contrib/forms/physician_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("$srcdir/calendar.inc");
   6 include_once("$srcdir/lists.inc");
   7 $frmn = 'form_physician_history';
   8 $ftitle = 'Physician history';
   9 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
  10 if ($old) {
  11   $dt = sqlFetchArray($old);
  12   $fid = $dt{'form_id'};
  13   if ($fid && ($fid != 0) && ($fid != '')){
  14   $fdir = $dt{'formdir'};
  15   unset($dt);
  16   $dt = formFetch($frmn, $fid);
  17   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  18   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  19   $id = $newid;
  20   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  21   exit;
  22   }
  23 }
  24 ?>
  25 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  26 "http://www.w3.org/TR/html4/loose.dtd">
  27
  28 <html>
  29 <head>
  30 <title>Physician history</title>
  31 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  32 <link rel=stylesheet href="../../acog.css" type="text/css">
  33 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  34 <script language="JavaScript" src="../../acogros.js" type="text/JavaScript"></script>
  35 <script language="JavaScript" type="text/JavaScript">
  36 window.onload = initialize;
  37 </script>
  38 </head>
  39
  40 <?
  41    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  42    if ($fres){
  43      $patient = sqlFetchArray($fres);
  44    }
  45    if ($encounter != ''){
  46    $fres=sqlStatement("select * from form_encounter where encounter=$encounter");
  47    if ($fres){
  48      $edata = sqlFetchArray($fres);
  49    }
  50    }
  51    $fres=sqlStatement("select * from history_data where pid=$pid");
  52    if ($fres){
  53      $history = sqlFetchArray($fres);
  54    }
  55 ?>
  56 <body <?echo $top_bg_line;?>>
  57 <form action="<?echo $rootdir;?>/forms/physician_history/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  58 <?
  59 $addmenu = <<<EOL
  60 <blockquote>
  61 <small><strong>Local sections:</strong><br>
  62 <a href="#gh">Gynecologic history</a> | <a href="#oh">Obstetric history</a> |
  63 <a href="#ph">Past history</a> | <a href="#fh">Family history</a> |
  64 <a href="#sh">Social history</a> | <a href="#ros">Review of systems</a>
  65 </small>
  66 </blockquote>
  67 EOL;
  68 ?>
  69 <? include("../../acog_menu.inc"); ?>
  70 <table width="70%"  border="0" cellspacing="0" cellpadding="4">
  71   <tr>
  72     <td width="120" align="left" valign="bottom" class="srvCaption">Patient name:</td>
  73     <td align="left" valign="bottom"><input name="pname" type="text" class="fullin" id="pname" value="<?
  74           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  75           ?>"></td>
  76   </tr>
  77   <tr>
  78     <td width="120" align="left" valign="bottom" class="srvCaption">Birth date: </td>
  79     <td align="left" valign="bottom"><input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
  80           echo $patient{'DOB'};
  81           ?>"></td>
  82   </tr>
  83   <tr>
  84     <td width="120" align="left" valign="bottom" class="srvCaption">ID No:</td>
  85     <td align="left" valign="bottom"><input name="ph_pid" type="text" class="fullin" id="ph_pid" value="<?
  86           echo $patient{'id'};
  87           ?>"></td>
  88   </tr>
  89   <tr>
  90     <td width="120" align="left" valign="bottom" class="srvCaption">Date</td>
  91     <td align="left" valign="bottom"><input name="ph_date" type="text" class="fullin" id="ph_date" value="<?
  92         echo date('Y-m-d');
  93         ?>"></td>
  94   </tr>
  95 </table>
  96 <?
  97 $tip1 = <<<EOL
  98 The <strong>Physician History</strong> can be used record the history for every type of outpatient encounter, including consultations. A new Physician History should be completed by the physician at each visit when clinically indicated.
  99 EOL;
 100 ?>
 101 <div class="srvChapter">Physician 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>
 102 <div style="border: solid 2px black; background-color:#FFFFFF;">
 103   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 104     <tr>
 105       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 106           <tr align="left" valign="baseline">
 107             <td width="25%" class="fibody2" id="bordR"><input name="established" type="radio" value="0" checked>
 108               New patient </td>
 109             <td width="25%" class="fibody2" id="bordR"><input name="established" type="radio" value="1">
 110               Established patient </td>
 111             <td width="20%" nowrap class="fibody2" id="bordR"><input name="consultation" type="checkbox" id="consultation" value="1">
 112               Consultation</td>
 113             <td width="30%" valign="bottom" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 114                 <tr>
 115                   <td width="60%" align="left" valign="bottom"><input name="report_sent" type="checkbox" id="ph_report_sent2" value="1">
 116                     Report sent</td>
 117                   <td width="40%" align="left" valign="bottom"><input name="report_sent_date" type="text" class="fullin2" id="ph_report_sent_date2" value="YYYY-MM-DD" size="12"></td>
 118                 </tr>
 119             </table></td>
 120           </tr>
 121           <tr align="left" valign="bottom">
 122             <td colspan="2" class="fibody2" id="bordR">Primary care physician:<br>
 123                 <input name="primary_care" type="text" class="fullin2" id="primary_care"></td>
 124             <td colspan="2" class="fibody2">Who sent patient:<br>
 125                 <input name="who_sent" type="text" class="fullin2" id="who_sent"></td>
 126           </tr>
 127           <tr align="left" valign="bottom">
 128             <td colspan="2" class="fibody2" id="bordR"> Other physician(s):<br>
 129                 <input name="other_physician" type="text" class="fullin2" id="other_physician">
 130             </td>
 131             <td colspan="2" class="fibody2">&nbsp;</td>
 132           </tr>
 133       </table></td>
 134     </tr>
 135     <tr>
 136       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 137           <tr align="left" valign="baseline">
 138             <td width="50%" class="ficaption2" id="bordR">Chief complaint (CC) (<small>Required for all visits except preventive</small>):</td>
 139             <td width="50%" class="ficaption2">Current prescription medications: </td>
 140           </tr>
 141           <tr align="left" valign="baseline">
 142             <td width="50%" nowrap class="fibody2" id="bordR"><textarea name="chief_complaint" rows="3" wrap="VIRTUAL" class="fullin2" id="chief_complaint"><? echo $edata['reason']; ?></textarea>
 143             </td>
 144             <td width="50%" nowrap class="fibody2"><textarea name="current_prescription" rows="3" wrap="VIRTUAL" class="fullin2" id="current_prescription"><?
