordR">birth date
 113           <br>
 114           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
 115           echo $patient{'DOB'};
 116           ?>" size="12"> </td>
 117         <td width="20%" class="bordR">ID No<br>
 118           <input name="pih_pid" type="text" class="fullin" id="pih_pid" size="12" value="<?
 119           echo $patient{'id'};
 120           ?>"></td>
 121         <td width="20%">date<br>
 122         <input name="pih_date" type="text" class="fullin" id="pih_date" value="<?
 123         echo date('Y-m-d');
 124         ?>" size="12"></td>
 125       </tr>
 126     </table>
 127 </td>
 128   </tr>
 129   <tr>
 130     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 131       <tr align="left" valign="bottom">
 132         <td colspan="3" class="fibody2">Address:
 133           <input name="address" type="text" class="fullin" id="address" style="width: 90%" value="<? echo $patient{'street'}; ?>"></td>
 134         </tr>
 135       <tr align="left" valign="bottom">
 136         <td width="50%" class="fibody2" id="bordR">City:
 137           <input name="city" type="text" class="fullin" id="city" style="width: 250px" value="<? echo $patient{'city'}; ?>"></td>
 138         <td width="50%" colspan="2" class="fibody2">State/ZIP:
 139           <input name="state" type="text" class="fullin" id="state" style="width: 250px" value="<? echo $patient{'state'}; ?>"></td>
 140       </tr>
 141       <tr align="left" valign="bottom">
 142         <td class="fibody2" id="bordR">Home telephone:
 143           <span style="width:auto">
 144           <input name="home_phone" type="text" class="fullin" id="home_phone" style="width: 120px" value="<? echo $patient{'phone_home'}; ?>">
 145           </span></td>
 146         <td colspan="2" class="fibody2">Work telephone:
 147           <input name="work_phone" type="text" class="fullin" id="work_phone" style="width: 120px" value="<? echo $patient{'phone_biz'}; ?>"></td>
 148       </tr>
 149       <tr align="left" valign="bottom">
 150         <td class="fibody2" id="bordR">Employer:
 151           <input name="employer" type="text" class="fullin" id="employer" style="width: 80%"></td>
 152         <td width="25%" class="fibody2" id="bordR">Insurance
 153           <input name="insurance" type="text" class="fullin" id="insurance" style="width: 120px"></td>
 154         <td width="25%" class="fibody2">Policy No:
 155           <input name="policy_no" type="text" class="fullin" id="policy_no" style="width: 120px"></td>
 156       </tr>
 157       <tr align="left" valign="bottom">
 158         <td class="fibody2" id="bordR">Name you would like us to use:           <input name="name_to_use" type="text" class="fullin" id="name_to_use" style="width: 50%">          </td>
 159         <td colspan="2" class="fibody2">Primary language:
 160           <input name="primary_language" type="text" class="fullin" id="primary_language" style="width: 150px"></td>
 161       </tr>
 162     </table></td>
 163   </tr>
 164   <tr>
 165     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 166       <tr align="left" valign="bottom">
 167         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 168         <td colspan="2" class="fibody2">Emergency contact:
 169           <input name="partner_emergency_contact" type="text" class="fullin" id="partner_emergency_contact" style="width: 70%" value="<? echo $patient{'phone_contact'}; ?>"></td>
 170         </tr>
 171       <tr align="left" valign="bottom">
 172         <td rowspan="2" valign="top" class="fibody2" id="bordR"><textarea name="partner_name" rows="2" wrap="VIRTUAL" class="fullin2" id="partner_name" style="height:100%"></textarea></td>
 173         <td colspan="2" class="fibody2">Relationship:
 174           <input name="relationship" type="text" class="fullin" id="relationship" style="width:80%" value="<? echo $patient{'contact_relationship'}; ?>"></td>
 175         </tr>
 176       <tr align="left" valign="bottom">
 177         <td width="30%" class="fibody2" id="bordR">Home telephone:
 178           <input name="partner_home_phone" type="text" class="fullin" id="partner_home_phone" style="width: 120px"></td>
 179         <td width="30%" class="fibody2">Work telephone:
 180           <input name="partner_work_phone" type="text" class="fullin" id="partner_work_phone" style="width: 120px"></td>
 181       </tr>
 182     </table></td>
 183   </tr>
 184   <tr>
 185     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 186       <tr>
 187         <td align="left" valign="bottom" class="fibody2">Referred by:
 188           <input name="referred_by" type="text" class="fullin" id="referred_by" style="width: 85%;"></td>
 189       </tr>
 190       <tr>
 191         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 192           <input name="why_come_to_office" type="text" class="fullin" id="why_come_to_office"></td>
 193       </tr>
 194       <tr>
 195         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 196           <input name="primary_care_visit" type="radio" value="1" checked>
 197           Primary care visit or
 198           <input name="primary_care_visit" type="radio" value="0">
 199           Gynecology only </td>
 200       </tr>
 201       <tr>
 202         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 203           <input name="new_problem" type="radio" value="1" checked>
 204           yes &nbsp;&nbsp;&nbsp;&nbsp;
 205           <input name="new_problem" type="radio" value="0">
 206           no</td>
 207       </tr>
 208       <tr>
 209         <td align="left" valign="bottom" class="fibody2">Please, describe your problem, including, where it is, how severe it is, and how long it has lasted <br>
 210           <textarea name="problem_description" rows="6" class="fullin2" id="problem_description"></textarea></td>
 211       </tr>
 212     </table></td>
 213   </tr>
 214 </table>
 215 </div>
 216 <h2 align="center"><small>If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.</small></h2>
 217 <p align="center">&nbsp;</p>
 218 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 219   </h2>
 220 <div style="border: solid 2px black; background-color: white;">
 221     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 222       <tr>
 223         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 224           <tr align="left" valign="bottom">
 225             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 226             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 227           </tr>
 228           <tr align="left" valign="bottom">
 229             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 230               <input name="last_period_date" type="text" class="fullin" id="last_period_date" style="width: 90px"></td>
 231             <td class="fibody2"><input name="gh_notes_1" type="text" class="fullin2" id="gh_notes_1"></td>
 232           </tr>
 233           <tr align="left" valign="bottom">
 234             <td nowrap class="fibody2" id="bordR">Age periods began:
 235               <input name="periods_began" type="text" class="fullin" id="periods_began" style="width: 90px"></td>
 236             <td class="fibody2"><input name="gh_notes_2" type="text" class="fullin2" id="gh_notes_2"></td>
 237           </tr>
 238           <tr align="left" valign="bottom">
 239             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 240               <input name="period_lenght" type="text" class="fullin" id="period_lenght" style="width: 90px"></td>
 241             <td class="fibody2"><input name="gh_notes_3" type="text" class="fullin2" id="gh_notes_3"></td>
 242           </tr>
 243           <tr align="left" valign="bottom">
 244             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 245               <input name="period_days_between" type="text" class="fullin" id="period_days_between" style="width: 90px"></td>
 246             <td class="fibody2"><input name="gh_notes_4" type="text" class="fullin2" id="gh_notes_4"></td>
 247           </tr>
 248           <tr align="left" valign="bottom">
 249             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 250               <input name="period_changes" type="radio" value="1">
 251 Yes
 252 <input name="pih_gh_recent_changes_periods" type="radio" value="0" checked>
 253 No</td>
 254             <td class="fibody2"><input name="gh_notes_5" type="text" class="fullin2" id="gh_notes_5"></td>
 255           </tr>
 256           <tr align="left" valign="bottom">
 257             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 258               <input name="sexually_active" type="radio" value="1" checked>
 259 Yes
 260 <input name="sexually_active" type="radio" value="0">
 261 No</td>
 262             <td class="fibody2"><input name="gh_notes_6" type="text" class="fullin2" id="gh_notes_6"></td>
 263           </tr>
 264           <tr align="left" valign="bottom">
 265             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 266               <input name="ever_had_sex" type="radio" value="1" checked>
 267 Yes
 268 <input name="ever_had_sex" type="radio" value="0">
 269 No</td>
 270             <td class="fibody2"><input name="gh_notes_7" type="text" class="fullin2" id="gh_notes_7"></td>
 271           </tr>
 272           <tr align="left" valign="bottom">
 273             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 274               <input name="number_of_partners" type="text" class="fullin" id="number_of_partners" style="width: 90px" value="not sure"></td>
 275             <td class="fibody2"><input name="gh_notes_8" type="text" class="fullin2" id="gh_notes_8"></td>
 276           </tr>
 277           <tr align="left" valign="bottom">
 278             <td nowrap class="fibody2" id="bordR">Sexual partners are
 279               <input name="partners" type="radio" value="men" checked>
 280               Men
 281               <input name="partners" type="radio" value="women">
 282               Women
 283               <input name="partners" type="radio" value="both">
 284               Both </td>
 285             <td class="fibody2"><input name="gh_notes_9" type="text" class="fullin2" id="gh_notes_9"></td>
 286           </tr>
 287           <tr align="left" valign="bottom">
 288             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 289               <input name="present_birth_control" type="text" class="fullin" id="present_birth_control" style="width: 90px" value="none"></td>
 290             <td class="fibody2"><input name="gh_notes_10" type="text" class="fullin2" id="gh_notes_10"></td>
 291           </tr>
 292           <tr align="left" valign="bottom">
 293             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 294               <input name="pills_iud" type="radio" value="1">
 295 Yes
 296 <input name="pills_iud" type="radio" value="0" checked>
 297 No </td>
 298             <td class="fibody2"><input name="gh_notes_11" type="text" class="fullin2" id="gh_notes_11"></td>
 299           </tr>
 300           <tr align="left" valign="bottom">
 301             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 302               <input name="pills_how_long" type="text" class="fullin" id="pills_how_long" style="width: 90px"></td>
 303             <td class="fibody2"><input name="gh_notes_12" type="text" class="fullin2" id="gh_notes_12"></td>
 304           </tr>
 305           <tr align="left" valign="bottom">
 306             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 307               <input name="pap_test" type="text" class="fullin" id="pap_test" style="width: 90px"></td>
 308             <td class="fibody2"><input name="gh_notes_13" type="text" class="fullin2" id="gh_notes_13"></td>
 309           </tr>
 310           <tr align="left" valign="bottom">
 311             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 312               <input name="breast_self_exam" type="radio" value="1">
 313               Yes
 314               <input name="breast_self_exam" type="radio" value="0" checked>
 315               No</td>
 316             <td class="fibody2"><input name="gh_notes_14" type="text" class="fullin2" id="gh_notes_14"></td>
 317           </tr>
 318           <tr align="left" valign="bottom">
 319             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 320               <input name="des" type="radio" value="1">
 321 Yes
 322 <input name="des" type="radio" value="0">
 323 No </td>
 324             <td class="fibody2"><input name="gh_notes_15" type="text" class="fullin2" id="gh_notes_15"></td>
 325           </tr>
 326         </table></td>
 327       </tr>
 328     </table>
 329   </div>
 330   <p align="center">&nbsp;</p>
 331   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 332   </h2>
 333   <div style="border: solid 2px black; background-color:#FFFFFF;">
 334     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 335       <tr>
 336         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 337             <tr align="left" valign="bottom">
 338               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 339               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 340               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 341               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 342               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 343               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 344             </tr>
 345             <tr align="left" valign="bottom">
 346               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 347               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2" id="oh_pregnancies" value="0"></td>
 348               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 349               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2" id="gh_abortions" value="0"></td>
