contrib/forms/patient_intake_history/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <?php html_header_show();?>
  23
  24 <title>Patient intake history</title>
  25
  26 <?php include("../../acog_printable_v.css"); ?>
  27
  28 </head>
  29
  30
  31
  32 <body>
  33
  34 <?php
  35
  36    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  37
  38    if ($fres){
  39
  40      $patient = sqlFetchArray($fres);
  41
  42    }
  43
  44    $fres=sqlStatement("select * from form_patient_intake_history where id=$id");
  45
  46    if ($fres){
  47
  48      $fdata = sqlFetchArray($fres);
  49
  50    }
  51
  52    $fres=sqlStatement("select * from form_patient_intake_history_ros where id=".$fdata['linked_ros_id']);
  53
  54    if ($fres){
  55
  56      $fros = sqlFetchArray($fres);
  57
  58    }
  59
  60 ?>
  61
  62   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  63
  64     <tr>
  65
  66       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  67
  68     </tr>
  69
  70     <tr>
  71
  72       <td align="left" valign="bottom" nowrap class="fibody3"> <?php echo (($fdata{'pih_patient'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  73
  74       New patient </td>
  75
  76     </tr>
  77
  78     <tr>
  79
  80       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_patient'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  81
  82       Established patient </td>
  83
  84     </tr>
  85
  86     <tr>
  87
  88       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_consultation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  89
  90       Consultation</td>
  91
  92     </tr>
  93
  94     <tr>
  95
  96       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_report_sent'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  97
  98       Report sent: <?php echo $fdata{'pih_report_sent_date'}; ?>&nbsp</td>
  99
 100     </tr>
 101
 102 </table>
 103
 104 <div class="srvChapter">Patient Intake history</div>
 105
 106 <div style="border: solid 1.5pt black; background-color: white;">
 107
 108 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 109
 110   <tr>
 111
 112     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
 113
 114       <tr align="left" valign="bottom" class="fibody">
 115
 116         <td width="40%" class="bordR">Patient name:<?php
 117
 118
 119           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
 120
 121           ?>&nbsp</td>
 122
 123         <td width="20%" class="bordR">Birth date: <?php
 124
 125
 126           echo $patient{'DOB'};
 127
 128           ?>&nbsp</td>
 129
 130         <td width="20%" class="bordR">ID No: <?php
 131
 132
 133           echo $patient{'id'};
 134
 135           ?>&nbsp</td>
 136
 137         <td width="20%">Date: <?php
 138
 139
 140         echo date('Y-m-d');
 141
 142         ?>&nbsp</td>
 143
 144       </tr>
 145
 146     </table>
 147
 148 </td>
 149
 150   </tr>
 151
 152   <tr>
 153
 154     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 155
 156       <tr align="left" valign="bottom">
 157
 158         <td colspan="3" class="fibody2">Address:<?php echo $fdata{'address'}; ?>&nbsp</td></tr>
 159
 160       <tr align="left" valign="bottom">
 161
 162         <td width="50%" class="fibody2" id="bordR">City: <?php echo $fdata{'city'}; ?>&nbsp</td>
 163
 164         <td width="50%" colspan="2" class="fibody2">State/ZIP: <?php echo $fdata{'state'}; ?>&nbsp</td>
 165
 166       </tr>
 167
 168       <tr align="left" valign="bottom">
 169
 170         <td class="fibody2" id="bordR">Home telephone: <?php echo $fdata{'home_phone'}; ?>&nbsp</td>
 171
 172         <td colspan="2" class="fibody2">Work telephone: <?php echo $fdata{'work_phone'}; ?>&nbsp</td>
 173
 174       </tr>
 175
 176       <tr align="left" valign="bottom">
 177
 178         <td class="fibody2" id="bordR">Employer: <?php echo $fdata{'employer'}; ?>&nbsp</td>
 179
 180         <td width="25%" class="fibody2" id="bordR">Insurance: <?php echo $fdata{'insurance'}; ?>&nbsp</td>
 181
 182         <td width="25%" class="fibody2">Policy No: <?php echo $fdata{'policy_no'}; ?>&nbsp</td>
 183
 184       </tr>
 185
 186       <tr align="left" valign="bottom">
 187
 188         <td class="fibody2" id="bordR">Name you would like us to use: <?php echo $fdata{'name_to_use'}; ?> </td>
 189
 190         <td colspan="2" class="fibody2">Primary language: <?php echo $fdata{'primary_language'}; ?>&nbsp</td>
 191
 192       </tr>
 193
 194     </table></td>
 195
 196   </tr>
 197
 198   <tr>
 199
 200     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 201
 202       <tr align="left" valign="bottom">
 203
 204         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 205
 206         <td colspan="2" class="fibody2">Emergency contact: <?php echo $fdata{'partner_emergency_contact'}; ?>&nbsp</td>
 207
 208         </tr>
 209
 210       <tr align="left" valign="bottom">
 211
 212         <td rowspan="2" valign="top" class="fibody2" id="bordR"><?php echo $fdata{'partner_name'}; ?>&nbsp</td>
 213
 214         <td colspan="2" class="fibody2">Relationship: <?php echo $fdata{'relationship'}; ?>&nbsp</td>
 215
 216         </tr>
 217
 218       <tr align="left" valign="bottom">
 219
 220         <td width="30%" class="fibody2" id="bordR">Home telephone:
 221
 222           <?php echo $fdata{'partner_home_phone'}; ?>&nbsp</td>
 223
 224         <td width="30%" class="fibody2">Work telephone:
 225
 226           <?php echo $fdata{'partner_work_phone'}; ?>&nbsp</td>
 227
 228       </tr>
 229
 230     </table></td>
 231
 232   </tr>
 233
 234   <tr>
 235
 236     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 237
 238       <tr>
 239
 240         <td align="left" valign="bottom" class="fibody2">Referred by:
 241
 242           <?php echo $fdata{'referred_by'}; ?>&nbsp</td>
 243
 244       </tr>
 245
 246       <tr>
 247
 248         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 249
 250           <?php echo $fdata{'why_come_to_office'}; ?>&nbsp</td>
 251
 252       </tr>
 253
 254       <tr>
 255
 256         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 257
 258           <?php echo (($fdata{'primary_care_visit'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 259
 260           Primary care visit or
 261
 262           <?php echo (($fdata{'primary_care_visit'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 263
 264           Gynecology only </td>
 265
 266       </tr>
 267
 268       <tr>
 269
 270         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 271
 272           <?php echo (($fdata{'new_problem'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 273
 274           yes &nbsp;&nbsp;&nbsp;&nbsp;
 275
 276           <?php echo (($fdata{'new_problem'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 277
 278           no</td>
 279
 280       </tr>
 281
 282       <tr>
 283
 284         <td align="left" valign="bottom" class="fibody2">Please, describe your problem, including, where it is, how severe it is, and how long it has lasted <br>
 285
 286           <?php echo $fdata{'problem_description'}; ?>&nbsp</td>
 287
 288       </tr>
 289
 290     </table></td>
 291
 292   </tr>
 293
 294 </table>
 295
 296 </div>
 297
 298 <h2 align="center"><small>If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.</small></h2>
 299
 300 <p align="center">&nbsp;</p>
 301
 302 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 303
 304   </h2>
 305
 306 <div style="border: solid 1.5pt black; background-color: white;">
 307
 308     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 309
 310       <tr>
 311
 312         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 313
 314           <tr align="left" valign="bottom">
 315
 316             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 317
 318             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 319
 320           </tr>
 321
 322           <tr align="left" valign="bottom">
 323
 324             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 325
 326               <?php echo $fdata{'last_period_date'}; ?>&nbsp</td>
 327