 145 if ($result = getListByType($pid, "medication", "id,title,comments,activity,date", 1, "all", 0)){
 146         foreach ($result as $iter) {
 147           $tmp_med[] = $iter{"title"}.' ('.$iter{"comments"}.') ';
 148         }
 149 echo join(', ', $tmp_med);
 150 }
 151 ?>
 152 </textarea></td>
 153           </tr>
 154           <tr align="left" valign="baseline">
 155             <td width="50%" valign="bottom" class="ficaption2" id="bordR">History of present ilness (HPI): <br>
 156             </td>
 157             <td width="50%" valign="bottom" class="ficaption2">Current nonpresription, complementary, and alternative medications: </td>
 158           </tr>
 159           <tr align="left" valign="baseline">
 160             <td width="50%" valign="bottom" nowrap class="fibody2" id="bordR"><textarea name="hpi" rows="3" wrap="VIRTUAL" class="fullin2" id="hpi"></textarea></td>
 161             <td width="50%" valign="bottom" nowrap class="fibody2"><textarea name="current_nonprescription" rows="3" wrap="VIRTUAL" class="fullin2" id="current_nonprescription"></textarea></td>
 162           </tr>
 163       </table></td>
 164     </tr>
 165     <tr>
 166       <td class="fibody2">&nbsp;</td>
 167     </tr>
 168     <tr>
 169       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 170           <tr align="left" valign="bottom">
 171             <td width="200" class="ficaption2">Changes since last visit </td>
 172             <td width="40" align="center" class="ficaption2">yes</td>
 173             <td width="40" align="center" class="ficaption2" id="bordR">no</td>
 174             <td colspan="2" align="center" class="ficaption2">Notes</td>
 175           </tr>
 176           <tr align="left" valign="bottom">
 177             <td width="200" class="fibody2">Illnesses</td>
 178             <td width="40" align="center" class="fibody2"><input name="ph_lvch_ill" type="radio" value="1"></td>
 179             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_ill" type="radio" value="0" checked></td>
 180             <td colspan="2" rowspan="7" valign="top" class="fibody2"><textarea name="ph_lvch_notes" rows="7" wrap="VIRTUAL" class="fullin2" id="ph_lvch_notes" style="height: 100%"></textarea></td>
 181           </tr>
 182           <tr align="left" valign="bottom">
 183             <td width="200" class="fibody2">Surgery</td>
 184             <td width="40" align="center" class="fibody2"><input name="ph_lvch_surg" type="radio" value="1"></td>
 185             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_surg" type="radio" value="0" checked></td>
 186           </tr>
 187           <tr align="left" valign="bottom">
 188             <td width="200" class="fibody2">New medications </td>
 189             <td width="40" align="center" class="fibody2"><input name="ph_lvch_newmed" type="radio" value="1"></td>
 190             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_newmed" type="radio" value="0" checked></td>
 191           </tr>
 192           <tr align="left" valign="bottom">
 193             <td width="200" class="fibody2">Change in family history </td>
 194             <td width="40" align="center" class="fibody2"><input name="ph_lvch_famhist" type="radio" value="1"></td>
 195             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_famhist" type="radio" value="0" checked></td>
 196           </tr>
 197           <tr align="left" valign="bottom">
 198             <td width="200" class="fibody2">New allergies </td>
 199             <td width="40" align="center" class="fibody2"><input name="ph_lvch_newallerg" type="radio" value="1"></td>
 200             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_newallerg" type="radio" value="0" checked></td>
 201           </tr>
 202           <tr align="left" valign="bottom">
 203             <td width="200" class="fibody2">Change in gynecologic history </td>
 204             <td width="40" align="center" class="fibody2"><input name="ph_lvch_gynhist" type="radio" value="1"></td>
 205             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_gynhist" type="radio" value="0" checked></td>
 206           </tr>
 207           <tr align="left" valign="bottom">
 208             <td width="200" class="fibody2">Change in obstetric history </td>
 209             <td width="40" align="center" class="fibody2"><input name="ph_lvch_obsthist" type="radio" value="1"></td>
 210             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_obsthist" type="radio" value="0" checked></td>
 211           </tr>
 212       </table></td>
 213     </tr>
 214     <tr>
 215       <td class="fibody2">&nbsp;</td>
 216     </tr>
 217     <tr>
 218       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 219           <tr align="left" valign="bottom">
 220             <?
 221 $allergies = ''; $checked = 'checked';
 222 if ($result = getListByType($pid, "allergy", "id,title,comments,activity,date", 1, "all", 0)){
 223         foreach ($result as $iter) {
 224           $al_tmp[] = $iter{"title"}.' ('.$iter{"comments"}.') ';
 225           $checked = '';
 226         }
 227         $allergies = join(',', $al_tmp);
 228 }
 229 ?>
 230             <td width="225" class="fibody2"><a name="allergies"></a>Allergies (describe reaction):
 231                 <input name="ph_allergies_none" type="checkbox" id="ph_allergies_none" value="1" <? echo $checked ?>>
 232               None</td>
 233             <td class="fibody2"><input name="ph_allergies_data" type="text" class="fullin2" id="ph_allergies_data" value="<? echo $allergies; ?>"></td>
 234           </tr>
 235       </table></td>
 236     </tr>
 237     <tr>
 238       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 239           <tr align="left" valign="bottom">
 240             <td width="70%" class="fibody2" id="bordR">Last cervical cancer screening:
 241                 <input name="cancer_scr_cytology" type="checkbox" id="cancer_scr_cytology" value="1">
 242               Cytology
 243               <input name="cancer_scr_cytology_date" type="text" class="fullin2" id="cancer_scr_cytology_date" style="width: 70px" value="YYYY-MM-DD">
 244               <input name="cancer_scr_hpv" type="checkbox" id="cancer_scr_hpv" value="checkbox">
 245               HPV test
 246               <input name="cancer_scr_hpv_date" type="text" class="fullin2" id="cancer_scr_hpv_date" style="width: 70px" value="YYYY-MM-DD"></td>
 247             <td width="30%" class="fibody2"><input name="cancer_scr_notes" type="text" class="fullin2" id="cancer_scr_notes"></td>
 248           </tr>
 249           <tr align="left" valign="bottom">
 250             <td width="70%" class="fibody2" id="bordR">last mammogram:
 251                 <input name="last_mammogram" type="text" class="fullin2" id="last_mammogram" style="width: 70px" value="<? echo $history{'last_mammogram'}; ?>"></td>
 252         <td class="fibody2"><input name="last_mammogram_notes" type="text" class="fullin2" id="last_mammogram_notes"></td>
 253       </tr>
 254       <tr align="left" valign="bottom">
 255         <td width="70%" class="fibody2" id="bordR">Last colorectal screening:
 256           <input name="last_colorectal" type="text" class="fullin2" id="last_colorectal" style="width: 70px" value="YYYY-MM-DD"></td>
 257         <td class="fibody2"><input name="last_colorectal_notes" type="text" class="fullin2" id="last_colorectal_notes"></td>
 258       </tr>
 259     </table></td>
 260   </tr>
 261 </table>
 262 </div>
 263 <p>&nbsp;</p>
 264 <h2 align="center"><a name="gh"></a>Gynecologic history (PH)</h2>
 265 <div style="border: solid 2px black; background-color:#FFFFFF;">
 266   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 267     <tr align="left" valign="bottom">
 268       <td colspan="4"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 269         <tr align="left" valign="bottom">
 270           <td nowrap class="fibody2">Imp</td>
 271           <td nowrap class="fibody2"><input name="gh_imp" type="text" class="fullin2" id="gh_imp" style="width: 70px" value="YYYY-MM-DD"></td>
 272           <td nowrap class="fibody2">Age at menarche </td>
 273           <td nowrap class="fibody2"><input name="gh_age_at_menarche" type="text" class="fullin" id="gh_age_at_menarche"></td>
 274           <td nowrap class="fibody2">Length of flow </td>
 275           <td nowrap class="fibody2"><input name="gh_length_of_flow" type="text" class="fullin" id="gh_length_of_flow"></td>
 276           <td nowrap class="fibody2">Interval between periods </td>