 350               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 351               <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2" id="oh_miscarriages" value="0"></td>
 352             </tr>
 353             <tr align="left" valign="bottom">
 354               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 355               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_premature_births" type="text" class="fullin2" value="0"></td>
 356               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 357               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_live_births" type="text" class="fullin2" value="0"></td>
 358               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 359               <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2" value="0"></td>
 360             </tr>
 361         </table></td>
 362       </tr>
 363       <tr>
 364         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 365             <tr align="center" valign="middle">
 366               <td class="ficaption2" id="bordR">No</td>
 367               <td class="ficaption2" id="bordR">birth date </td>
 368               <td class="ficaption2" id="bordR">weight at birth </td>
 369               <td class="ficaption2" id="bordR">baby's sex </td>
 370               <td class="ficaption2" id="bordR">weeks pregnant </td>
 371               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 372               <td class="ficaption2">physician's notes</td>
 373             </tr>
 374 <?
 375   $bi = 0;
 376   while ($bi<4) {
 377     $n = $bi+1;
 378     print <<<EOL
 379         <tr align="left" valign="bottom">
 380           <td nowrap class="fibody2" id="bordR">$n.</td>
 381           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" class="fullin2"></td>
 382           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" class="fullin2"></td>
 383           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" class="fullin2"></td>
 384           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" class="fullin2"></td>
 385           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" class="fullin2"></td>
 386           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" class="fullin2"></td>
 387         </tr>
 388 EOL;
 389      $bi++;
 390   }
 391 ?>
 392         </table></td>
 393       </tr>
 394       <tr>
 395         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 396             <tr align="left" valign="bottom">
 397               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 398               <td class="fibody2"><input name="oh_complications" type="text" class="fullin2" id="oh_complications" value="n/a"></td>
 399             </tr>
 400         </table></td>
 401       </tr>
 402       <tr>
 403         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 404             <tr align="left" valign="bottom">
 405               <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox" id="oh_diabetes" value="1">
 406               diabetes
 407                 <input name="oh_hipertension" type="checkbox" id="oh_hipertension" value="1">
 408               hypertension/high blood pressure
 409               <input name="oh_preemclampsia" type="checkbox" id="oh_preemclampsia" value="1">
 410               preeclampsia/foxemia
 411               <input name="oh_complic_other" type="checkbox" id="oh_complic_other" value="1">
 412               other </td>
 413             </tr>
 414             <tr align="left" valign="bottom">
 415               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 416                   <input name="oh_depression" type="radio" value="0" checked>
 417               no
 418               <input name="oh_depression" type="radio" value="1">
 419               yes, How treated </td>
 420               <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2" id="oh_depression_treated"></td>
 421             </tr>
 422         </table></td>
 423       </tr>
 424     </table>
 425   </div>
 426   <p align="center">&nbsp;</p>
 427   <h2 align="center"><a name="cm"></a>Current medications <br>
 428     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 429   </h2>
 430   <div style="border: solid 2px black; background-color: white;">
 431     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 432       <tr align="center">
 433         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 434         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 435         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 436         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 437         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 438         <td valign="top" class="ficaption2">Who prescribed</td>
 439       </tr>
 440 <?
 441   $bi = 0;
 442   while ($bi<5) {
 443     $bi2 = $bi+5;
 444     print <<<EOL
 445       <tr>
 446         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi}" type="text" class="fullin2"></td>
 447         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi}" type="text" class="fullin2"></td>
 448         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_who_${bi}" type="text" class="fullin2"></td>
 449         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi2}" type="text" class="fullin2"></td>
 450         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi2}" type="text" class="fullin2"></td>
 451         <td align="left" valign="top" class="fibody2"><input name="pres_who_${bi2}" type="text" class="fullin2"></td>
 452       </tr>
 453 EOL;
 454      $bi++;
 455   }
 456 ?>
 457     </table>
 458   </div>
 459   <p align="center">&nbsp;</p>
 460   <h2 align="center"><a name="fh"></a>Family history <br>
 461   </h2>
 462   <div style="border: solid 2px black; background-color: white;">
 463     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 464       <tr>
 465         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 466           <tr align="left" valign="bottom">
 467             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 468               <input name="fh_mother" type="radio" value="0" checked>
 469               living
 470               <input name="fh_mother" type="radio" value="1">
 471               deceased - cause:
 472               <input name="fh_mother_dec_cause" type="text" class="fullin" id="fh_mother_dec_cause" style="width: 20%">
 473               Age:
 474               <input name="fh_mother_dec_age" type="text" class="fullin" id="fh_mother_dec_age" style="width:40px"></td>
 475             <td width="50%" nowrap class="fibody2">father:
 476               <input name="fh_father" type="radio" value="0" checked>
 477 living
 478 <input name="fh_father" type="radio" value="1">
 479 deceased - cause:
 480 <input name="fh_father_dec_cause" type="text" class="fullin" id="fh_father_dec_cause" style="width: 20%">
 481 Age:
 482 <input name="fh_father_dec_age" type="text" class="fullin" id="fh_father_dec_age" style="width:40px"></td>
 483           </tr>
 484           <tr align="left" valign="bottom">
 485             <td nowrap class="fibody2">Siblings: Num.living:
 486               <input name="fh_sibl_living" type="text" class="fullin" id="fh_sibl_living" style="width:40px">
 487               , num.deceased:
 488               <input name="fh_sib_deceased" type="text" class="fullin" id="fh_sib_deceased" style="width:40px">
 489               , cause(s)/age(s): </td>
 490             <td nowrap class="fibody2"><input name="fh_sib_dec_cause" type="text" class="fullin" id="fh_sib_dec_cause"></td>
 491           </tr>
 492           <tr align="left" valign="bottom">
 493             <td nowrap class="fibody2">Children: Num.living:
 494               <input name="fh_children_living" type="text" class="fullin" id="fh_children_living" style="width:40px">
 495 , num.deceased:
 496 <input name="fh_children_deceased" type="text" class="fullin" id="fh_children_deceased" style="width:40px">
 497 , cause(s)/age(s):</td>
 498             <td nowrap class="fibody2"><input name="fh_children_dec_cause" type="text" class="fullin" id="fh_children_dec_cause"></td>
 499           </tr>
 500         </table></td>
 501       </tr>
 502       <tr>
 503         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 504           <tr valign="bottom">
 505             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 506             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 507             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 508             <td align="center" class="ficaption2">Physician's notes </td>
 509           </tr>
 510           <tr align="left" valign="bottom">
 511             <td nowrap class="fibody2" id="bordR">diabetes</td>
 512             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_diabetes" type="checkbox" id="fh_diabetes" value="1"></td>
 513             <td class="fibody2" id="bordR"><input name="fh_diabetes_info" type="text" class="fullin2" id="fh_diabetes_info"></td>
 514             <td class="fibody2"><input name="fh_notes_1" type="text" class="fullin2" id="fh_notes_1"></td>
 515           </tr>
 516           <tr align="left" valign="bottom">
 517             <td nowrap class="fibody2" id="bordR">Stroke</td>
 518             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_stroke" type="checkbox" id="fh_stroke" value="1"></td>
 519             <td class="fibody2" id="bordR"><input name="fh_stroke_info" type="text" class="fullin2" id="fh_stroke_info"></td>
 520             <td class="fibody2"><input name="fh_notes_2" type="text" class="fullin2" id="fh_notes_2"></td>
 521           </tr>
 522           <tr align="left" valign="bottom">
 523             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 524             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_heart_disease" type="checkbox" id="fh_heart_disease" value="1"></td>
 525             <td class="fibody2" id="bordR">              <input name="fh_heart_disease_info" type="text" class="fullin2" id="fh_heart_disease_info"></td>
 526             <td class="fibody2"><input name="fh_notes_3" type="text" class="fullin2" id="fh_notes_3"></td>
 527           </tr>
 528           <tr align="left" valign="bottom">
 529             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 530             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fhbllod_clots" type="checkbox" id="fhbllod_clots" value="1"></td>
 531             <td class="fibody2" id="bordR"><input name="fhbllod_clots_info" type="text" class="fullin2" id="fhbllod_clots_info"></td>
 532             <td class="fibody2"><input name="fh_notes_4" type="text" class="fullin2" id="fh_notes_4"></td>
 533           </tr>
 534           <tr align="left" valign="bottom">
 535             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 536             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_pressure" type="checkbox" id="fh_high_pressure" value="1"></td>
 537             <td class="fibody2" id="bordR"><input name="fh_high_pressure_info" type="text" class="fullin2" id="fh_high_pressure_info"></td>
 538             <td class="fibody2"><input name="fh_notes_5" type="text" class="fullin2" id="fh_notes_5"></td>
 539           </tr>
 540           <tr align="left" valign="bottom">
 541             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 542             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_cholesterol" type="checkbox" id="fh_high_cholesterol" value="1"></td>
 543             <td class="fibody2" id="bordR"><input name="fh_high_cholesterol_info" type="text" class="fullin2" id="fh_high_cholesterol_info"></td>
 544             <td class="fibody2"><input name="fh_notes_6" type="text" class="fullin2" id="fh_notes_6"></td>
 545           </tr>
 546           <tr align="left" valign="bottom">
 547             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 548             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_osteoporosis" type="checkbox" id="fh_osteoporosis" value="1"></td>
 549             <td class="fibody2" id="bordR"><input name="fh_osteoporosis_info" type="text" class="fullin2" id="fh_osteoporosis_info"></td>
 550             <td class="fibody2"><input name="fh_notes_7" type="text" class="fullin2" id="fh_notes_7"></td>
 551           </tr>
 552           <tr align="left" valign="bottom">
 553             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 554             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hepatitis" type="checkbox" id="fh_hepatitis" value="1"></td>
 555             <td class="fibody2" id="bordR"><input name="fh_hepatitis_info" type="text" class="fullin2" id="fh_hepatitis_info"></td>
 556             <td class="fibody2"><input name="fh_notes_8" type="text" class="fullin2" id="fh_notes_8"></td>
 557           </tr>
 558           <tr align="left" valign="bottom">
 559             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 560             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hiv" type="checkbox" id="fh_hiv" value="1"></td>
 561             <td class="fibody2" id="bordR"><input name="fh_hiv_info" type="text" class="fullin2" id="fh_hiv_info"></td>
 562             <td class="fibody2"><input name="fh_notes_9" type="text" class="fullin2" id="fh_notes_9"></td>
 563           </tr>
 564           <tr align="left" valign="bottom">
 565             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 566             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_tuberculosis" type="checkbox" id="fh_tuberculosis" value="1"></td>
 567             <td class="fibody2" id="bordR"><input name="fh_tuberculosis_info" type="text" class="fullin2" id="fh_tuberculosis_info"></td>
 568             <td class="fibody2"><input name="fh_notes_10" type="text" class="fullin2" id="fh_notes_10"></td>
 569           </tr>