 328             <td class="fibody2"><?php echo $fdata{'gh_notes_1'}; ?>&nbsp</td>
 329
 330           </tr>
 331
 332           <tr align="left" valign="bottom">
 333
 334             <td nowrap class="fibody2" id="bordR">Age periods began:
 335
 336               <?php echo $fdata{'periods_began'}; ?>&nbsp</td>
 337
 338             <td class="fibody2"><?php echo $fdata{'gh_notes_2'}; ?>&nbsp</td>
 339
 340           </tr>
 341
 342           <tr align="left" valign="bottom">
 343
 344             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 345
 346               <?php echo $fdata{'period_lenght'}; ?>&nbsp</td>
 347
 348             <td class="fibody2"><?php echo $fdata{'gh_notes_3'}; ?>&nbsp</td>
 349
 350           </tr>
 351
 352           <tr align="left" valign="bottom">
 353
 354             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 355
 356               <?php echo $fdata{'period_days_between'}; ?>&nbsp</td>
 357
 358             <td class="fibody2"><?php echo $fdata{'gh_notes_4'}; ?>&nbsp</td>
 359
 360           </tr>
 361
 362           <tr align="left" valign="bottom">
 363
 364             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 365
 366               <?php echo (($fdata{'period_changes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 367
 368 Yes
 369
 370 <?php echo (($fdata{'pih_gh_recent_changes_periods'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 371
 372 No</td>
 373
 374             <td class="fibody2"><?php echo $fdata{'gh_notes_5'}; ?>&nbsp</td>
 375
 376           </tr>
 377
 378           <tr align="left" valign="bottom">
 379
 380             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 381
 382               <?php echo (($fdata{'sexually_active'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 383
 384 Yes
 385
 386 <?php echo (($fdata{'sexually_active'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 387
 388 No</td>
 389
 390             <td class="fibody2"><?php echo $fdata{'gh_notes_6'}; ?>&nbsp</td>
 391
 392           </tr>
 393
 394           <tr align="left" valign="bottom">
 395
 396             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 397
 398               <?php echo (($fdata{'ever_had_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 399
 400 Yes
 401
 402 <?php echo (($fdata{'ever_had_sex'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 403
 404 No</td>
 405
 406             <td class="fibody2"><?php echo $fdata{'gh_notes_7'}; ?>&nbsp</td>
 407
 408           </tr>
 409
 410           <tr align="left" valign="bottom">
 411
 412             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 413
 414               <?php echo $fdata{'number_of_partners'}; ?>&nbsp</td>
 415
 416             <td class="fibody2"><?php echo $fdata{'gh_notes_8'}; ?>&nbsp</td>
 417
 418           </tr>
 419
 420           <tr align="left" valign="bottom">
 421
 422             <td nowrap class="fibody2" id="bordR">Sexual partners are
 423
 424               <?php echo (($fdata{'partners'} == 'men')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 425
 426               Men
 427
 428               <?php echo (($fdata{'partners'} == 'women')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 429
 430               Women
 431
 432               <?php echo (($fdata{'partners'} == 'both')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 433
 434               Both </td>
 435
 436             <td class="fibody2"><?php echo $fdata{'gh_notes_9'}; ?>&nbsp</td>
 437
 438           </tr>
 439
 440           <tr align="left" valign="bottom">
 441
 442             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 443
 444               <?php echo $fdata{'present_birth_control'}; ?>&nbsp</td>
 445
 446             <td class="fibody2"><?php echo $fdata{'gh_notes_10'}; ?>&nbsp</td>
 447
 448           </tr>
 449
 450           <tr align="left" valign="bottom">
 451
 452             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 453
 454               <?php echo (($fdata{'pills_iud'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 455
 456 Yes
 457
 458 <?php echo (($fdata{'pills_iud'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 459
 460 No </td>
 461
 462             <td class="fibody2"><?php echo $fdata{'gh_notes_11'}; ?>&nbsp</td>
 463
 464           </tr>
 465
 466           <tr align="left" valign="bottom">
 467
 468             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 469
 470               <?php echo $fdata{'pills_how_long'}; ?>&nbsp</td>
 471
 472             <td class="fibody2"><?php echo $fdata{'gh_notes_12'}; ?>&nbsp</td>
 473
 474           </tr>
 475
 476           <tr align="left" valign="bottom">
 477
 478             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 479
 480               <?php echo $fdata{'pap_test'}; ?>&nbsp</td>
 481
 482             <td class="fibody2"><?php echo $fdata{'gh_notes_13'}; ?>&nbsp</td>
 483
 484           </tr>
 485
 486           <tr align="left" valign="bottom">
 487
 488             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 489
 490               <?php echo (($fdata{'breast_self_exam'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 491
 492               Yes
 493
 494               <?php echo (($fdata{'breast_self_exam'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 495
 496               No</td>
 497
 498             <td class="fibody2"><?php echo $fdata{'gh_notes_14'}; ?>&nbsp</td>
 499
 500           </tr>
 501
 502           <tr align="left" valign="bottom">
 503
 504             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 505
 506               <?php echo (($fdata{'des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 507
 508 Yes
 509
 510 <?php echo (($fdata{'des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 511
 512 No </td>
 513
 514             <td class="fibody2"><?php echo $fdata{'gh_notes_15'}; ?>&nbsp</td>
 515
 516           </tr>
 517
 518         </table></td>
 519
 520       </tr>
 521
 522     </table>
 523
 524   </div>
 525
 526   <p align="center">&nbsp;</p>
 527
 528   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 529
 530   </h2>
 531
 532   <div style="border: solid 1.5pt black; background-color:#FFFFFF;">
 533
 534     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 535
 536       <tr>
 537
 538         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 539
 540             <tr align="left" valign="bottom">
 541
 542               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 543
 544               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 545
 546               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 547
 548               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 549
 550               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 551
 552               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 553
 554             </tr>
 555
 556             <tr align="left" valign="bottom">
 557
 558               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 559
 560               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_pregnancies'}; ?>&nbsp</td>
 561
 562               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 563
 564               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_abortions'}; ?>&nbsp</td>
 565
 566               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 567
 568               <td width="50" nowrap class="fibody2"><?php echo $fdata{'oh_miscarriages'}; ?>&nbsp</td>
 569
 570             </tr>
 571
 572             <tr align="left" valign="bottom">
 573
 574               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 575
 576               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_premature_births'}; ?>&nbsp</td>
 577
 578               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 579
 580               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_live_births'}; ?>&nbsp</td>
 581
 582               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 583