 277           <td nowrap class="fibody2"><input name="gh_interval_periods" type="text" class="fullin" id="gh_interval_periods"></td>
 278           <td nowrap class="fibody2">Recent changes </td>
 279           <td nowrap class="fibody2"><input name="gh_recent_changes" type="text" class="fullin" id="gh_recent_changes"></td>
 280         </tr>
 281       </table></td>
 282     </tr>
 283     <tr align="left" valign="bottom">
 284       <td colspan="4" nowrap class="fibody2">Sexually active:
 285         <input name="gh_sexually_active" type="radio" value="1" checked>
 286         Yes
 287         <input name="gh_sexually_active" type="radio" value="0">
 288         No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ever had sex:
 289         <input name="gh_had_sex" type="radio" value="1" checked>
 290 Yes
 291 <input name="gh_had_sex" type="radio" value="0">
 292 No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Number of partners (Lifetime)
 293 <input name="gh_partners" type="text" class="fullin" id="gh_partners" style="width: 70px"></td>
 294       </tr>
 295     <tr align="left" valign="bottom">
 296       <td colspan="4" nowrap class="fibody2">Partners are:
 297         <input name="gh_partners_are" type="radio" value="men" checked>
 298         men
 299         <input name="gh_partners_are" type="radio" value="women">
 300         women
 301         <input name="ph_gh_partners_are" type="radio" value="both">
 302         both</td>
 303       </tr>
 304     <tr align="left" valign="bottom">
 305       <td width="202" nowrap class="fibody2">Current method of contraception: </td>
 306       <td width="30%" nowrap class="fibody2"><input name="gh_method_contraception" type="text" class="fullin2" id="gh_method_contraception" value="none"></td>
 307       <td width="161" nowrap class="fibody2">past contraceptive history:</td>
 308       <td width="34%" nowrap class="fibody2"><input name="gh_contraceptive_history" type="text" class="fullin2" id="gh_contraceptive_history"></td>
 309     </tr>
 310   </table>
 311 </div>
 312 <p>&nbsp;</p>
 313 <h2 align="center"><a name="oh"></a>Obstetric history (PH)</h2>
 314 <div style="border: solid 2px black; background-color:#FFFFFF;">
 315   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 316     <tr>
 317       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 318         <tr align="left" valign="bottom">
 319           <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 320           <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 321           <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 322           <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 323           <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 324           <td width="50" align="center" nowrap class="ficaption2">Number</td>
 325         </tr>
 326         <tr align="left" valign="bottom">
 327           <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 328           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2" id="oh_pregnancies" value="0"></td>
 329           <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 330           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2" id="gh_abortions" value="0"></td>
 331           <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 332           <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2" id="oh_miscarriages" value="0"></td>
 333         </tr>
 334         <tr align="left" valign="bottom">
 335           <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 336           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_premature_births" type="text" class="fullin2" value="0"></td>
 337           <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 338           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_live_births" type="text" class="fullin2" value="0"></td>
 339           <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 340           <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2" value="0"></td>
 341         </tr>
 342       </table></td>
 343     </tr>
 344     <tr>
 345       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 346         <tr align="center" valign="middle">
 347           <td class="ficaption2" id="bordR">No</td>
 348           <td class="ficaption2" id="bordR">birth date </td>
 349           <td class="ficaption2" id="bordR">weight at birth </td>
 350           <td class="ficaption2" id="bordR">baby's sex </td>
 351           <td class="ficaption2" id="bordR">weeks pregnant </td>
 352           <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 353           <td class="ficaption2">physician's notes</td>
 354         </tr>
 355 <?
 356   $bi = 0;
 357   while ($bi<4) {
 358     $n = $bi+1;
 359     print <<<EOL
 360         <tr align="left" valign="bottom">
 361           <td nowrap class="fibody2" id="bordR">$n.</td>
 362           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" class="fullin2"></td>
 363           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" class="fullin2"></td>
 364           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" class="fullin2"></td>
 365           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" class="fullin2"></td>
 366           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" class="fullin2"></td>
 367           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" class="fullin2"></td>
 368         </tr>
 369 EOL;
 370      $bi++;
 371   }
 372 ?>
 373       </table></td>
 374     </tr>
 375     <tr>
 376       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 377           <tr align="left" valign="bottom">
 378             <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 379             <td class="fibody2"><input name="oh_complications" type="text" class="fullin2" id="oh_complications" value="n/a"></td>
 380           </tr>
 381       </table></td>
 382     </tr>
 383     <tr>
 384       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 385           <tr align="left" valign="bottom">
 386             <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox" id="oh_diabetes" value="1">
 387               diabetes
 388                 <input name="oh_hipertension" type="checkbox" id="oh_hipertension" value="1">
 389               hypertension/high blood pressure
 390               <input name="oh_preemclampsia" type="checkbox" id="oh_preemclampsia" value="1">
 391               preeclampsia/foxemia
 392               <input name="oh_complic_other" type="checkbox" id="oh_complic_other" value="1">
 393               other </td>
 394           </tr>
 395           <tr align="left" valign="bottom">
 396             <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 397                 <input name="oh_depression" type="radio" value="0" checked>
 398               no
 399               <input name="oh_depression" type="radio" value="1">
 400               yes, How treated </td>
 401             <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2" id="oh_depression_treated"></td>
 402           </tr>
 403       </table></td>
 404     </tr>
 405   </table>
 406 </div>
 407 <p>&nbsp;</p>
 408 <h2 align="center"><a name="ph"></a>Past history (PH)</h2>
 409 <div style="border: solid 2px black; background-color:#FFFFFF;">
 410   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 411     <tr>
 412       <td class="fibody2"><input name="ph_noncontrib" type="checkbox" id="ph_noncontrib" value="1">
 413         Noncontributory
 414         <input name="ph_nochange_since" type="checkbox" id="ph_nochange_since" value="1">
 415         no interval change since
 416         <input name="ph_nochange_since_date" type="text" class="fullin2" id="ph_nochange_since_date" style="width: 70px" value="YYYY-MM-DD"></td>
 417     </tr>
 418     <tr>
 419       <td class="fibody2">SUrgeries:<br>
 420         <textarea name="ph_surgeries" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_surgeries">none</textarea></td>
 421     </tr>
 422     <tr>
 423       <td class="fibody2">Illnesses (Physical and mental):<br>
 424         <textarea name="ph_illnesses" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_illnesses">none</textarea></td>
 425     </tr>
 426     <tr>
 427       <td class="fibody2">Injuries:<br>
 428         <textarea name="ph_injuries" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_injuries">none</textarea></td>
 429     </tr>
 430     <tr>
 431       <td class="fibody2">Immunizations/Tuberculosis test: <br>
 432 <textarea name="ph_immunizations_tuberculosis" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_immunizations_tuberculosis">
 433 <?