 570           <tr align="left" valign="bottom">
 571             <td nowrap class="fibody2" id="bordR">Birth defects </td>
 572             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="dh_birth_defects" type="checkbox" id="dh_birth_defects" value="1"></td>
 573             <td class="fibody2" id="bordR"><input name="dh_birth_defects_info" type="text" class="fullin2" id="dh_birth_defects_info"></td>
 574             <td class="fibody2"><input name="fh_notes_11" type="text" class="fullin2" id="fh_notes_11"></td>
 575           </tr>
 576           <tr align="left" valign="bottom">
 577             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
 578             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alcohol_drugs" type="checkbox" id="fh_alcohol_drugs" value="1"></td>
 579             <td class="fibody2" id="bordR"><input name="fh_alcohol_drugs_info" type="text" class="fullin2" id="fh_alcohol_drugs_info"></td>
 580             <td class="fibody2"><input name="fh_notes_12" type="text" class="fullin2" id="fh_notes_12"></td>
 581           </tr>
 582           <tr align="left" valign="bottom">
 583             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
 584             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_breast_cancer" type="checkbox" id="fh_breast_cancer" value="1"></td>
 585             <td class="fibody2" id="bordR"><input name="fh_breast_cancer_info" type="text" class="fullin2" id="fh_breast_cancer_info"></td>
 586             <td class="fibody2"><input name="fh_notes_13" type="text" class="fullin2" id="fh_notes_13"></td>
 587           </tr>
 588           <tr align="left" valign="bottom">
 589             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
 590             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_colon_cancer" type="checkbox" id="fh_colon_cancer" value="1"></td>
 591             <td class="fibody2" id="bordR"><input name="fh_colon_cancer_info" type="text" class="fullin2" id="fh_colon_cancer_info"></td>
 592             <td class="fibody2"><input name="fh_notes_14" type="text" class="fullin2" id="fh_notes_14"></td>
 593           </tr>
 594           <tr align="left" valign="bottom">
 595             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
 596             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="checkbox" id="fh_ovarian_cancer" value="1"></td>
 597             <td class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="text" class="fullin2" id="fh_ovarian_cancer"></td>
 598             <td class="fibody2"><input name="fh_notes_15" type="text" class="fullin2" id="fh_notes_15"></td>
 599           </tr>
 600           <tr align="left" valign="bottom">
 601             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
 602             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_uterine_cancer" type="checkbox" id="fh_uterine_cancer" value="1"></td>
 603             <td class="fibody2" id="bordR"><input name="fh_uterine_cancer_info" type="text" class="fullin2" id="fh_uterine_cancer_info"></td>
 604             <td class="fibody2"><input name="fh_notes_16" type="text" class="fullin2" id="fh_notes_16"></td>
 605           </tr>
 606           <tr align="left" valign="bottom">
 607             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
 608             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_mental_illness" type="checkbox" id="fh_mental_illness" value="1"></td>
 609             <td class="fibody2" id="bordR"><input name="fh_mental_illness_info" type="text" class="fullin2" id="fh_mental_illness_info"></td>
 610             <td class="fibody2"><input name="fh_notes_17" type="text" class="fullin2" id="fh_notes_17"></td>
 611           </tr>
 612           <tr align="left" valign="bottom">
 613             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
 614             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alzheimer" type="checkbox" id="fh_alzheimer" value="1"></td>
 615             <td class="fibody2" id="bordR"><input name="fh_alzheimer_info" type="text" class="fullin2" id="fh_alzheimer_info"></td>
 616             <td class="fibody2"><input name="fh_notes_18" type="text" class="fullin2" id="fh_notes_18"></td>
 617           </tr>
 618           <tr align="left" valign="bottom">
 619             <td nowrap class="fibody2" id="bordR">Other</td>
 620             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_other_illness" type="checkbox" id="fh_other_illness" value="1"></td>
 621             <td class="fibody2" id="bordR"><input name="fh_other_illness_info" type="text" class="fullin2" id="fh_other_illness_info"></td>
 622             <td class="fibody2"><input name="fh_notes_19" type="text" class="fullin2" id="fh_notes_19"></td>
 623           </tr>
 624         </table></td>
 625       </tr>
 626     </table>
 627   </div>
 628   <p align="center">&nbsp;</p>
 629   <h2 align="center"><a name="sh"></a>Social history <br>
 630   </h2>
 631   <div style="border: solid 2px black; background-color: white;">
 632     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 633       <tr>
 634         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 635           <tr align="left" valign="bottom">
 636             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
 637             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 638             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 639             <td align="center" class="ficaption2">physician's notes                           </td>
 640           </tr>
 641           <tr align="left" valign="bottom">
 642             <td nowrap class="fibody2" id="bordR">Ever smoked? current smoking: packs/day:
 643               <input name="sh_smoked_packs" type="text" class="fullin" id="sh_smoked_packs" style="width: 40px">
 644               , years:
 645               <input name="sh_smoked_years" type="text" class="fullin" id="sh_smoked_years" style="width: 40px"></td>
 646             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="1"></td>
 647             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="0" checked></td>
 648             <td class="fibody2"><input name="sh_notes_1" type="text" class="fullin2" id="sh_notes_1"></td>
 649           </tr>
 650           <tr align="left" valign="bottom">
 651             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
 652               <input name="sh_alcohol_drinks_day" type="text" class="fullin" id="sh_alcohol_drinks_day" style="width: 40px">
 653               ,
 654               drinks/week:
 655               <input name="sh_alcohol_drinks_week" type="text" class="fullin" id="sh_alcohol_drinks_week" style="width: 40px">
 656               ,
 657               type of drink:
 658               <input name="sh_alcohol_drinks_type" type="text" class="fullin" id="sh_alcohol_drinks_type" style="width: 40px"></td>
 659             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="1"></td>
 660             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="0" checked></td>
 661             <td class="fibody2"><input name="sh_notes_2" type="text" class="fullin2" id="sh_notes_2"></td>
 662           </tr>
 663           <tr align="left" valign="bottom">
 664             <td nowrap class="fibody2" id="bordR">Drug use </td>
 665             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="1"></td>
 666             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="0" checked></td>
 667             <td class="fibody2"><input name="sh_notes_3" type="text" class="fullin2" id="sh_notes_3"></td>
 668           </tr>
 669           <tr align="left" valign="bottom">
 670             <td nowrap class="fibody2" id="bordR">seat belt use </td>
 671             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="1"></td>
 672             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="0" checked></td>
 673             <td class="fibody2"><input name="sh_notes_4" type="text" class="fullin2" id="sh_notes_4"></td>
 674           </tr>
 675           <tr align="left" valign="bottom">
 676             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
 677               <input name="sh_exercise_info" type="text" class="fullin" id="sh_exercise_info" style="width: 150px"></td>
 678             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="1"></td>
 679             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="0" checked></td>
 680             <td width="400" class="fibody2"><input name="sh_notes_5" type="text" class="fullin2" id="sh_notes_5"></td>
 681           </tr>
 682           <tr align="left" valign="bottom">
 683             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
 684               <input name="sh_dairy_daily" type="text" class="fullin" id="sh_dairy_daily" style="width: 40px"></td>
 685             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="1"></td>
 686             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="0" checked></td>
 687             <td width="400" class="fibody2"><input name="sh_notes_6" type="text" class="fullin2" id="sh_notes_6"></td>
 688           </tr>
 689           <tr align="left" valign="bottom">
 690             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
 691             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="1"></td>
 692             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="0" checked></td>
 693             <td width="400" class="fibody2"><input name="sh_notes_7" type="text" class="fullin2" id="sh_notes_7"></td>
 694           </tr>
 695           <tr align="left" valign="bottom">
 696             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
 697             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="1"></td>
 698             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="0" checked></td>
 699             <td width="400" class="fibody2"><input name="sh_notes_8" type="text" class="fullin2" id="sh_notes_8"></td>
 700           </tr>
 701           <tr align="left" valign="bottom">
 702             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
 703             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="1"></td>
 704             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="0" checked></td>
 705             <td class="fibody2"><input name="sh_notes_9" type="text" class="fullin2" id="sh_notes_9"></td>
 706           </tr>
 707           <tr align="left" valign="bottom">
 708             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
 709             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="1"></td>
 710             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="0" checked></td>
 711             <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2" id="sh_notes_10"></td>
 712           </tr>
 713         </table></td>
 714       </tr>
 715     </table>
 716   </div>
 717   <p align="center">&nbsp;</p>
 718   <h2 align="center"><a name="pp"></a>Personal profile <br>
 719   </h2>
 720   <div style="border: solid 2px black; background-color: white;">
 721     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 722       <tr>
 723         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
 724           <input name="pih_pp_orientation" type="radio" value="hetero" checked>
 725         heterosexual
 726         <input name="pih_pp_orientation" type="radio" value="homo">
 727         homosexual
 728         <input name="pih_pp_orientation" type="radio" value="bi">
 729         bisexual </td>
 730       </tr>
 731       <tr>
 732         <td align="left" valign="bottom" class="fibody2">Marital status:
 733           <input name="pih_pp_status" type="radio" value="married">
 734         married
 735         &nbsp;&nbsp;
 736         <input name="pih_pp_status" type="radio" value="partner">
 737         living with partner&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="single" checked>
 738         single
 739         &nbsp;&nbsp;
 740         <input name="pih_pp_status" type="radio" value="widowed">
 741         widowed&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="divorced">
 742         divorced </td>
 743       </tr>
 744       <tr>
 745         <td align="left" valign="bottom" class="fibody2">Number of living children:
 746         <input name="pp_living_children" type="text" class="fullin" id="pp_living_children" style="width: 70px" value="0"></td>
 747       </tr>
 748       <tr>
 749         <td align="left" valign="bottom" class="fibody2">Number of people in household:
 750         <input name="pp_number_household" type="text" class="fullin" id="pp_number_household" style="width: 70px" value="1"></td>
 751       </tr>
 752       <tr>
 753         <td align="left" valign="bottom" class="fibody2">School completed:
 754           <input name="pih_pp_education" type="radio" id="pih_pp_education" value="highschool">
 755         high school
 756         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="aadegree">
 757         some college/AA degree
 758         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="college">
 759         college
 760         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="gdegree">
 761         graduate degree
 762         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="other" checked>
 763         other </td>
 764       </tr>
 765       <tr>
 766         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
 767         <input name="pp_current_job" type="text" class="fullin" id="pp_current_job" style="width: 77%" value="none"></td>
 768       </tr>
 769       <tr>
 770         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
 771           <input name="pp_travel_outside_us" type="radio" value="1">
 772           yes
 773           <input name="pp_travel_outside_us" type="radio" value="0" checked>
