contrib/forms/physician_history/view.php

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