 434 if ($result = getListByType($pid, "immunization", "id,title,comments,activity,date", 1, "all", 0)){
 435 foreach ($result as $iter) {
 436   $tmp_im[] = $iter{'date'}.' - '.$iter{'title'}.' ('.$iter{'comments'}.')';
 437 }
 438 $imm = join(', ', $tmp_im);
 439 echo $imm;}
 440 ?>
 441 </textarea></td>
 442     </tr>
 443   </table>
 444 </div>
 445 <p>&nbsp;</p>
 446 <h2 align="center"><a name="fh"></a>Family history (FH) </h2>
 447 <div style="border: solid 2px black; background-color:#FFFFFF;">
 448   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 449     <tr align="left" valign="bottom">
 450       <td colspan="3" class="fibody2"><input name="fh_noncontrib" type="checkbox" id="fh_noncontrib" value="checkbox">
 451 Noncontributory
 452   <input name="fh_nochange_since" type="checkbox" id="fh_nochange_since" value="checkbox">
 453 no interval change since
 454 <input name="fh_nochange_since_date" type="text" class="fullin2" id="fh_nochange_since_date" style="width: 70px" value="YYYY-MM-DD"></td>
 455     </tr>
 456     <tr align="left" valign="bottom">
 457       <td colspan="3" class="fibody2">Mother:
 458         <input name="fh_mother" type="radio" value="0" checked>
 459         living
 460         <input name="fh_mother" type="radio" value="1">
 461         deceased - cause:
 462         <input name="fh_mother_dec_cause" type="text" class="fullin" id="fh_mother_dec_cause" style="width: 7%">
 463         age:
 464         <input name="fh_mother_dec_age" type="text" class="fullin" id="fh_mother_dec_age" style="width: 30px">
 465 &nbsp;&nbsp;&nbsp;        Father:
 466         <input name="fh_father" type="radio" value="0" checked>
 467 living
 468 <input name="fh_father" type="radio" value="1">
 469 deceased - cause:
 470 <input name="fh_father_dec_cause" type="text" class="fullin" id="fh_father_dec_cause" style="width: 7%">
 471 age:
 472 <input name="fh_father_dec_age" type="text" class="fullin" id="fh_father_dec_age" style="width: 30px"></td>
 473     </tr>
 474     <tr align="left" valign="bottom">
 475       <td colspan="3" class="fibody2">Siblings: number living:
 476         <input name="fh_sibl_living" type="text" class="fullin" id="fh_sibl_living" style="width: 7%">
 477         Number deceased:
 478         <input name="fh_sibl_deceased" type="text" class="fullin" id="fh_sibl_deceased" style="width: 7%">
 479         cause(s) / Age(s) :<br>
 480         <input name="fh_sibl_cause" type="text" class="fullin2" id="fh_sibl_cause"></td>
 481     </tr>
 482     <tr align="left" valign="bottom">
 483       <td colspan="3" class="fibody2">Children: number living:
 484         <input name="fh_children_living" type="text" class="fullin" id="fh_children_living" style="width: 7%">
 485 Number deceased:
 486 <input name="fh_children_deceased" type="text" class="fullin" id="fh_children_deceased" style="width: 7%">
 487 cause(s) / Age(s) :<br>
 488 <input name="fh_children_cause" type="text" class="fullin2" id="fh_children_cause"></td>
 489     </tr>
 490     <tr align="left" valign="bottom">
 491       <td colspan="3" class="fibody2" style="border: none">(IF YES, indicate whom, and age of diagnosis) </td>
 492     </tr>
 493     <tr align="left" valign="bottom">
 494       <td width="33%" class="fibody2" id="bordR"><input name="fhd_diabetes" type="checkbox" id="fhd_diabetes" value="1">
 495         diabetes
 496         <input name="fhd_diabetes_who" type="text" class="fullin" id="fhd_diabetes" style="width:50%"></td>
 497       <td width="33%" class="fibody2" id="bordR"><input name="fhd_heart" type="checkbox" id="fhd_heart" value="1">
 498         heart disease
 499         <input name="fhd_heart_who" type="text" class="fullin" id="fhd_heart_who" style="width:50%"></td>
 500       <td width="33%" class="fibody2"> <input name="fhd_hyperlipidemia" type="checkbox" id="fhd_hyperlipidemia" value="1">
 501         hyperlipidemia
 502         <input name="fhd_hyperlipidemia_who" type="text" class="fullin" id="fhd_hyperlipidemia_who" style="width:50%"></td>
 503     </tr>
 504     <tr align="left" valign="bottom">
 505       <td class="fibody2" id="bordR"><input name="fhd_cancer" type="checkbox" id="fhd_cancer" value="1">
 506         cancer
 507         <input name="fhd_cancer_who" type="text" class="fullin" id="fhd_cancer_who" style="width:50%"></td>
 508       <td class="fibody2" id="bordR"><input name="fhd_hipertension" type="checkbox" id="fhd_hipertension" value="1">
 509         Hypertension
 510         <input name="fhd_hipertension_who" type="text" class="fullin" id="fhd_hipertension_who" style="width:50%"></td>
 511       <td rowspan="2" valign="middle" class="fibody2"><input name="fhd_deepvenous" type="checkbox" id="fhd_deepvenous" value="1">
 512         deep venous tromboembolIsm / Pulmonary embolism
 513         <input name="fhd_deepvenous_who" type="text" class="fullin" id="fhd_deepvenous_who" style="width:50%"></td>
 514     </tr>
 515     <tr align="left" valign="bottom">
 516       <td class="fibody2" id="bordR"><input name="fhd_osteoporosis" type="checkbox" id="fhd_osteoporosis" value="1">
 517         osteoporosis
 518         <input name="fhd_osteoporosis_who" type="text" class="fullin" id="fhd_osteoporosis_who" style="width:50%"></td>
 519       <td class="fibody2" id="bordR"><input name="fhd_other" type="checkbox" id="fhd_other" value="1">
 520         other illnesses
 521         <input name="fhd_other_who" type="text" class="fullin" id="fhd_other_who" style="width:50%"></td>
 522       </tr>
 523   </table>
 524 </div>
 525 <p></p>
 526 <p>&nbsp;</p>
 527 <h2 align="center"><a name="sh"></a>Social history (SH) </h2>
 528 <div style="border: solid 2px black; background-color:#FFFFFF;">
 529   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 530     <tr>
 531       <td align="left" valign="bottom" class="fibody2">        <input name="sh_noncontrib" type="checkbox" id="sh_noncontrib" value="checkbox">
 532 Noncontributory
 533 <input name="sh_nochange_since" type="checkbox" id="sh_nochange_since" value="checkbox">
 534 no interval change since
 535 <input name="sh_nochange_since_date" type="text" class="fullin2" id="sh_nochange_since_date" style="width: 70px" value="YYYY-MM-DD">      </td>
 536     </tr>
 537     <tr>
 538       <td align="left" valign="bottom"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 539         <tr align="center" valign="bottom">
 540           <td width="190" class="ficaption2">&nbsp;</td>
 541           <td width="30" class="ficaption2">yes</td>
 542           <td width="30" class="ficaption2" id="bordR">no</td>
 543           <td class="ficaption2" id="bordR">notes</td>
 544           <td width="190" class="ficaption2">&nbsp;</td>
 545           <td width="30" class="ficaption2">yes</td>