 774           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
 775           <input name="pp_travel_outside_locations" type="text" class="fullin" id="pp_travel_outside_locations" style="width:50%">
 776         </span></td>
 777       </tr>
 778     </table>
 779   </div>
 780   <p align="center">&nbsp;</p>
 781   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
 782   </h2>
 783   <div style="border: solid 2px black; background-color: white;">
 784     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 785       <tr>
 786         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 787             <tr align="left" valign="bottom">
 788               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
 789               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
 790               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 791               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
 792               <td align="center" class="ficaption2">Physician's notes </td>
 793             </tr>
 794             <tr align="left" valign="bottom">
 795               <td nowrap class="fibody2" id="bordR">Asthma</td>
 796               <td class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="1">
 797                   <input name="pih_ih_asthma_date" type="text" class="fullin" id="pih_ih_asthma_date" style="width: 70px"></td>
 798               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="0" checked></td>
 799               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="2"></td>
 800               <td class="fibody2"><input name="ih_notes_1" type="text" class="fullin2" id="ih_notes_1"></td>
 801             </tr>
 802             <tr align="left" valign="bottom">
 803               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
 804               <td class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="1">
 805                   <input name="pih_ih_pneumonia_date" type="text" class="fullin" id="pih_ih_pneumonia_date" style="width: 70px"></td>
 806               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="0" checked></td>
 807               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="2"></td>
 808               <td class="fibody2"><input name="ih_notes_2" type="text" class="fullin2" id="ih_notes_2"></td>
 809             </tr>
 810             <tr align="left" valign="bottom">
 811               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
 812               <td class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="1">
 813                   <input name="pih_ih_kidney_date" type="text" class="fullin" id="pih_ih_kidney_date" style="width: 70px"></td>
 814               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="0" checked></td>
 815               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="2"></td>
 816               <td class="fibody2"><input name="ih_notes_3" type="text" class="fullin2" id="ih_notes_3"></td>
 817             </tr>
 818             <tr align="left" valign="bottom">
 819               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 820               <td class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="1">
 821                   <input name="pih_ih_tuber_date" type="text" class="fullin" id="pih_ih_tuber_date" style="width: 70px"></td>
 822               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="0" checked></td>
 823               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="2"></td>
 824               <td class="fibody2"><input name="ih_notes_4" type="text" class="fullin2" id="ih_notes_4"></td>
 825             </tr>
 826             <tr align="left" valign="bottom">
 827               <td nowrap class="fibody2" id="bordR">Fibroids</td>
 828               <td class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="1">
 829                   <input name="pih_ih_fibroids_date" type="text" class="fullin" id="pih_ih_fibroids_date" style="width: 70px"></td>
 830               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="0" checked></td>
 831               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="2"></td>
 832               <td class="fibody2"><input name="ih_notes_5" type="text" class="fullin2" id="ih_notes_5"></td>
 833             </tr>
 834             <tr align="left" valign="bottom">
 835               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
 836               <td class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="1">
 837                   <input name="pih_ih_sexually_date" type="text" class="fullin" id="pih_ih_sexually_date" style="width: 70px"></td>
 838               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="0" checked></td>
 839               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="2"></td>
 840               <td class="fibody2"><input name="ih_notes_6" type="text" class="fullin2" id="ih_notes_6"></td>
 841             </tr>
 842             <tr align="left" valign="bottom">
 843               <td nowrap class="fibody2" id="bordR">Infertility</td>
 844               <td class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="1">
 845                   <input name="pih_ih_infertil_date" type="text" class="fullin" id="pih_ih_infertil_date" style="width: 70px"></td>
 846               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="0" checked></td>
 847               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="2"></td>
 848               <td class="fibody2"><input name="ih_notes_7" type="text" class="fullin2" id="ih_notes_7"></td>
 849             </tr>
 850             <tr align="left" valign="bottom">
 851               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
 852               <td class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="1">
 853                   <input name="pih_ih_hiv_date" type="text" class="fullin" id="pih_ih_hiv_date" style="width: 70px"></td>
 854               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="0" checked></td>
 855               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="2"></td>
 856               <td class="fibody2"><input name="ih_notes_8" type="text" class="fullin2" id="ih_notes_8"></td>
 857             </tr>
 858             <tr align="left" valign="bottom">
 859               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
 860               <td class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="1">
 861                   <input name="pih_ih_heart_date" type="text" class="fullin" id="pih_ih_heart_date" style="width: 70px"></td>
 862               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="0" checked></td>
 863               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="2"></td>
 864               <td class="fibody2"><input name="ih_notes_9" type="text" class="fullin2" id="ih_notes_9"></td>
 865             </tr>
 866             <tr align="left" valign="bottom">
 867               <td nowrap class="fibody2" id="bordR">Diabetes</td>
 868               <td class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="1">
 869                   <input name="pih_ih_diabetes_date" type="text" class="fullin" id="pih_ih_diabetes_date" style="width: 70px"></td>
 870               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="0" checked></td>
 871               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="2"></td>
 872               <td class="fibody2"><input name="ih_notes_10" type="text" class="fullin2" id="ih_notes_10"></td>
 873             </tr>
 874             <tr align="left" valign="bottom">
 875               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 876               <td class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="1">
 877                   <input name="pih_ih_high_pressure_date" type="text" class="fullin" id="pih_ih_high_pressure_date" style="width: 70px"></td>
 878               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="0" checked></td>
 879               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="2"></td>
 880               <td class="fibody2"><input name="ih_notes_11" type="text" class="fullin2" id="ih_notes_11"></td>
 881             </tr>
 882             <tr align="left" valign="bottom">
 883               <td nowrap class="fibody2" id="bordR">Stroke</td>
 884               <td class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="1">
 885                   <input name="pih_ih_stroke_date" type="text" class="fullin" id="pih_ih_stroke_date" style="width: 70px"></td>
 886               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="0" checked></td>
 887               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="2"></td>
 888               <td class="fibody2"><input name="ih_notes_12" type="text" class="fullin2" id="ih_notes_12"></td>
 889             </tr>
 890             <tr align="left" valign="bottom">
 891               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
 892               <td class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="1">
 893                   <input name="pih_ih_rheumatic_date" type="text" class="fullin" id="pih_ih_rheumatic_date" style="width: 70px"></td>
 894               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="0" checked></td>
 895               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="2"></td>
 896               <td class="fibody2"><input name="ih_notes_13" type="text" class="fullin2" id="ih_notes_13"></td>
 897             </tr>
 898             <tr align="left" valign="bottom">
 899               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 900               <td class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="1">
 901                   <input name="pih_ih_blood_clots_date" type="text" class="fullin" id="pih_ih_blood_clots_date" style="width: 70px"></td>
 902               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="0" checked></td>
 903               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="2"></td>
 904               <td class="fibody2"><input name="ih_notes_14" type="text" class="fullin2" id="ih_notes_14"></td>
 905             </tr>
 906             <tr align="left" valign="bottom">
 907               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
 908               <td class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="1">
 909                   <input name="pih_ih_eating_disorder_date" type="text" class="fullin" id="pih_ih_eating_disorder_date" style="width: 70px"></td>
 910               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="0" checked></td>
 911               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="2"></td>
 912               <td class="fibody2"><input name="ih_notes_15" type="text" class="fullin2" id="ih_notes_15"></td>
 913             </tr>
 914             <tr align="left" valign="bottom">
 915               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
 916               <td class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="1">
 917                   <input name="pih_ih_autoimmune_date" type="text" class="fullin" id="pih_ih_autoimmune_date" style="width: 70px"></td>
 918               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="0" checked></td>
 919               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="2"></td>
 920               <td class="fibody2"><input name="ih_notes_16" type="text" class="fullin2" id="ih_notes_16"></td>
 921             </tr>
 922             <tr align="left" valign="bottom">
 923               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
 924               <td class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="1">
 925                   <input name="pih_ih_chickenpox_date" type="text" class="fullin" id="pih_ih_chickenpox_date" style="width: 70px"></td>
 926               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="0" checked></td>
 927               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="2"></td>
 928               <td class="fibody2"><input name="ih_notes_17" type="text" class="fullin2" id="ih_notes_17"></td>
 929             </tr>
 930             <tr align="left" valign="bottom">
 931               <td nowrap class="fibody2" id="bordR">Cancer</td>
 932               <td class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="1">
 933                   <input name="pih_ih_cancer_date" type="text" class="fullin" id="pih_ih_cancer_date" style="width: 70px"></td>
 934               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="0" checked></td>
 935               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="2"></td>
 936               <td class="fibody2"><input name="ih_notes_18" type="text" class="fullin2" id="ih_notes_18"></td>
 937             </tr>
 938             <tr align="left" valign="bottom">
 939               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
 940               <td class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="1">
 941                   <input name="pih_ih_reflux_date" type="text" class="fullin" id="pih_ih_reflux_date" style="width: 70px"></td>
 942               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="0" checked></td>
 943               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="2"></td>
 944               <td class="fibody2"><input name="ih_notes_19" type="text" class="fullin2" id="ih_notes_19"></td>
 945             </tr>
 946             <tr align="left" valign="bottom">
 947               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
 948               <td class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="1">
 949                   <input name="pih_ih_depression_date" type="text" class="fullin" id="pih_ih_depression_date" style="width: 70px"></td>
 950               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="0" checked></td>