 584               <td width="50" nowrap class="fibody2"><?php echo $fdata{'oh_living_children'}; ?>&nbsp</td>
 585
 586             </tr>
 587
 588         </table></td>
 589
 590       </tr>
 591
 592       <tr>
 593
 594         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 595
 596             <tr align="center" valign="middle">
 597
 598               <td class="ficaption2" id="bordR">No</td>
 599
 600               <td class="ficaption2" id="bordR">birth date </td>
 601
 602               <td class="ficaption2" id="bordR">weight at birth </td>
 603
 604               <td class="ficaption2" id="bordR">baby's sex </td>
 605
 606               <td class="ficaption2" id="bordR">weeks pregnant </td>
 607
 608               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 609
 610               <td class="ficaption2">physician's notes</td>
 611
 612             </tr>
 613
 614 <?php
 615
 616
 617   $bi = 0;
 618
 619   while ($bi<4) {
 620
 621     $n = $bi+1;
 622
 623     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 624
 625     print <<<EOL
 626
 627         <tr align="left" valign="bottom">
 628
 629           <td nowrap class="fibody2" id="bordR">$n.</td>
 630
 631           <td nowrap class="fibody2" id="bordR">${oh_ch_date}&nbsp;</td>
 632
 633           <td nowrap class="fibody2" id="bordR">${oh_ch_width}&nbsp;</td>
 634
 635           <td nowrap class="fibody2" id="bordR">${oh_ch_sex}&nbsp;</td>
 636
 637           <td nowrap class="fibody2" id="bordR">${oh_ch_weeks}&nbsp;</td>
 638
 639           <td nowrap class="fibody2" id="bordR">${oh_ch_delivery}&nbsp;</td>
 640
 641           <td nowrap class="fibody2">${oh_ch_notes}&nbsp;</td>
 642
 643         </tr>
 644
 645 EOL;
 646
 647      $bi++;
 648
 649   }
 650
 651 ?>
 652
 653         </table></td>
 654
 655       </tr>
 656
 657       <tr>
 658
 659         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 660
 661             <tr align="left" valign="bottom">
 662
 663               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 664
 665               <td class="fibody2"><?php echo $fdata{'oh_complications'}; ?>&nbsp</td>
 666
 667             </tr>
 668
 669         </table></td>
 670
 671       </tr>
 672
 673       <tr>
 674
 675         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 676
 677             <tr align="left" valign="bottom">
 678
 679               <td colspan="2" class="fibody2"><?php echo (($fdata{'oh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 680
 681               diabetes
 682
 683                 <?php echo (($fdata{'oh_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 684
 685               hypertension/high blood pressure
 686
 687               <?php echo (($fdata{'oh_preemclampsia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 688
 689               preeclampsia/foxemia
 690
 691               <?php echo (($fdata{'oh_complic_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 692
 693               other </td>
 694
 695             </tr>
 696
 697             <tr align="left" valign="bottom">
 698
 699               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 700
 701                   <?php echo (($fdata{'oh_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 702
 703               no
 704
 705               <?php echo (($fdata{'oh_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 706
 707               yes, How treated </td>
 708
 709               <td class="fibody2"><?php echo $fdata{'oh_depression_treated'}; ?>&nbsp</td>
 710
 711             </tr>
 712
 713         </table></td>
 714
 715       </tr>
 716
 717     </table>
 718
 719   </div>
 720
 721   <p align="center">&nbsp;</p>
 722
 723   <h2 align="center"><a name="cm"></a>Current medications <br>
 724
 725     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 726
 727   </h2>
 728
 729   <div style="border: solid 1.5pt black; background-color: white;">
 730
 731     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 732
 733       <tr align="center">
 734
 735         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 736
 737         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 738
 739         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 740
 741         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 742
 743         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 744
 745         <td valign="top" class="ficaption2">Who prescribed</td>
 746
 747       </tr>
 748
 749 <?php
 750
 751
 752   $bi = 0;
 753
 754   while ($bi<5) {
 755
 756   $bi2 = $bi+5;
 757
 758       list ($pres_drug, $pres_dosage, $pres_who) = explode('|~', $fdata["pres_drug_rec_".$bi] );
 759
 760       list ($pres_drug1, $pres_dosage1, $pres_who1) = explode('|~', $fdata["pres_drug_rec_".$bi2] );
 761
 762     print <<<EOL
 763
 764       <tr>
 765
 766         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage}&nbsp;</td>
 767
 768         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug}&nbsp;</td>
 769
 770         <td align="left" valign="top" class="fibody2" id="bordR">${pres_who}&nbsp;</td>
 771
 772         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug1}&nbsp;</td>
 773
 774         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage1}&nbsp;</td>
 775
 776         <td align="left" valign="top" class="fibody2">${pres_who1}&nbsp;</td>
 777
 778       </tr>
 779
 780 EOL;
 781
 782      $bi++;
 783
 784   }
 785
 786 ?>
 787
 788     </table>
 789
 790   </div>
 791
 792   <p align="center">&nbsp;</p>
 793
 794   <h2 align="center"><a name="fh"></a>Family history <br>
 795
 796   </h2>
 797
 798   <div style="border: solid 1.5pt black; background-color: white;">
 799
 800     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 801
 802       <tr>
 803
 804         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 805
 806           <tr align="left" valign="bottom">
 807
 808             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 809
 810               <?php echo (($fdata{'fh_mother'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 811
 812               living
 813
 814               <?php echo (($fdata{'fh_mother'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 815
 816               deceased - cause:
 817
 818               <?php echo $fdata{'fh_mother_dec_cause'}; ?>
 819
 820               Age:
 821
 822               <?php echo $fdata{'fh_mother_dec_age'}; ?>&nbsp</td>
 823
 824             <td width="50%" nowrap class="fibody2">father:
 825
 826               <?php echo (($fdata{'fh_father'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 827
 828 living
 829
 830 <?php echo (($fdata{'fh_father'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 831
 832 deceased - cause:
 833
 834 <?php echo $fdata{'fh_father_dec_cause'}; ?>
 835
 836 Age:
 837
 838 <?php echo $fdata{'fh_father_dec_age'}; ?>&nbsp</td>
 839
 840           </tr>
 841
 842           <tr align="left" valign="bottom">
 843
 844             <td nowrap class="fibody2">Siblings: Num.living:
 845
 846               <?php echo $fdata{'fh_sibl_living'}; ?>
 847
 848               , num.deceased:
 849
 850               <?php echo $fdata{'fh_sib_deceased'}; ?>
 851
 852               , cause(s)/age(s): </td>
 853
 854             <td nowrap class="fibody2"><?php echo $fdata{'fh_sib_dec_cause'}; ?>&nbsp</td>
 855
 856           </tr>
 857
 858           <tr align="left" valign="bottom">
 859
 860             <td nowrap class="fibody2">Children: Num.living:
 861
 862               <?php echo $fdata{'fh_children_living'}; ?>
 863
 864 , num.deceased:
 865
 866 <?php echo $fdata{'fh_children_deceased'}; ?>
 867
 868 , cause(s)/age(s):</td>
 869
 870             <td nowrap class="fibody2"><?php echo $fdata{'fh_children_dec_cause'}; ?>&nbsp</td>
 871
 872           </tr>
 873
 874         </table></td>
 875
 876       </tr>
 877
 878       <tr>
 879
 880         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 881
 882           <tr valign="bottom">
 883
 884             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 885
 886             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 887