 546           <td width="30" class="ficaption2" id="bordR">no</td>
 547           <td class="ficaption2">notes</td>
 548         </tr>
 549         <tr align="left" valign="bottom">
 550           <td nowrap class="fibody2">Tobacco use </td>
 551           <td class="fibody2"><input name="sh_tobacco" type="radio" value="1"></td>
 552           <td class="fibody2" id="bordR"><input name="sh_tobacco" type="radio" value="0"></td>
 553           <td class="fibody2" id="bordR"><input name="sh_notes_1" type="text" class="fullin2" id="sh_notes_1"></td>
 554           <td nowrap class="fibody2">diet discussed </td>
 555           <td class="fibody2"><input name="sh_diet" type="radio" value="1"></td>
 556           <td class="fibody2" id="bordR"><input name="sh_diet" type="radio" value="0"></td>
 557           <td class="fibody2">
 558             <input name="sh_notes_9" type="text" class="fullin2" id="sh_notes_9"></td>
 559         </tr>
 560         <tr align="left" valign="bottom">
 561           <td rowspan="2" valign="middle" nowrap class="fibody2">Alcohol use<br>
 562             specify amount and type<br>
 563             <small>12 OZ beer = 5 oz wine = 1 1/2 oz liquor</small>  </td>
 564           <td rowspan="2" valign="middle" class="fibody2"><input name="sh_alcohol" type="radio" value="1"></td>
 565           <td rowspan="2" valign="middle" class="fibody2" id="bordR"><input name="sh_alcohol" type="radio" value="0"></td>
 566           <td rowspan="2" valign="middle" class="fibody2" id="bordR"><input name="sh_notes_2" type="text" class="fullin2" id="sh_notes_2"></td>
 567           <td nowrap class="fibody2">folic acid intake </td>
 568           <td class="fibody2"><input name="sh_folic_acid" type="radio" value="1"></td>
 569           <td class="fibody2" id="bordR"><input name="sh_folic_acid" type="radio" value="0"></td>
 570           <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2" id="sh_notes_10"></td>
 571         </tr>
 572         <tr align="left" valign="bottom">
 573           <td nowrap class="fibody2">calcium intake </td>
 574           <td class="fibody2"><input name="sh_calcium" type="radio" value="1"></td>
 575           <td class="fibody2" id="bordR"><input name="sh_calcium" type="radio" value="0"></td>
 576           <td class="fibody2"><input name="sh_notes_11" type="text" class="fullin2" id="sh_notes_11"></td>
 577         </tr>
 578         <tr align="left" valign="bottom">
 579           <td nowrap class="fibody2">Illegal/Street drug use </td>
 580           <td class="fibody2"><input name="sh_drugs" type="radio" value="1"></td>
 581           <td class="fibody2" id="bordR"><input name="sh_drugs" type="radio" value="0"></td>
 582           <td class="fibody2" id="bordR"><input name="sh_notes_3" type="text" class="fullin2" id="sh_notes_3"></td>
 583           <td nowrap class="fibody2">regular exercise </td>
 584           <td class="fibody2"><input name="sh_reg_exercise" type="radio" value="1"></td>
 585           <td class="fibody2" id="bordR"><input name="sh_reg_exercise" type="radio" value="0"></td>
 586           <td class="fibody2"><input name="sh_notes_12" type="text" class="fullin2" id="sh_notes_12"></td>
 587         </tr>
 588         <tr align="left" valign="bottom">
 589           <td nowrap class="fibody2">misuse of prescription drugs </td>
 590           <td class="fibody2"><input name="sh_misuse" type="radio" value="1"></td>
 591           <td class="fibody2" id="bordR"><input name="sh_misuse" type="radio" value="0"></td>
 592           <td class="fibody2" id="bordR"><input name="sh_notes_4" type="text" class="fullin2" id="sh_notes_4"></td>
 593           <td nowrap class="fibody2">caffeine intake </td>
 594           <td class="fibody2"><input name="sh_caffeine" type="radio" value="1"></td>
 595           <td class="fibody2" id="bordR"><input name="sh_caffeine" type="radio" value="0"></td>
 596           <td class="fibody2"><input name="sh_notes_13" type="text" class="fullin2" id="sh_notes_13"></td>
 597         </tr>
 598         <tr align="left" valign="bottom">
 599           <td nowrap class="fibody2">intimate partner violence </td>
 600           <td class="fibody2"><input name="sh_partner_violence" type="radio" value="1"></td>
 601           <td class="fibody2" id="bordR"><input name="sh_partner_violence" type="radio" value="0"></td>
 602           <td class="fibody2" id="bordR"><input name="sh_notes_5" type="text" class="fullin2" id="sh_notes_5"></td>
 603           <td nowrap class="fibody2">advance directive (living will) </td>
 604           <td class="fibody2"><input name="sh_advance" type="radio" value="1"></td>
 605           <td class="fibody2" id="bordR"><input name="sh_advance" type="radio" value="0"></td>
 606           <td class="fibody2"><input name="sh_notes_14" type="text" class="fullin2" id="sh_notes_14"></td>
 607         </tr>
 608         <tr align="left" valign="bottom">
 609           <td nowrap class="fibody2">sexual abuse </td>
 610           <td class="fibody2"><input name="sh_sexual_abuse" type="radio" value="1"></td>
 611           <td class="fibody2" id="bordR"><input name="sh_sexual_abuse" type="radio" value="0"></td>
 612           <td class="fibody2" id="bordR"><input name="sh_notes_6" type="text" class="fullin2" id="sh_notes_6"></td>
 613           <td nowrap class="fibody2">organ donation </td>
 614           <td class="fibody2"><input name="sh_organ_donation" type="radio" value="1"></td>
 615           <td class="fibody2" id="bordR"><input name="sh_organ_donation" type="radio" value="0"></td>
 616           <td class="fibody2"><input name="sh_notes_15" type="text" class="fullin2" id="sh_notes_15"></td>
 617         </tr>
 618         <tr align="left" valign="bottom">
 619           <td nowrap class="fibody2">health hazards at home/work </td>
 620           <td class="fibody2"><input name="sh_health_hazards" type="radio" value="1"></td>
 621           <td class="fibody2" id="bordR"><input name="sh_health_hazards" type="radio" value="0"></td>
 622           <td class="fibody2" id="bordR"><input name="sh_notes_7" type="text" class="fullin2" id="sh_notes_7"></td>
 623           <td nowrap class="fibody2">other</td>
 624           <td class="fibody2"><input name="sh_other" type="radio" value="1"></td>
 625           <td class="fibody2" id="bordR"><input name="sh_other" type="radio" value="0"></td>
 626           <td class="fibody2"><input name="sh_notes_16" type="text" class="fullin2" id="sh_notes_16"></td>
 627         </tr>
 628         <tr align="left" valign="bottom">
 629           <td nowrap class="fibody2">seat belt use </td>
 630           <td class="fibody2"><input name="sh_seat_belt" type="radio" value="1"></td>
 631           <td class="fibody2" id="bordR"><input name="sh_seat_belt" type="radio" value="0"></td>