 951               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="2"></td>
 952               <td class="fibody2"><input name="ih_notes_20" type="text" class="fullin2" id="ih_notes_20"></td>
 953             </tr>
 954             <tr align="left" valign="bottom">
 955               <td nowrap class="fibody2" id="bordR">Anemia</td>
 956               <td class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="1">
 957                   <input name="pih_ih_anemia_date" type="text" class="fullin" id="pih_ih_anemia_date" style="width: 70px"></td>
 958               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="0" checked></td>
 959               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="2"></td>
 960               <td class="fibody2"><input name="ih_notes_21" type="text" class="fullin2" id="ih_notes_21"></td>
 961             </tr>
 962             <tr align="left" valign="bottom">
 963               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
 964               <td class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="1">
 965                   <input name="pih_ih_blood_transf_date" type="text" class="fullin" id="pih_ih_blood_transf_date" style="width: 70px"></td>
 966               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="0" checked></td>
 967               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="2"></td>
 968               <td class="fibody2"><input name="ih_notes_22" type="text" class="fullin2" id="ih_notes_22"></td>
 969             </tr>
 970             <tr align="left" valign="bottom">
 971               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
 972               <td class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="1">
 973                   <input name="pih_ih_seizures_date" type="text" class="fullin" id="pih_ih_seizures_date" style="width: 70px"></td>
 974               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="0" checked></td>
 975               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="2"></td>
 976               <td class="fibody2"><input name="ih_notes_23" type="text" class="fullin2" id="ih_notes_23"></td>
 977             </tr>
 978             <tr align="left" valign="bottom">
 979               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
 980               <td class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="1">
 981                   <input name="pih_ih_bowel_problems_date" type="text" class="fullin" id="pih_ih_bowel_problems_date" style="width: 70px"></td>
 982               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="0" checked></td>
 983               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="2"></td>
 984               <td class="fibody2"><input name="ih_notes_24" type="text" class="fullin2" id="ih_notes_24"></td>
 985             </tr>
 986             <tr align="left" valign="bottom">
 987               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
 988               <td class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="1">
 989                   <input name="pih_ih_glaucoma_date" type="text" class="fullin" id="pih_ih_glaucoma_date" style="width: 70px"></td>
 990               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="0" checked></td>
 991               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="2"></td>
 992               <td class="fibody2"><input name="ih_notes_25" type="text" class="fullin2" id="ih_notes_25"></td>
 993             </tr>
 994             <tr align="left" valign="bottom">
 995               <td nowrap class="fibody2" id="bordR">Cataracts</td>
 996               <td class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="1">
 997                   <input name="pih_ih_cataracts_date" type="text" class="fullin" id="pih_ih_cataracts_date" style="width: 70px"></td>
 998               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="0" checked></td>
 999               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="2"></td>
1000               <td class="fibody2"><input name="ih_notes_26" type="text" class="fullin2" id="ih_notes_26"></td>
1001             </tr>
1002             <tr align="left" valign="bottom">
1003               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
1004               <td class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="1">
1005                   <input name="pih_ih_joint_pain_date" type="text" class="fullin" id="pih_ih_joint_pain_date" style="width: 70px"></td>
1006               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="0" checked></td>
1007               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="2"></td>
1008               <td class="fibody2"><input name="ih_notes_27" type="text" class="fullin2" id="ih_notes_27"></td>
1009             </tr>
1010             <tr align="left" valign="bottom">
1011               <td nowrap class="fibody2" id="bordR">Broken bones </td>
1012               <td class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="1">
1013                   <input name="pih_ih_broken_bones_date" type="text" class="fullin" id="pih_ih_broken_bones_date" style="width: 70px"></td>
1014               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="0" checked></td>
1015               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="2"></td>
1016               <td class="fibody2"><input name="ih_notes_28" type="text" class="fullin2" id="ih_notes_28"></td>
1017             </tr>
1018             <tr align="left" valign="bottom">
1019               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
1020               <td class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="1">
1021                   <input name="pih_ih_hepatitis_date" type="text" class="fullin" id="pih_ih_hepatitis_date" style="width: 70px"></td>
1022               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="0" checked></td>
1023               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="2"></td>
1024               <td class="fibody2"><input name="ih_notes_29" type="text" class="fullin2" id="ih_notes_29"></td>
1025             </tr>
1026             <tr align="left" valign="bottom">
1027               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
1028               <td class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="1">
1029                   <input name="pih_ih_thyroid_date" type="text" class="fullin" id="pih_ih_thyroid_date" style="width: 70px"></td>
1030               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="0" checked></td>
1031               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="2"></td>
1032               <td class="fibody2"><input name="ih_notes_30" type="text" class="fullin2" id="ih_notes_30"></td>
1033             </tr>
1034             <tr align="left" valign="bottom">
1035               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
1036               <td class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="1">
1037                   <input name="pih_ih_galibladder_date" type="text" class="fullin" id="pih_ih_galibladder_date" style="width: 70px"></td>
1038               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="0" checked></td>
1039               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="2"></td>
1040               <td class="fibody2"><input name="ih_notes_31" type="text" class="fullin2" id="ih_notes_31"></td>
1041             </tr>
1042             <tr align="left" valign="bottom">
1043               <td nowrap class="fibody2" id="bordR">Headaches</td>
1044               <td class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="1">
1045                   <input name="pih_ih_headaches_date" type="text" class="fullin" id="pih_ih_headaches_date" style="width: 70px"></td>
1046               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="0" checked></td>
1047               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="2"></td>
1048               <td class="fibody2"><input name="ih_notes_32" type="text" class="fullin2" id="ih_notes_32"></td>
1049             </tr>
1050             <tr align="left" valign="bottom">
1051               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
1052               <td class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="1">
1053                   <input name="pih_ih_des_date" type="text" class="fullin" id="pih_ih_des_date" style="width: 70px"></td>
1054               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="0" checked></td>
1055               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="2"></td>
1056               <td class="fibody2"><input name="ih_notes_33" type="text" class="fullin2" id="ih_notes_33"></td>
1057             </tr>
1058             <tr align="left" valign="bottom">
1059               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
1060               <td class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="1">
1061                   <input name="pih_ih_bleeding_disorders_date" type="text" class="fullin" id="pih_ih_bleeding_disorders_date" style="width: 70px"></td>
1062               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="0" checked></td>
1063               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="2"></td>
1064               <td class="fibody2"><input name="ih_notes_34" type="text" class="fullin2" id="ih_notes_34"></td>
1065             </tr>
1066             <tr align="left" valign="bottom">
1067               <td nowrap class="fibody2" id="bordR">other</td>
1068               <td class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="1">
1069                   <input name="pih_ih_other_date" type="text" class="fullin" id="pih_ih_other_date" style="width: 70px"></td>
1070               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="0" checked></td>
1071               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="2"></td>
1072               <td class="fibody2"><input name="ih_notes_35" type="text" class="fullin2" id="ih_notes_35"></td>
1073             </tr>
1074             <tr align="left" valign="bottom">
1075               <td colspan="5" nowrap class="fibody3"><textarea name="pih_ih_extended_info" rows="4" wrap="VIRTUAL" class="fullin2" id="pih_ih_extended_info"></textarea></td>
1076             </tr>
1077         </table></td>
1078       </tr>
1079     </table>
1080   </div>
1081   <p align="center">&nbsp;</p>
1082   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
1083   </h2>
1084   <div style="border: solid 2px black; background-color: white;">
1085     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1086       <tr>
1087         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
1088         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
1089         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
1090       </tr>
1091 <?
1092 $ii = 0;
1093 while ($ii<6){
1094 print <<<EOL
1095       <tr>
1096         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_reason_${ii}" type="text" class="fullin2"></td>
1097         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_date_${ii}" type="text" class="fullin2"></td>
1098         <td align="left" valign="bottom" class="fibody2"><input name="op_hospital_${ii}" type="text" class="fullin2"></td>
1099       </tr>
1100 EOL;
1101 $ii++;
1102 }
1103 ?>
1104     </table>
1105   </div>
1106   <p align="center">&nbsp;</p>
1107   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
1108   </h2>
1109   <div style="border: solid 2px black; background-color: white;">
1110     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1111       <tr valign="bottom">
1112         <td align="left" class="ficaption2" id="bordR">Type</td>
1113         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
1114         <td align="left" class="ficaption2" id="bordR">Type</td>
1115         <td width="90" align="center" nowrap class="ficaption2">date</td>
1116       </tr>
1117 <?
1118 $ii = 0;
1119 while ($ii<6){
1120 $ij = $ii+6;
1121 print <<<EOL
1122       <tr valign="bottom">
1123         <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ii}" type="text" class="fullin2"></td>
1124         <td align="left" nowrap class="fibody2" id="bordR"><input name="ii_date_${ii}" type="text" class="fullin2"></td>
1125         <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ij}" type="text" class="fullin2"></td>
1126         <td align="left" nowrap class="fibody2"><input name="ii_date_${ij}" type="text" class="fullin2"></td>
1127       </tr>
1128 EOL;
1129 $ii++;
1130 }
1131 ?>
1132     </table>
1133   </div>
1134   <p align="center">&nbsp;</p>
1135   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
1136   </h2>
1137   <div style="border: solid 2px black; background-color: white;">
1138     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1139       <tr valign="bottom">
1140         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
1141         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
1142         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
1143         <td width="90" align="center" class="ficaption2">date</td>
1144       </tr>
1145       <tr valign="bottom">
1146         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
1147         <td align="left" nowrap class="fibody2" id="bordR">
1148           <input name="imm_tetanus" type="text" class="fullin2" id="imm_tetanus">
1149         </td>
1150         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
1151         <td align="left" valign="bottom" nowrap class="fibody2">
1152           <input name="imm_influenza" type="text" class="fullin2" id="imm_influenza">
1153         </td>
1154       </tr>
1155       <tr valign="bottom">
1156         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