 888             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 889
 890             <td align="center" class="ficaption2">Physician's notes </td>
 891
 892           </tr>
 893
 894           <tr align="left" valign="bottom">
 895
 896             <td nowrap class="fibody2" id="bordR">diabetes</td>
 897
 898             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 899
 900             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_diabetes_info'}; ?>&nbsp</td>
 901
 902             <td class="fibody2"><?php echo $fdata{'fh_notes_1'}; ?>&nbsp</td>
 903
 904           </tr>
 905
 906           <tr align="left" valign="bottom">
 907
 908             <td nowrap class="fibody2" id="bordR">Stroke</td>
 909
 910             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 911
 912             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_stroke_info'}; ?>&nbsp</td>
 913
 914             <td class="fibody2"><?php echo $fdata{'fh_notes_2'}; ?>&nbsp</td>
 915
 916           </tr>
 917
 918           <tr align="left" valign="bottom">
 919
 920             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 921
 922             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_heart_disease'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 923
 924             <td class="fibody2" id="bordR"> <?php echo $fdata{'fh_heart_disease_info'}; ?>&nbsp</td>
 925
 926             <td class="fibody2"><?php echo $fdata{'fh_notes_3'}; ?>&nbsp</td>
 927
 928           </tr>
 929
 930           <tr align="left" valign="bottom">
 931
 932             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 933
 934             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fhbllod_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 935
 936             <td class="fibody2" id="bordR"><?php echo $fdata{'fhbllod_clots_info'}; ?>&nbsp</td>
 937
 938             <td class="fibody2"><?php echo $fdata{'fh_notes_4'}; ?>&nbsp</td>
 939
 940           </tr>
 941
 942           <tr align="left" valign="bottom">
 943
 944             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 945
 946             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 947
 948             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_high_pressure_info'}; ?>&nbsp</td>
 949
 950             <td class="fibody2"><?php echo $fdata{'fh_notes_5'}; ?>&nbsp</td>
 951
 952           </tr>
 953
 954           <tr align="left" valign="bottom">
 955
 956             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 957
 958             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_high_cholesterol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 959
 960             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_high_cholesterol_info'}; ?>&nbsp</td>
 961
 962             <td class="fibody2"><?php echo $fdata{'fh_notes_6'}; ?>&nbsp</td>
 963
 964           </tr>
 965
 966           <tr align="left" valign="bottom">
 967
 968             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 969
 970             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_osteoporosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 971
 972             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_osteoporosis_info'}; ?>&nbsp</td>
 973
 974             <td class="fibody2"><?php echo $fdata{'fh_notes_7'}; ?>&nbsp</td>
 975
 976           </tr>
 977
 978           <tr align="left" valign="bottom">
 979
 980             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 981
 982             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 983
 984             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_hepatitis_info'}; ?>&nbsp</td>
 985
 986             <td class="fibody2"><?php echo $fdata{'fh_notes_8'}; ?>&nbsp</td>
 987
 988           </tr>
 989
 990           <tr align="left" valign="bottom">
 991
 992             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 993
 994             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 995
 996             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_hiv_info'}; ?>&nbsp</td>
 997
 998             <td class="fibody2"><?php echo $fdata{'fh_notes_9'}; ?>&nbsp</td>
 999
1000           </tr>
1001
1002           <tr align="left" valign="bottom">
1003
1004             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
1005
1006             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_tuberculosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1007
1008             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_tuberculosis_info'}; ?>&nbsp</td>
1009
1010             <td class="fibody2"><?php echo $fdata{'fh_notes_10'}; ?>&nbsp</td>
1011
1012           </tr>
1013
1014           <tr align="left" valign="bottom">
1015
1016             <td nowrap class="fibody2" id="bordR">Birth defects </td>
1017
1018             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'dh_birth_defects'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1019
1020             <td class="fibody2" id="bordR"><?php echo $fdata{'dh_birth_defects_info'}; ?>&nbsp</td>
1021
1022             <td class="fibody2"><?php echo $fdata{'fh_notes_11'}; ?>&nbsp</td>
1023
1024           </tr>
1025
1026           <tr align="left" valign="bottom">
1027
1028             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
1029
1030             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_alcohol_drugs'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1031
1032             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_alcohol_drugs_info'}; ?>&nbsp</td>
1033
1034             <td class="fibody2"><?php echo $fdata{'fh_notes_12'}; ?>&nbsp</td>
1035
1036           </tr>
1037
1038           <tr align="left" valign="bottom">
1039
1040             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
1041
1042             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_breast_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1043
1044             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_breast_cancer_info'}; ?>&nbsp</td>
1045
1046             <td class="fibody2"><?php echo $fdata{'fh_notes_13'}; ?>&nbsp</td>
1047
1048           </tr>
1049
1050           <tr align="left" valign="bottom">
1051
1052             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
1053
1054             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_colon_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1055
1056             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_colon_cancer_info'}; ?>&nbsp</td>
1057
1058             <td class="fibody2"><?php echo $fdata{'fh_notes_14'}; ?>&nbsp</td>
1059
1060           </tr>
1061
1062           <tr align="left" valign="bottom">
1063
1064             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
1065
1066             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_ovarian_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1067
1068             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_ovarian_cancer'}; ?>&nbsp</td>
1069
1070             <td class="fibody2"><?php echo $fdata{'fh_notes_15'}; ?>&nbsp</td>
1071
1072           </tr>
1073
1074           <tr align="left" valign="bottom">
1075
1076             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
1077
1078             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_uterine_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1079
1080             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_uterine_cancer_info'}; ?>&nbsp</td>
1081
1082             <td class="fibody2"><?php echo $fdata{'fh_notes_16'}; ?>&nbsp</td>
1083
1084           </tr>
1085
1086           <tr align="left" valign="bottom">
1087
1088             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
1089
1090             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_mental_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1091
1092             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_mental_illness_info'}; ?>&nbsp</td>
1093
1094             <td class="fibody2"><?php echo $fdata{'fh_notes_17'}; ?>&nbsp</td>