 632           <td class="fibody2" id="bordR"><input name="sh_notes_8" type="text" class="fullin2" id="sh_notes_8"></td>
 633           <td nowrap class="fibody2"><input name="sh_nochanges_since2" type="checkbox" id="sh_nochanges_since2" value="1">
 634             no changes since              <input name="sh_nochanges_since2_date" type="text" class="fullin2" id="ph_gh_imp22222" style="width: 70px" value="YYYY-MM-DD">            </td>
 635           <td class="fibody2">&nbsp;</td>
 636           <td class="fibody2">&nbsp;</td>
 637           <td class="fibody2">&nbsp;</td>
 638         </tr>
 639       </table></td>
 640     </tr>
 641   </table>
 642 </div>
 643 <p>&nbsp;  </p>
 644 <h2 align="center"><a name="ros"></a>Review of systems (ROS)</h2>
 645 <div style="border: solid 2px black; background-color:#FFFFFF;">
 646 <table width="100%"  border="0" cellspacing="0" cellpadding="2" class="fitable">
 647   <tr>
 648     <td width="190" align="left" valign="top" class="ficaption">1. Constitutional </td>
 649     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 650       <tr align="left" valign="baseline">
 651         <td width="20%" nowrap><input name="ros_const_negative" type="checkbox" value="1" checked onClick="ToggleSection('ros_const', ros_const_negative.checked);">
 652         Negative</td>
 653         <td width="20%" nowrap><input type="checkbox" name="ros_const_weight_loss" value="1" disabled="disabled">
 654           weight loss</td>
 655         <td width="20%" nowrap><input type="checkbox" name="ros_const_weight_gain" value="1" disabled="disabled">
 656           weight gain
 657 </td>
 658         <td>&nbsp;</td>
 659         <td width="20%">&nbsp;</td>
 660       </tr>
 661       <tr align="left" valign="baseline">
 662         <td width="20%" nowrap><input name="ros_const_fever" type="checkbox" value="1" disabled="disabled">
 663           fever</td>
 664         <td width="20%" nowrap><input type="checkbox" name="ros_const_fatigue" value="1" disabled="disabled">
 665           fatigue</td>
 666         <td nowrap><input type="checkbox" name="ros_const_other" value="1" disabled="disabled">
 667           other</td>
 668         <td align="right" nowrap>tallest height&nbsp; </td>
 669         <td><input name="ros_const_tallest_height" type="text" class="fullin"></td>
 670       </tr>
 671     </table></td>
 672   </tr>
 673   <tr>
 674     <td width="190" align="left" valign="top" class="ficaption">2. Eyes </td>
 675     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 676       <tr align="left" valign="baseline">
 677         <td width="20%" nowrap><input name="ros_eyes_negative" type="checkbox" value="1" checked>
 678       Negative</td>
 679         <td colspan="2" nowrap><input type="checkbox" name="ros_eyes_vision_change" value="1" disabled="disabled">
 680       Vision change </td>
 681         <td colspan="2" nowrap><input type="checkbox" name="ros_eyes_glasses" value="1" disabled="disabled">
 682 Glasses/contacts</td>
 683         </tr>
 684       <tr align="left" valign="baseline">
 685         <td width="20%" nowrap><input type="checkbox" name="ros_eyes_other" value="1" disabled="disabled">
 686       Other</td>
 687         <td width="20%" nowrap>&nbsp;</td>
 688         <td width="20%" nowrap>&nbsp;</td>
 689         <td align="right" nowrap>&nbsp; </td>
 690         <td width="20%">&nbsp;</td>
 691       </tr>
 692     </table></td>
 693   </tr>
 694   <tr>
 695     <td width="190" align="left" valign="top" class="ficaption">3. Ear, nose and throat </td>
 696     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 697       <tr align="left" valign="baseline">
 698         <td width="20%" nowrap><input name="ros_ear_negative" type="checkbox" value="1" checked>
 699       Negative</td>
 700         <td width="20%" nowrap><input type="checkbox" name="ros_ear_ulcers" value="1" disabled="disabled">
 701       Ulcers</td>
 702         <td width="20%" nowrap><input type="checkbox" name="ros_ear_sinusitis" value="1" disabled="disabled">
 703       sinusitis</td>
 704         <td width="20%">&nbsp;</td>
 705         <td width="20%">&nbsp;</td>
 706       </tr>
 707       <tr align="left" valign="baseline">
 708         <td nowrap><input type="checkbox" name="ros_ear_headache" value="1" disabled="disabled">
 709       Headache</td>
 710         <td nowrap><input type="checkbox" name="ros_ear_hearing_loss" value="1" disabled="disabled">
 711       Hearing loss </td>
 712         <td nowrap><input type="checkbox" name="ros_ear_other" value="1" disabled="disabled">
 713       other</td>
 714         <td width="20%" align="right" nowrap>&nbsp;</td>
 715         <td>&nbsp;</td>
 716       </tr>
 717     </table></td>
 718   </tr>
 719   <tr>
 720     <td width="190" align="left" valign="top" class="ficaption">4. Cardiovascular </td>
 721     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 722       <tr align="left" valign="baseline">
 723         <td width="20%" nowrap><input name="ros_cv_negative" type="checkbox" value="1" checked>
 724       Negative</td>
 725         <td width="20%" nowrap><input type="checkbox" name="ros_cv_orthopnea" value="1" disabled="disabled">
 726       Orthopnea</td>
 727         <td width="20%" nowrap><input type="checkbox" name="ros_cv_chest_pain" value="1" disabled="disabled">
 728       Chest pain </td>
 729         <td colspan="2" rowspan="2"><input type="checkbox" name="ros_cv_difficulty_breathing" value="1" disabled="disabled">
 730           Difficulty breathing on exertion
 731 </td>
 732         </tr>
 733       <tr align="left" valign="baseline">
 734         <td nowrap><input type="checkbox" name="ros_cv_edema" value="1" disabled="disabled">
 735       Edema</td>
 736         <td nowrap><input type="checkbox" name="ros_cv_palpitation" value="1" disabled="disabled">
 737       Palpitation</td>
 738         <td nowrap><input type="checkbox" name="ros_cv_other" value="1" disabled="disabled">
 739       other</td>
 740         </tr>
 741     </table></td>
 742   </tr>
 743   <tr>
 744     <td width="190" align="left" valign="top" class="ficaption">5. Respiratory </td>
 745     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 746       <tr align="left" valign="baseline">
 747         <td width="20%" nowrap><input name="ros_resp_negative" type="checkbox" value="1" checked>
 748       Negative</td>
 749         <td width="20%" nowrap><input type="checkbox" name="ros_resp_wheezing" value="1" disabled="disabled">
 750       Wheezing</td>
 751         <td width="20%" nowrap><input name="ros_resp_hemoptysis" type="checkbox" id="ros_hemoptysis" value="1" disabled="disabled">
 752       Hemoptysis</td>
 753         <td width="20%">&nbsp;</td>
 754         <td width="20%">&nbsp;</td>