1157         <td align="left" nowrap class="fibody2" id="bordR">
1158           <input name="imm_hepatitis_a" type="text" class="fullin2" id="imm_hepatitis_a">
1159         </td>
1160         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
1161         <td align="left" valign="bottom" nowrap class="fibody2">
1162           <input name="imm_hepatitis_b" type="text" class="fullin2" id="imm_hepatitis_b">
1163         </td>
1164       </tr>
1165       <tr valign="bottom">
1166         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
1167         <td align="left" nowrap class="fibody2" id="bordR">
1168           <input name="imm_varicella" type="text" class="fullin2" id="imm_varicella">
1169         </td>
1170         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
1171         <td align="left" valign="bottom" nowrap class="fibody2">
1172           <input name="imm_pneumococcal" type="text" class="fullin2" id="imm_pneumococcal">
1173         </td>
1174       </tr>
1175       <tr valign="bottom">
1176         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
1177         <td align="left" nowrap class="fibody2" id="bordR">
1178           <input name="imm_mmr" type="text" class="fullin2" id="imm_mmr">
1179         </td>
1180         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
1181         <input name="imm_tuberculosis_skin" type="text" class="fullin" id="imm_tuberculosis_skin" style="width:40px">
1182         , result:
1183         <input name="imm_tuberculosis_result" type="text" class="fullin" id="imm_tuberculosis_result" style="width:40px"></td>
1184         <td align="left" valign="bottom" nowrap class="fibody2">
1185           <input name="imm_tuberculosis" type="text" class="fullin2" id="imm_tuberculosis">
1186         </td>
1187       </tr>
1188     </table>
1189   </div>
1190   <p align="center">&nbsp;</p>
1191   <div style="border: solid 2px black; background-color: white;">
1192     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1193       <tr>
1194         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
1195         <textarea name="imm_extended_info" rows="6" wrap="VIRTUAL" class="fullin2" id="imm_extended_info"></textarea></td>
1196       </tr>
1197     </table>
1198   </div>
1199   <p align="center">&nbsp;</p>
1200   <a name="ros">
1201   <h2 align="center"><a ></a>Review of systems<br>
1202     <small>Please check (x), if any of the following symptoms
1203 apply to you now or since adulthood</small> </h2>
1204   <div style="border: solid 2px black; background-color: white;">
1205     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1206       <tr>
1207         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
1208         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
1209         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
1210         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
1211         <td align="center" valign="top" class="ficaption2">physician's notes </td>
1212       </tr>
1213       <tr valign="bottom">
1214         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
1215         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1216         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1217         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1218         <td align="left" class="fibody2">&nbsp;</td>
1219       </tr>
1220       <tr valign="bottom">
1221         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
1222         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="1"></td>
1223         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="2"></td>
1224         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="3"></td>
1225         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_1"  ></td>
1226       </tr>
1227       <tr valign="bottom">
1228         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
1229         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="1"></td>
1230         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="2"></td>
1231         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="3"></td>
1232         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_2"  ></td>
1233       </tr>
1234       <tr valign="bottom">
1235         <td align="left" class="fibody4"  id="bordR" >Fever</td>
1236         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="1"></td>
1237         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="2"></td>
1238         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="3"></td>
1239         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_3"  ></td>
1240       </tr>
1241       <tr valign="bottom">
1242         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
1243         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="1"></td>
1244         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="2"></td>
1245         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="3"></td>
1246         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_4"  ></td>
1247       </tr>
1248       <tr valign="bottom">
1249         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
1250         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="1"></td>
1251         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="2"></td>
1252         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="3"></td>
1253         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_5"  ></td>
1254       </tr>
1255       <tr valign="bottom">
1256         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
1257         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1258         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1259         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1260         <td align="left" class="fibody2">&nbsp;</td>
1261       </tr>
1262       <tr valign="bottom">
1263         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
1264         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="1"></td>
1265         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="2"></td>
1266         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="3"></td>
1267         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_6"  ></td>
1268       </tr>
1269       <tr valign="bottom">
1270         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
1271         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="1"></td>
1272         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="2"></td>
1273         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="3"></td>
1274         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_7"  ></td>
1275       </tr>
1276       <tr valign="bottom">
1277         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
1278         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="1"></td>
1279         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="2"></td>
1280         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="3"></td>
1281         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_8"  ></td>
1282       </tr>
1283       <tr valign="bottom">
1284         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
1285         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="1"></td>
1286         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="2"></td>
1287         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="3"></td>
1288         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_9"  ></td>
1289       </tr>
1290       <tr valign="bottom">
1291         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
1292         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1293         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1294         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1295         <td align="left" class="fibody2">&nbsp;</td>
1296       </tr>
1297       <tr valign="bottom">
1298         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
1299         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="1"></td>
1300         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="2"></td>
1301         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="3"></td>
1302         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_10"  ></td>
1303       </tr>
1304       <tr valign="bottom">
1305         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
1306         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="1"></td>
1307         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="2"></td>
1308         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="3"></td>
1309         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_11"  ></td>
1310       </tr>
1311       <tr valign="bottom">
1312         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
1313         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="1"></td>
1314         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="2"></td>
1315         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="3"></td>
1316         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_12"  ></td>
1317       </tr>
1318       <tr valign="bottom">
1319         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
1320         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="1"></td>
1321         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="2"></td>
1322         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="3"></td>
1323         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_13"  ></td>
1324       </tr>
1325       <tr valign="bottom">
1326         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
1327         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="1"></td>
1328         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="2"></td>
1329         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="3"></td>
1330         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_14"  ></td>
1331       </tr>
1332       <tr valign="bottom">
1333         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
1334         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="1"></td>
1335         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="2"></td>
1336         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="3"></td>
1337         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_15"  ></td>
1338       </tr>
1339       <tr valign="bottom">
1340         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
1341         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="1"></td>
1342         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="2"></td>
1343         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="3"></td>
1344         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_16"  ></td>
1345       </tr>
1346       <tr valign="bottom">
1347         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
1348         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1349         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1350         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1351         <td align="left" class="fibody2">&nbsp;</td>
1352       </tr>
1353       <tr valign="bottom">
1354         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
1355         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="1"></td>
1356         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="2"></td>
1357         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="3"></td>
1358         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_17"  ></td>
1359       </tr>
1360       <tr valign="bottom">
1361         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
1362         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="1"></td>
1363         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="2"></td>
1364         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="3"></td>
1365         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_18"  ></td>
1366       </tr>
1367       <tr valign="bottom">
1368         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
1369         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="1"></td>
1370         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="2"></td>
1371         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="3"></td>
1372         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_19"  ></td>
1373       </tr>
1374       <tr valign="bottom">
1375         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
1376         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="1"></td>
1377         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="2"></td>
1378         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="3"></td>
1379         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_20"  ></td>
1380       </tr>
1381       <tr valign="bottom">
1382         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
1383         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1384         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1385         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1386         <td align="left" class="fibody2">&nbsp;</td>
1387       </tr>
1388       <tr valign="bottom">
1389         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
1390         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="1"></td>
1391         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="2"></td>
1392         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="3"></td>
1393         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_21"  ></td>
1394       </tr>
1395       <tr valign="bottom">
1396         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
1397         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="1"></td>