1095
1096           </tr>
1097
1098           <tr align="left" valign="bottom">
1099
1100             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
1101
1102             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_alzheimer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1103
1104             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_alzheimer_info'}; ?>&nbsp</td>
1105
1106             <td class="fibody2"><?php echo $fdata{'fh_notes_18'}; ?>&nbsp</td>
1107
1108           </tr>
1109
1110           <tr align="left" valign="bottom">
1111
1112             <td nowrap class="fibody2" id="bordR">Other</td>
1113
1114             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_other_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1115
1116             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_other_illness_info'}; ?>&nbsp</td>
1117
1118             <td class="fibody2"><?php echo $fdata{'fh_notes_19'}; ?>&nbsp</td>
1119
1120           </tr>
1121
1122         </table></td>
1123
1124       </tr>
1125
1126     </table>
1127
1128   </div>
1129
1130   <p align="center">&nbsp;</p>
1131
1132   <h2 align="center"><a name="sh"></a>Social history <br>
1133
1134   </h2>
1135
1136   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
1137
1138     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
1139
1140       <tr>
1141
1142         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
1143
1144           <tr align="left" valign="bottom">
1145
1146             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
1147
1148             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
1149
1150             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
1151
1152             <td align="center" class="ficaption2">physician's notes                           </td>
1153
1154           </tr>
1155
1156           <tr align="left" valign="bottom">
1157
1158             <td nowrap class="fibody2" id="bordR">Ever smoked? Current smoking: packs/day:
1159
1160               <?php echo $fdata{'sh_smoked_packs'}; ?>
1161
1162               , years:
1163
1164               <?php echo $fdata{'sh_smoked_years'}; ?>&nbsp</td>
1165
1166             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_smoked'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1167
1168             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_smoked'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1169
1170             <td class="fibody2"><?php echo $fdata{'sh_notes_1'}; ?>&nbsp</td>
1171
1172           </tr>
1173
1174           <tr align="left" valign="bottom">
1175
1176             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
1177
1178               <?php echo $fdata{'sh_alcohol_drinks_day'}; ?>
1179
1180               ,
1181
1182               drinks/week:
1183
1184               <?php echo $fdata{'sh_alcohol_drinks_week'}; ?>
1185
1186               ,
1187
1188               type of drink:
1189
1190               <?php echo $fdata{'sh_alcohol_drinks_type'}; ?>&nbsp</td>
1191
1192             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_alcohol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1193
1194             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_alcohol'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1195
1196             <td class="fibody2"><?php echo $fdata{'sh_notes_2'}; ?>&nbsp</td>
1197
1198           </tr>
1199
1200           <tr align="left" valign="bottom">
1201
1202             <td nowrap class="fibody2" id="bordR">Drug use </td>
1203
1204             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_drug'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1205
1206             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_drug'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1207
1208             <td class="fibody2"><?php echo $fdata{'sh_notes_3'}; ?>&nbsp</td>
1209
1210           </tr>
1211
1212           <tr align="left" valign="bottom">
1213
1214             <td nowrap class="fibody2" id="bordR">seat belt use </td>
1215
1216             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_seat_belt'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1217
1218             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_seat_belt'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1219
1220             <td class="fibody2"><?php echo $fdata{'sh_notes_4'}; ?>&nbsp</td>
1221
1222           </tr>
1223
1224           <tr align="left" valign="bottom">
1225
1226             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
1227
1228               <?php echo $fdata{'sh_exercise_info'}; ?>&nbsp</td>
1229
1230             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1231
1232             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_exercise'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1233
1234             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_5'}; ?>&nbsp</td>
1235
1236           </tr>
1237
1238           <tr align="left" valign="bottom">
1239
1240             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
1241
1242               <?php echo $fdata{'sh_dairy_daily'}; ?>&nbsp</td>
1243
1244             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_dairy'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1245
1246             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_dairy'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1247
1248             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_6'}; ?>&nbsp</td>
1249
1250           </tr>
1251
1252           <tr align="left" valign="bottom">
1253
1254             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
1255
1256             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_hazards'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1257
1258             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_hazards'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1259
1260             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_7'}; ?>&nbsp</td>
1261
1262           </tr>
1263
1264           <tr align="left" valign="bottom">
1265
1266             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
1267
1268             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_abuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1269
1270             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_abuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1271
1272             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_8'}; ?>&nbsp</td>
1273
1274           </tr>
1275
1276           <tr align="left" valign="bottom">
1277
1278             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
1279
1280             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_living_will'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1281
1282             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_living_will'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1283
1284             <td class="fibody2"><?php echo $fdata{'sh_notes_9'}; ?>&nbsp</td>
1285
1286           </tr>
1287
1288           <tr align="left" valign="bottom">
1289
1290             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
1291
1292             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_donor'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1293
1294             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_donor'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1295
1296             <td class="fibody2"><?php echo $fdata{'sh_notes_10'}; ?>&nbsp</td>
1297
1298           </tr>
1299
1300         </table></td>
1301
1302       </tr>
1303
1304     </table>
1305
1306   </div>
1307
1308   <p align="center">&nbsp;</p>
1309
1310   <h2 align="center"><a name="pp"></a>Personal profile <br>
1311
1312   </h2>
1313
1314   <div style="border: solid 1.5pt black; background-color: white;">
1315
1316     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1317
1318       <tr>
1319
1320         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