 755       </tr>
 756       <tr align="left" valign="baseline">
 757         <td colspan="2" nowrap><input type="checkbox" name="ros_resp_shortness" value="1" disabled="disabled">
 758       Shortness of breath </td>
 759         <td nowrap><input type="checkbox" name="ros_resp_cough" value="1" disabled="disabled">
 760       Cough</td>
 761         <td colspan="2" align="left" nowrap><input type="checkbox" name="ros_resp_other" value="1" disabled="disabled">
 762           Other
 763 </td>
 764         </tr>
 765     </table></td>
 766   </tr>
 767   <tr>
 768     <td width="190" align="left" valign="top" class="ficaption">6. Gastrointestinal </td>
 769     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 770       <tr align="left" valign="baseline">
 771         <td width="20%" nowrap><input name="ros_gastr_negative" type="checkbox" value="1" checked>
 772       Negative</td>
 773         <td width="20%" nowrap><input type="checkbox" name="ros_gastr_diarrhea" value="1" disabled="disabled">
 774       Diarrhea</td>
 775         <td width="20%" nowrap><input type="checkbox" name="ros_gastr_bloody_stool" value="1" disabled="disabled">
 776       Bloody stool </td>
 777         <td colspan="2"><input type="checkbox" name="ros_gastr_nausea" value="1" disabled="disabled">
 778           Nausea/Vomiting/Indigestion
 779 </td>
 780         </tr>
 781       <tr align="left" valign="baseline">
 782         <td nowrap><input type="checkbox" name="ros_gastr_constipation" value="1" disabled="disabled">
 783       Constipation</td>
 784         <td nowrap><input type="checkbox" name="ros_gastr_flatulence" value="1" disabled="disabled">
 785       Flatulence</td>
 786         <td nowrap><input type="checkbox" name="ros_gastr_pain" value="1" disabled="disabled">
 787       pain</td>
 788         <td align="left" nowrap><input type="checkbox" name="ros_gastr_fecal" value="1" disabled="disabled">
 789           Fecal incontinence</td>
 790         <td nowrap><input type="checkbox" name="ros_gastr_other" value="1" disabled="disabled">
 791           Other</td>
 792       </tr>
 793     </table></td>
 794   </tr>
 795   <tr>
 796     <td width="190" align="left" valign="top" class="ficaption">7. Genitourinary </td>
 797     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 798       <tr align="left" valign="baseline">
 799         <td width="20%" nowrap><input name="ros_genit_negative" type="checkbox" value="1" checked>
 800       Negative</td>
 801         <td width="20%" nowrap><input type="checkbox" name="ros_genit_hematuria" value="1" disabled="disabled">
 802       Hematuria</td>
 803         <td nowrap><input type="checkbox" name="ros_genit_dysuria" value="1" disabled="disabled">
 804       Dysuria</td>
 805         <td align="left" nowrap><input type="checkbox" name="ros_genit_urgency" value="1" disabled="disabled">
 806           Urgency</td>
 807         <td align="left" nowrap>&nbsp;</td>
 808       </tr>
 809       <tr align="left" valign="baseline">
 810         <td width="20%" nowrap><input type="checkbox" name="ros_genit_frequency" value="1" disabled="disabled">
 811       Frequency</td>
 812         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_incomplete_emptying" value="1" disabled="disabled">
 813       Incomplete emptying </td>
 814         <td align="left" nowrap><input type="checkbox" name="ros_genit_incontinence" value="1" disabled="disabled">
 815           Incontinence</td>
 816         <td align="left" nowrap>&nbsp;</td>
 817       </tr>
 818       <tr align="left" valign="baseline">
 819         <td width="20%" nowrap><input type="checkbox" name="ros_genit_dyspareunia" value="1" disabled="disabled">
 820   Dyspareunia</td>
 821         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_abnormal_periods" value="1" disabled="disabled">
 822           Abnormal or painful periods </td>
 823         <td nowrap><input type="checkbox" name="ros_genit_pms" value="1" disabled="disabled">
 824   PMS</td>
 825         <td align="left" nowrap>&nbsp;</td>
 826       </tr>
 827       <tr align="left" valign="baseline">
 828         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_abnormal_bleeding" value="1" disabled="disabled">
 829   Abnormal vaginal bleeding </td>
 830         <td nowrap><input type="checkbox" name="ros_genit_abnormal_discharge" value="1" disabled="disabled">
 831   Abnormal vaginal discharge </td>
 832         <td nowrap><input type="checkbox" name="ros_genit_other" value="1" disabled="disabled">
 833   other</td>
 834         <td align="left" nowrap>&nbsp;</td>
 835       </tr>
 836     </table></td>
 837   </tr>
 838   <tr>
 839     <td width="190" align="left" valign="top" class="ficaption">8. Musculoskeletal </td>
 840     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 841       <tr align="left" valign="baseline">
 842         <td width="40%" nowrap><input name="ros_muscul_negative" type="checkbox" value="1" checked>
 843       Negative</td>
 844         <td width="40%" nowrap><input type="checkbox" name="ros_muscul_weakness" value="1" disabled="disabled">
 845       Muscle weakness </td>
 846         <td nowrap>&nbsp;</td>
 847         <td width="10%">&nbsp;</td>
 848         <td width="10%">&nbsp;</td>
 849       </tr>
 850       <tr align="left" valign="baseline">
 851         <td nowrap><input type="checkbox" name="ros_muscul_pain" value="1" disabled="disabled">
 852       Muscle or joint pain </td>
 853         <td width="40%" nowrap><input type="checkbox" name="ros_muscul_other" value="1" disabled="disabled">
 854 other</td>
 855         <td nowrap>&nbsp;</td>
 856         <td width="10%" align="left" nowrap>&nbsp;</td>
 857         <td width="10%">&nbsp;</td>
 858       </tr>
 859     </table></td>
 860   </tr>
 861   <tr>
 862     <td width="190" align="left" valign="top" class="ficaption">9a. Skin </td>
 863     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 864       <tr align="left" valign="baseline">
 865         <td width="20%" nowrap><input name="ros_skin_negative" type="checkbox" value="1" checked>
 866       Negative</td>
 867         <td width="20%" nowrap><input type="checkbox" name="ros_skin_rash" value="1" disabled="disabled">
 868       Rash</td>
 869         <td width="20%" nowrap><input type="checkbox" name="ros_skin_ulcers" value="1" disabled="disabled">
 870       Ulcers</td>
 871         <td width="20%">&nbsp;</td>
 872         <td width="20%">&nbsp;</td>
 873       </tr>
 874       <tr align="left" valign="baseline">
 875         <td nowrap><input type="checkbox" name="ros_skin_dry" value="1" disabled="disabled">
 876       Dry skin </td>
 877         <td colspan="2" nowrap><input type="checkbox" name="ros_skin_pigmented" value="1" disabled="disabled">
 878       Pigmented lesions </td>