1398         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="2"></td>
1399         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="3"></td>
1400         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_22"  ></td>
1401       </tr>
1402       <tr valign="bottom">
1403         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
1404         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="1"></td>
1405         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="2"></td>
1406         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="3"></td>
1407         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_23"  ></td>
1408       </tr>
1409       <tr valign="bottom">
1410         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
1411         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="1"></td>
1412         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="2"></td>
1413         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="3"></td>
1414         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_24"  ></td>
1415       </tr>
1416       <tr valign="bottom">
1417         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
1418         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="1"></td>
1419         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="2"></td>
1420         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="3"></td>
1421         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_25"  ></td>
1422       </tr>
1423       <tr valign="bottom">
1424         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
1425         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1426         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1427         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1428         <td align="left" class="fibody2">&nbsp;</td>
1429       </tr>
1430       <tr valign="bottom">
1431         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
1432         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="1"></td>
1433         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="2"></td>
1434         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="3"></td>
1435         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_26"  ></td>
1436       </tr>
1437       <tr valign="bottom">
1438         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
1439         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="1"></td>
1440         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="2"></td>
1441         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="3"></td>
1442         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_27"  ></td>
1443       </tr>
1444       <tr valign="bottom">
1445         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
1446         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="1"></td>
1447         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="2"></td>
1448         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="3"></td>
1449         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_28"  ></td>
1450       </tr>
1451       <tr valign="bottom">
1452         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
1453         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="1"></td>
1454         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="2"></td>
1455         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="3"></td>
1456         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_29"  ></td>
1457       </tr>
1458       <tr valign="bottom">
1459         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
1460         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="1"></td>
1461         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="2"></td>
1462         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="3"></td>
1463         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_30"  ></td>
1464       </tr>
1465       <tr valign="bottom">
1466         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
1467         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1468         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1469         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1470         <td align="left" class="fibody2">&nbsp;</td>
1471       </tr>
1472       <tr valign="bottom">
1473         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
1474         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="1"></td>
1475         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="2"></td>
1476         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="3"></td>
1477         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_31"  ></td>
1478       </tr>
1479       <tr valign="bottom">
1480         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
1481         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="1"></td>
1482         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="2"></td>
1483         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="3"></td>
1484         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_32"  ></td>
1485       </tr>
1486       <tr valign="bottom">
1487         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
1488         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="1"></td>
1489         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="2"></td>
1490         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="3"></td>
1491         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_33"  ></td>
1492       </tr>
1493       <tr valign="bottom">
1494         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
1495         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="1"></td>
1496         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="2"></td>
1497         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="3"></td>
1498         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_34"  ></td>
1499       </tr>
1500       <tr valign="bottom">
1501         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
1502         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="1"></td>
1503         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="2"></td>
1504         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="3"></td>
1505         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_35"  ></td>
1506       </tr>
1507       <tr valign="bottom">
1508         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
1509         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="1"></td>
1510         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="2"></td>
1511         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="3"></td>
1512         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_36"  ></td>
1513       </tr>
1514       <tr valign="bottom">
1515         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
1516         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="1"></td>
1517         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="2"></td>
1518         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="3"></td>
1519         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_37"  ></td>
1520       </tr>
1521       <tr valign="bottom">
1522         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
1523         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="1"></td>
1524         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="2"></td>
1525         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="3"></td>
1526         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_38"  ></td>
1527       </tr>
1528       <tr valign="bottom">
1529         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
1530         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="1"></td>
1531         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="2"></td>
1532         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="3"></td>
1533         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_39"  ></td>
1534       </tr>
1535       <tr valign="bottom">
1536         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
1537         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="1"></td>
1538         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="2"></td>
1539         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="3"></td>
1540         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_40"  ></td>
1541       </tr>
1542       <tr valign="bottom">
1543         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
1544         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="1"></td>
1545         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="2"></td>
1546         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="3"></td>
1547         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_41"  ></td>
1548       </tr>
1549       <tr valign="bottom">
1550         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
1551         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="1"></td>
1552         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="2"></td>
1553         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="3"></td>
1554         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_42"  ></td>
1555       </tr>
1556       <tr valign="bottom">
1557         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
1558         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1559         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1560         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1561         <td align="left" class="fibody2">&nbsp;</td>
1562       </tr>
1563       <tr valign="bottom">
1564         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
1565         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="1"></td>
1566         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="2"></td>
1567         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="3"></td>
1568         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_43"  ></td>
1569       </tr>
1570       <tr valign="bottom">
1571         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
1572         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="1"></td>
1573         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="2"></td>
1574         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="3"></td>
1575         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_44"  ></td>
1576       </tr>
1577       <tr valign="bottom">
1578         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
1579         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1580         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1581         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1582         <td align="left" class="fibody2">&nbsp;</td>
1583       </tr>
1584       <tr valign="bottom">
1585         <td align="left" class="fibody4"  id="bordR" >Rash</td>
1586         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="1"></td>
1587         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="2"></td>
1588         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="3"></td>
1589         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_45"  ></td>
1590       </tr>
1591       <tr valign="bottom">
1592         <td align="left" class="fibody4"  id="bordR" >Sores</td>
1593         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="1"></td>
1594         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="2"></td>
1595         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="3"></td>
1596         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_46"  ></td>
1597       </tr>
1598       <tr valign="bottom">
1599         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
1600         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="1"></td>
1601         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="2"></td>
1602         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="3"></td>
1603         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_47"  ></td>
1604       </tr>
1605       <tr valign="bottom">
1606         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
1607         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="1"></td>
1608         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="2"></td>
1609         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="3"></td>
1610         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_48"  ></td>
1611       </tr>
1612       <tr valign="bottom">
1613         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
1614         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1615         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1616         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1617         <td align="left" class="fibody2">&nbsp;</td>
1618       </tr>
1619       <tr valign="bottom">
1620         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
1621         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="1"></td>
1622         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="2"></td>
1623         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="3"></td>
1624         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_49"  ></td>
1625       </tr>
1626       <tr valign="bottom">
1627         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
1628         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="1"></td>
1629         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="2"></td>
1630         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="3"></td>
1631         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_50"  ></td>