1321
1322           <?php echo (($fdata{'pih_pp_orientation'} == 'hetero')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1323
1324         heterosexual
1325
1326         <?php echo (($fdata{'pih_pp_orientation'} == 'homo')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1327
1328         homosexual
1329
1330         <?php echo (($fdata{'pih_pp_orientation'} == 'bi')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1331
1332         bisexual </td>
1333
1334       </tr>
1335
1336       <tr>
1337
1338         <td align="left" valign="bottom" class="fibody2">Marital status:
1339
1340           <?php echo (($fdata{'pih_pp_status'} == 'married')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1341
1342         married
1343
1344         &nbsp;&nbsp;
1345
1346         <?php echo (($fdata{'pih_pp_status'} == 'partner')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1347
1348         living with partner&nbsp;&nbsp;        <?php echo (($fdata{'pih_pp_status'} == 'single')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1349
1350         single
1351
1352         &nbsp;&nbsp;
1353
1354         <?php echo (($fdata{'pih_pp_status'} == 'widowed')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1355
1356         widowed&nbsp;&nbsp;        <?php echo (($fdata{'pih_pp_status'} == 'divorced')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1357
1358         divorced </td>
1359
1360       </tr>
1361
1362       <tr>
1363
1364         <td align="left" valign="bottom" class="fibody2">Number of living children:
1365
1366         <?php echo $fdata{'pp_living_children'}; ?>&nbsp</td>
1367
1368       </tr>
1369
1370       <tr>
1371
1372         <td align="left" valign="bottom" class="fibody2">Number of people in household:
1373
1374         <?php echo $fdata{'pp_number_household'}; ?>&nbsp</td>
1375
1376       </tr>
1377
1378       <tr>
1379
1380         <td align="left" valign="bottom" class="fibody2">School completed:
1381
1382           <?php echo (($fdata{'pih_pp_education'} == 'highschool')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1383
1384         high school
1385
1386         <?php echo (($fdata{'pih_pp_education'} == 'aadegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1387
1388         some college/AA degree
1389
1390         <?php echo (($fdata{'pih_pp_education'} == 'college')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1391
1392         college
1393
1394         <?php echo (($fdata{'pih_pp_education'} == 'gdegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1395
1396         graduate degree
1397
1398         <?php echo (($fdata{'pih_pp_education'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1399
1400         other </td>
1401
1402       </tr>
1403
1404       <tr>
1405
1406         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
1407
1408         <?php echo $fdata{'pp_current_job'}; ?>&nbsp</td>
1409
1410       </tr>
1411
1412       <tr>
1413
1414         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
1415
1416           <?php echo (($fdata{'pp_travel_outside_us'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1417
1418           yes
1419
1420           <?php echo (($fdata{'pp_travel_outside_us'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1421
1422           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
1423
1424           <?php echo $fdata{'pp_travel_outside_locations'}; ?>
1425
1426         </span></td>
1427
1428       </tr>
1429
1430     </table>
1431
1432   </div>
1433
1434   <p align="center">&nbsp;</p>
1435
1436   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
1437
1438   </h2>
1439
1440   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
1441
1442     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
1443
1444       <tr>
1445
1446         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
1447
1448             <tr align="left" valign="bottom">
1449
1450               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
1451
1452               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
1453
1454               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
1455
1456               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
1457
1458               <td align="center" class="ficaption2">Physician's notes </td>
1459
1460             </tr>
1461
1462             <tr align="left" valign="bottom">
1463
1464               <td nowrap class="fibody2" id="bordR">Asthma</td>
1465
1466               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1467
1468                   <?php echo $fdata{'pih_ih_asthma_date'}; ?>&nbsp</td>
1469
1470               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1471
1472               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1473
1474               <td class="fibody2"><?php echo $fdata{'ih_notes_1'}; ?>&nbsp</td>
1475
1476             </tr>
1477
1478             <tr align="left" valign="bottom">
1479
1480               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
1481
1482               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1483
1484                   <?php echo $fdata{'pih_ih_pneumonia_date'}; ?>&nbsp</td>
1485
1486               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1487
1488               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1489
1490               <td class="fibody2"><?php echo $fdata{'ih_notes_2'}; ?>&nbsp</td>
1491
1492             </tr>
1493
1494             <tr align="left" valign="bottom">
1495
1496               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
1497
1498               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1499
1500                   <?php echo $fdata{'pih_ih_kidney_date'}; ?>&nbsp</td>
1501
1502               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1503
1504               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1505
1506               <td class="fibody2"><?php echo $fdata{'ih_notes_3'}; ?>&nbsp</td>
1507
1508             </tr>
1509
1510             <tr align="left" valign="bottom">
1511
1512               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
1513
1514               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1515
1516                   <?php echo $fdata{'pih_ih_tuber_date'}; ?>&nbsp</td>
1517
1518               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1519
1520               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1521
1522               <td class="fibody2"><?php echo $fdata{'ih_notes_4'}; ?>&nbsp</td>
1523
1524             </tr>
1525
1526             <tr align="left" valign="bottom">
1527
1528               <td nowrap class="fibody2" id="bordR">Fibroids</td>
1529
1530               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1531
1532                   <?php echo $fdata{'pih_ih_fibroids_date'}; ?>&nbsp</td>
1533
1534               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1535
1536               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1537
1538               <td class="fibody2"><?php echo $fdata{'ih_notes_5'}; ?>&nbsp</td>
1539
1540             </tr>
1541
1542             <tr align="left" valign="bottom">
1543
1544               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
1545
1546               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1547
1548                   <?php echo $fdata{'pih_ih_sexually_date'}; ?>&nbsp</td>
1549
1550               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1551
1552               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1553
1554               <td class="fibody2"><?php echo $fdata{'ih_notes_6'}; ?>&nbsp</td>
1555
1556             </tr>
1557
1558             <tr align="left" valign="bottom">
1559
1560               <td nowrap class="fibody2" id="bordR">Infertility</td>
1561
1562               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1563
1564                   <?php echo $fdata{'pih_ih_infertil_date'}; ?>&nbsp</td>
1565
1566               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1567
1568               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1569