 879         <td align="left" nowrap><input type="checkbox" name="ros_skin_other" value="1" disabled="disabled">
 880 other</td>
 881         <td>&nbsp;</td>
 882       </tr>
 883     </table></td>
 884   </tr>
 885   <tr>
 886     <td width="190" align="left" valign="top" class="ficaption">9b. Breast </td>
 887     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 888       <tr align="left" valign="baseline">
 889         <td width="20%" nowrap><input name="ros_breast_negative" type="checkbox" value="1" checked>
 890       Negative</td>
 891         <td width="20%" nowrap><input type="checkbox" name="ros_breast_mastalgia" value="1" disabled="disabled">
 892       Mastalgia</td>
 893         <td width="20%" nowrap>&nbsp;</td>
 894         <td width="20%">&nbsp;</td>
 895         <td width="20%">&nbsp;</td>
 896       </tr>
 897       <tr align="left" valign="baseline">
 898         <td nowrap><input type="checkbox" name="ros_breast_discharge" value="1" disabled="disabled">
 899       Discharge</td>
 900         <td nowrap><input type="checkbox" name="ros_breast_masses" value="1" disabled="disabled">
 901       Masses</td>
 902         <td nowrap><input type="checkbox" name="ros_breast_other" value="1" disabled="disabled">
 903       other</td>
 904         <td align="right" nowrap>&nbsp;</td>
 905         <td width="20%">&nbsp;</td>
 906       </tr>
 907     </table></td>
 908   </tr>
 909   <tr>
 910     <td width="190" align="left" valign="top" class="ficaption">10. Neurologic </td>
 911     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 912       <tr align="left" valign="baseline">
 913         <td width="20%" nowrap><input name="ros_neuro_negative" type="checkbox" value="1" checked>
 914       Negative</td>
 915         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_syncope" value="1" disabled="disabled">
 916       Syncope</td>
 917         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_seizures" value="1" disabled="disabled">
 918       Seizures</td>
 919         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_numbness" value="1" disabled="disabled">
 920           Numbness</td>
 921         <td width="20%">&nbsp;</td>
 922       </tr>
 923       <tr align="left" valign="baseline">
 924         <td colspan="2" nowrap><input type="checkbox" name="ros_neuro_trouble_walking" value="1" disabled="disabled">
 925       Trouble walking </td>
 926         <td colspan="2" nowrap><input type="checkbox" name="ros_neuro_memory" value="1" disabled="disabled">
 927 Severe memory problems </td>
 928         <td><input type="checkbox" name="ros_neuro_other" value="1" disabled="disabled">
 929 other</td>
 930       </tr>
 931     </table></td>
 932   </tr>
 933   <tr>
 934     <td width="190" align="left" valign="top" class="ficaption">11. Psychiatric</td>
 935     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 936       <tr align="left" valign="baseline">
 937         <td nowrap><input name="ros_psych_negative" type="checkbox" value="1" checked>
 938       Negative</td>
 939         <td width="20%" nowrap><input type="checkbox" name="ros_psych_depression" value="1" disabled="disabled">
 940       Depression</td>
 941         <td width="20%" nowrap><input type="checkbox" name="ros_psych_crying" value="1" disabled="disabled">
 942       Crying</td>
 943         <td width="20%">&nbsp;</td>
 944         <td width="20%">&nbsp;</td>
 945       </tr>
 946       <tr align="left" valign="baseline">
 947         <td colspan="2" nowrap><input type="checkbox" name="ros_psych_anxiety" value="1" disabled="disabled">
 948       Severe anxiety </td>
 949         <td width="20%" nowrap><input type="checkbox" name="ros_psych_other" value="1" disabled="disabled">
 950 Other</td>
 951         <td align="right" nowrap>&nbsp;</td>
 952         <td>&nbsp;</td>
 953       </tr>
 954     </table></td>
 955   </tr>
 956   <tr>
 957     <td width="190" align="left" valign="top" class="ficaption">12. Endocrine </td>
 958     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 959       <tr align="left" valign="baseline">
 960         <td width="20%" nowrap><input name="ros_endo_negative" type="checkbox" value="1" checked>
 961       Negative</td>
 962         <td width="20%" nowrap><input type="checkbox" name="ros_endo_diabetes" value="1" disabled="disabled">
 963         Diabetes</td>
 964         <td nowrap><input type="checkbox" name="ros_endo_hipothyroid" value="1" disabled="disabled">
 965       HYpothyroid</td>
 966         <td nowrap><input type="checkbox" name="ros_endo_hiperthyroid" value="1" disabled="disabled">
 967 HYperthyroid</td>
 968       </tr>
 969       <tr align="left" valign="baseline">
 970         <td nowrap><input type="checkbox" name="ros_endo_flashes" value="1" disabled="disabled">
 971       Hot flashes </td>
 972         <td nowrap><input type="checkbox" name="ros_endo_hair_loss" value="1" disabled="disabled">
 973       Hair loss </td>
 974         <td nowrap><input type="checkbox" name="ros_endo_intolerance" value="1" disabled="disabled">
 975       Heat/cold intolerance </td>
 976         <td><input type="checkbox" name="ros_endo_other" value="1" disabled="disabled">
 977           Other
 978 </td>
 979  </tr>
 980 </table></td>
 981   </tr>
 982   <tr>
 983     <td width="190" align="left" valign="top" class="ficaption">13. Hematologic/Lymphatic</td>
 984     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 985       <tr align="left" valign="baseline">
 986         <td width="20%" nowrap><input name="ros_hemato_negative" type="checkbox" value="1" checked>
 987       Negative</td>
 988         <td width="20%" nowrap><input type="checkbox" name="ros_hemato_bruises" value="1" disabled="disabled">
 989       Bruises</td>
 990         <td width="20%" nowrap>&nbsp;</td>
 991         <td width="20%">&nbsp;</td>
 992         <td width="20%">&nbsp;</td>
 993       </tr>
 994       <tr align="left" valign="baseline">
 995         <td nowrap><input type="checkbox" name="ros_hemato_bleeding" value="1" disabled="disabled">
 996       Bleeding</td>
 997         <td nowrap><input type="checkbox" name="ros_hemato_adenopathy" value="1" disabled="disabled">
 998       Adenopathy</td>
 999         <td nowrap><input type="checkbox" name="ros_hemato_other" value="1" disabled="disabled">
1000       other</td>
1001         <td align="right" nowrap>&nbsp;</td>
1002         <td>&nbsp;</td>
1003       </tr>
1004     </table></td>
1005   </tr>
1006   <tr>
1007     <td width="190" align="left" valign="top" class="ficaption">14. Allergic/Immunologic </td>
1008     <td align="center" valign="middle" class="fibody"><a href="#allergies">See above (Page 1 of PH) </a></td>
1009   </tr>
1010 </table>
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