1632       </tr>
1633       <tr valign="bottom">
1634         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
1635         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="1"></td>
1636         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="2"></td>
1637         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="3"></td>
1638         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_51"  ></td>
1639       </tr>
1640       <tr valign="bottom">
1641         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
1642         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1643         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1644         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1645         <td align="left" class="fibody2">&nbsp;</td>
1646       </tr>
1647       <tr valign="bottom">
1648         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
1649         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="1"></td>
1650         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="2"></td>
1651         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="3"></td>
1652         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_52"  ></td>
1653       </tr>
1654       <tr valign="bottom">
1655         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
1656         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="1"></td>
1657         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="2"></td>
1658         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="3"></td>
1659         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_53"  ></td>
1660       </tr>
1661       <tr valign="bottom">
1662         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
1663         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="1"></td>
1664         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="2"></td>
1665         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="3"></td>
1666         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_54"  ></td>
1667       </tr>
1668       <tr valign="bottom">
1669         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
1670         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="1"></td>
1671         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="2"></td>
1672         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="3"></td>
1673         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_55"  ></td>
1674       </tr>
1675       <tr valign="bottom">
1676         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
1677         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="1"></td>
1678         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="2"></td>
1679         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="3"></td>
1680         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_56"  ></td>
1681       </tr>
1682       <tr valign="bottom">
1683         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
1684         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="1"></td>
1685         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="2"></td>
1686         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="3"></td>
1687         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_57"  ></td>
1688       </tr>
1689       <tr valign="bottom">
1690         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
1691         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1692         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1693         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1694         <td align="left" class="fibody2">&nbsp;</td>
1695       </tr>
1696       <tr valign="bottom">
1697         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
1698         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="1"></td>
1699         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="2"></td>
1700         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="3"></td>
1701         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_58"  ></td>
1702       </tr>
1703       <tr valign="bottom">
1704         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
1705         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="1"></td>
1706         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="2"></td>
1707         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="3"></td>
1708         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_59"  ></td>
1709       </tr>
1710       <tr valign="bottom">
1711         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
1712         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1713         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1714         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1715         <td align="left" class="fibody2">&nbsp;</td>
1716       </tr>
1717       <tr valign="bottom">
1718         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
1719         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="1"></td>
1720         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="2"></td>
1721         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="3"></td>
1722         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_60"  ></td>
1723       </tr>
1724       <tr valign="bottom">
1725         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
1726         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="1"></td>
1727         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="2"></td>
1728         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="3"></td>
1729         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_61"  ></td>
1730       </tr>
1731       <tr valign="bottom">
1732         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
1733         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="1"></td>
1734         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="2"></td>
1735         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="3"></td>
1736         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_62"  ></td>
1737       </tr>
1738       <tr valign="bottom">
1739         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
1740         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="1"></td>
1741         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="2"></td>
1742         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="3"></td>
1743         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_63"  ></td>
1744       </tr>
1745       <tr valign="bottom">
1746         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
1747         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1748         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1749         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1750         <td align="left" class="fibody2">&nbsp;</td>
1751       </tr>
1752       <tr valign="bottom">
1753         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
1754         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="1"></td>
1755         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="2"></td>
1756         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="3"></td>
1757         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_64"  ></td>
1758       </tr>
1759       <tr valign="bottom">
1760         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
1761         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="1"></td>
1762         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="2"></td>
1763         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="3"></td>
1764         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_65"  ></td>
1765       </tr>
1766       <tr valign="bottom">
1767         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
1768         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="1"></td>
1769         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="2"></td>
1770         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="3"></td>
1771         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_66"  ></td>
1772       </tr>
1773       <tr valign="bottom">
1774         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
1775         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1776         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1777         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1778         <td align="left" class="fibody2">&nbsp;</td>
1779       </tr>
1780       <tr valign="bottom">
1781         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
1782         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="1"></td>
1783         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="2"></td>
1784         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="3"></td>
1785         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_68"  ></td>
1786       </tr>
1787       <tr valign="bottom">
1788         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
1789         <td colspan="4" align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_med_allergy_reaction"  ></td>
1790       </tr>
1791       <tr valign="bottom">
1792         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
1793         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="1"></td>
1794         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="2"></td>
1795         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="3"></td>
1796         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_69"  ></td>
1797       </tr>
1798       <tr valign="bottom">
1799         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
1800         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="1"></td>
1801         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="2"></td>
1802         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="3"></td>
1803         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_70"  ></td>
1804       </tr>
1805       <tr valign="bottom">
1806         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
1807         <td colspan="4" align="left" class="fibody2"><input type="text" class="fullin2"   name="ros_other_allergy_reaction_"  ></td>
1808       </tr>
1809     </table>
1810   </div>
1811   <p align="center">&nbsp;</p>
1812   <div style="border: solid 2px black; background-color: white;">
1813     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1814       <tr valign="bottom">
1815         <td colspan="2" align="left" class="fibody2">Form completed by
1816           <input name="pih_completed_by" type="radio" value="patient" checked>
1817         patient
1818         <input name="pih_completed_by" type="radio" value="nurse">
1819         office nurse
1820         <input name="pih_completed_by" type="radio" value="physician">
1821         physician
1822         <input name="pih_completed_by" type="radio" value="other">
1823         other:
1824         <input name="pih_completed_by_other" type="text" class="fullin" id="pih_completed_by_other" style="width: 40%"></td>
1825       </tr>
1826       <tr valign="bottom">
1827         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
1828       </tr>
1829       <tr valign="bottom">
1830         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
1831         <input name="pih_date_reviewed_1" type="text" class="fullin" id="pih_date_reviewed_1" style="width:70px"></td>
1832         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
1833       </tr>
1834       <tr valign="bottom">
1835         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
1836       </tr>
1837       <tr valign="bottom">
1838         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1839           <input name="pih_date_reviewed_2" type="text" class="fullin" id="pih_date_reviewed_2" style="width:70px">
1840         </span></td>
1841         <td height="46" align="left" class="fibody2">Physician signature: </td>
1842       </tr>
1843       <tr valign="bottom">
1844         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1845           <input name="pih_date_reviewed_3" type="text" class="fullin" id="pih_date_reviewed_3" style="width:70px">
1846         </span> </td>
1847         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1848       </tr>
1849       <tr valign="bottom">
1850         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1851           <input name="pih_date_reviewed_4" type="text" class="fullin" id="pih_date_reviewed_4" style="width:70px">
1852         </span> </td>
1853         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1854       </tr>
1855       <tr valign="bottom">
1856         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1857           <input name="pih_date_reviewed_5" type="text" class="fullin" id="pih_date_reviewed_5" style="width:70px">
1858         </span> </td>
1859         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1860       </tr>
1861       <tr valign="bottom">
1862         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1863           <input name="pih_date_reviewed_6" type="text" class="fullin" id="pih_date_reviewed_6" style="width:70px">
1864         </span> </td>
1865         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1866       </tr>
1867     </table>
1868   </div>
1869   <p align="center">&nbsp;</p>
1870   <table width="100%" border="0">
1871     <tr>
1872       <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
1873       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
1874        onclick="top.restoreSession()">[Don't Save]</a> </td>
1875     </tr>
1876   </table>
1877 </form>
1878 <?php
1879 formFooter();
1880 ?>
1881 </body>
1882 </html>