1570               <td class="fibody2"><?php echo $fdata{'ih_notes_7'}; ?>&nbsp</td>
1571
1572             </tr>
1573
1574             <tr align="left" valign="bottom">
1575
1576               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
1577
1578               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1579
1580                   <?php echo $fdata{'pih_ih_hiv_date'}; ?>&nbsp</td>
1581
1582               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1583
1584               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1585
1586               <td class="fibody2"><?php echo $fdata{'ih_notes_8'}; ?>&nbsp</td>
1587
1588             </tr>
1589
1590             <tr align="left" valign="bottom">
1591
1592               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
1593
1594               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1595
1596                   <?php echo $fdata{'pih_ih_heart_date'}; ?>&nbsp</td>
1597
1598               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1599
1600               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1601
1602               <td class="fibody2"><?php echo $fdata{'ih_notes_9'}; ?>&nbsp</td>
1603
1604             </tr>
1605
1606             <tr align="left" valign="bottom">
1607
1608               <td nowrap class="fibody2" id="bordR">Diabetes</td>
1609
1610               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1611
1612                   <?php echo $fdata{'pih_ih_diabetes_date'}; ?>&nbsp</td>
1613
1614               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1615
1616               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1617
1618               <td class="fibody2"><?php echo $fdata{'ih_notes_10'}; ?>&nbsp</td>
1619
1620             </tr>
1621
1622             <tr align="left" valign="bottom">
1623
1624               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
1625
1626               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1627
1628                   <?php echo $fdata{'pih_ih_high_pressure_date'}; ?>&nbsp</td>
1629
1630               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1631
1632               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1633
1634               <td class="fibody2"><?php echo $fdata{'ih_notes_11'}; ?>&nbsp</td>
1635
1636             </tr>
1637
1638             <tr align="left" valign="bottom">
1639
1640               <td nowrap class="fibody2" id="bordR">Stroke</td>
1641
1642               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1643
1644                   <?php echo $fdata{'pih_ih_stroke_date'}; ?>&nbsp</td>
1645
1646               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1647
1648               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1649
1650               <td class="fibody2"><?php echo $fdata{'ih_notes_12'}; ?>&nbsp</td>
1651
1652             </tr>
1653
1654             <tr align="left" valign="bottom">
1655
1656               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
1657
1658               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1659
1660                   <?php echo $fdata{'pih_ih_rheumatic_date'}; ?>&nbsp</td>
1661
1662               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1663
1664               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1665
1666               <td class="fibody2"><?php echo $fdata{'ih_notes_13'}; ?>&nbsp</td>
1667
1668             </tr>
1669
1670             <tr align="left" valign="bottom">
1671
1672               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
1673
1674               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1675
1676                   <?php echo $fdata{'pih_ih_blood_clots_date'}; ?>&nbsp</td>
1677
1678               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1679
1680               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1681
1682               <td class="fibody2"><?php echo $fdata{'ih_notes_14'}; ?>&nbsp</td>
1683
1684             </tr>
1685
1686             <tr align="left" valign="bottom">
1687
1688               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
1689
1690               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1691
1692                   <?php echo $fdata{'pih_ih_eating_disorder_date'}; ?>&nbsp</td>
1693
1694               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1695
1696               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1697
1698               <td class="fibody2"><?php echo $fdata{'ih_notes_15'}; ?>&nbsp</td>
1699
1700             </tr>
1701
1702             <tr align="left" valign="bottom">
1703
1704               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
1705
1706               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1707
1708                   <?php echo $fdata{'pih_ih_autoimmune_date'}; ?>&nbsp</td>
1709
1710               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1711
1712               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1713
1714               <td class="fibody2"><?php echo $fdata{'ih_notes_16'}; ?>&nbsp</td>
1715
1716             </tr>
1717
1718             <tr align="left" valign="bottom">
1719
1720               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
1721
1722               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1723
1724                   <?php echo $fdata{'pih_ih_chickenpox_date'}; ?>&nbsp</td>
1725
1726               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1727
1728               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1729
1730               <td class="fibody2"><?php echo $fdata{'ih_notes_17'}; ?>&nbsp</td>
1731
1732             </tr>
1733
1734             <tr align="left" valign="bottom">
1735
1736               <td nowrap class="fibody2" id="bordR">Cancer</td>
1737
1738               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1739
1740                   <?php echo $fdata{'pih_ih_cancer_date'}; ?>&nbsp</td>
1741
1742               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1743
1744               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1745
1746               <td class="fibody2"><?php echo $fdata{'ih_notes_18'}; ?>&nbsp</td>
1747
1748             </tr>
1749
1750             <tr align="left" valign="bottom">
1751
1752               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
1753
1754               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1755
1756                   <?php echo $fdata{'pih_ih_reflux_date'}; ?>&nbsp</td>
1757
1758               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1759
1760               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1761
1762               <td class="fibody2"><?php echo $fdata{'ih_notes_19'}; ?>&nbsp</td>
1763
1764             </tr>
1765
1766             <tr align="left" valign="bottom">
1767
1768               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
1769
1770               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1771
1772                   <?php echo $fdata{'pih_ih_depression_date'}; ?>&nbsp</td>
1773
1774               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1775
1776               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1777
1778               <td class="fibody2"><?php echo $fdata{'ih_notes_20'}; ?>&nbsp</td>
1779
1780             </tr>
1781
1782             <tr align="left" valign="bottom">
1783
1784               <td nowrap class="fibody2" id="bordR">Anemia</td>
1785
1786               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1787
1788                   <?php echo $fdata{'pih_ih_anemia_date'}; ?>&nbsp</td>
1789
1790               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1791
1792               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1793
1794               <td class="fibody2"><?php echo $fdata{'ih_notes_21'}; ?>&nbsp</td>
1795
1796             </tr>
1797
1798             <tr align="left" valign="bottom">
1799
1800               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
1801
1802               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1803
1804                   <?php echo $fdata{'pih_ih_blood_transf_date'}; ?>&nbsp</td>
1805
1806               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1807
1808               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1809
1810               <td class="fibody2"><?php echo $fdata{'ih_notes_22'}; ?>&nbsp</td>
1811
1812             </tr>
1813
1814             <tr align="left" valign="bottom">
1815
1816               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
1817
1818               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1819
1820                   <?php echo $fdata{'pih_ih_seizures_date'}; ?>&nbsp</td>
1821
1822               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1823
1824               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1825
1826               <td class="fibody2"><?php echo $fdata{'ih_notes_23'}; ?>&nbsp</td>
1827
1828             </tr>
1829
1830             <tr align="left" valign="bottom">
1831
1832               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
1833
1834               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1835
1836                   <?php echo $fdata{'pih_ih_bowel_problems_date'}; ?>&nbsp</td>
1837
1838               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1839
1840               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1841
1842               <td class="fibody2"><?php echo $fdata{'ih_notes_24'}; ?>&nbsp</td>
1843
1844             </tr>
1845
1846             <tr align="left" valign="bottom">
1847
1848               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
1849
1850               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1851
1852                   <?php echo $fdata{'pih_ih_glaucoma_date'}; ?>&nbsp</td>
1853
1854               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1855
1856               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1857
1858               <td class="fibody2"><?php echo $fdata{'ih_notes_25'}; ?>&nbsp</td>
1859
1860             </tr>
1861
1862             <tr align="left" valign="bottom">
1863
1864               <td nowrap class="fibody2" id="bordR">Cataracts</td>
1865
1866               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1867
1868                   <?php echo $fdata{'pih_ih_cataracts_date'}; ?>&nbsp</td>
1869
1870               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1871
1872               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1873
1874               <td class="fibody2"><?php echo $fdata{'ih_notes_26'}; ?>&nbsp</td>
1875
1876             </tr>
1877
1878             <tr align="left" valign="bottom">
1879
1880               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
1881
1882               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1883
1884                   <?php echo $fdata{'pih_ih_joint_pain_date'}; ?>&nbsp</td>
1885
1886               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1887
1888               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1889
1890               <td class="fibody2"><?php echo $fdata{'ih_notes_27'}; ?>&nbsp</td>
1891
1892             </tr>
1893
1894             <tr align="left" valign="bottom">
1895
1896               <td nowrap class="fibody2" id="bordR">Broken bones </td>
1897
1898               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1899
1900                   <?php echo $fdata{'pih_ih_broken_bones_date'}; ?>&nbsp</td>
1901
1902               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1903
1904               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1905
1906               <td class="fibody2"><?php echo $fdata{'ih_notes_28'}; ?>&nbsp</td>
1907
1908             </tr>
1909
1910             <tr align="left" valign="bottom">
1911
1912               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
1913
1914               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1915
1916                   <?php echo $fdata{'pih_ih_hepatitis_date'}; ?>&nbsp</td>
1917
1918               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1919
1920               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1921
1922               <td class="fibody2"><?php echo $fdata{'ih_notes_29'}; ?>&nbsp</td>
1923
1924             </tr>
1925
1926             <tr align="left" valign="bottom">
1927
1928               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
1929
1930               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1931
1932                   <?php echo $fdata{'pih_ih_thyroid_date'}; ?>&nbsp</td>
1933
1934               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1935
1936               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1937
1938               <td class="fibody2"><?php echo $fdata{'ih_notes_30'}; ?>&nbsp</td>
1939
1940             </tr>
1941
1942             <tr align="left" valign="bottom">
1943
1944               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
1945
1946               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1947
1948                   <?php echo $fdata{'pih_ih_galibladder_date'}; ?>&nbsp</td>
1949
1950               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1951
1952               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1953
1954               <td class="fibody2"><?php echo $fdata{'ih_notes_31'}; ?>&nbsp</td>
1955
1956             </tr>
1957
1958             <tr align="left" valign="bottom">
1959
1960               <td nowrap class="fibody2" id="bordR">Headaches</td>
1961
1962               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1963
1964                   <?php echo $fdata{'pih_ih_headaches_date'}; ?>&nbsp</td>
1965
1966               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1967
1968               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1969
1970               <td class="fibody2"><?php echo $fdata{'ih_notes_32'}; ?>&nbsp</td>
1971
1972             </tr>
1973
1974             <tr align="left" valign="bottom">
1975
1976               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
1977
1978               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1979
1980                   <?php echo $fdata{'pih_ih_des_date'}; ?>&nbsp</td>
1981
1982               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1983
1984               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1985
1986               <td class="fibody2"><?php echo $fdata{'ih_notes_33'}; ?>&nbsp</td>
1987
1988             </tr>
1989
1990             <tr align="left" valign="bottom">
1991
1992               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
1993
1994               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1995
1996                   <?php echo $fdata{'pih_ih_bleeding_disorders_date'}; ?>&nbsp</td>
1997
1998               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1999
2000               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
2001
2002               <td class="fibody2"><?php echo $fdata{'ih_notes_34'}; ?>&nbsp</td>
2003
2004             </tr>
2005
2006             <tr align="left" valign="bottom">
2007
2008               <td nowrap class="fibody2" id="bordR">other</td>
2009
2010               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
2011
2012                   <?php echo $fdata{'pih_ih_other_date'}; ?>&nbsp</td>
2013
2014               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
2015
2016               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
2017
2018               <td class="fibody2"><?php echo $fdata{'ih_notes_35'}; ?>&nbsp</td>
2019
2020             </tr>
2021
2022             <tr align="left" valign="bottom">
2023
2024               <td colspan="5" nowrap class="fibody3"><?php echo $fdata{'pih_ih_extended_info'}; ?>&nbsp</td>
2025
2026             </tr>
2027
2028         </table></td>
2029
2030       </tr>
2031
2032     </table>
2033
2034   </div>
2035
2036   <p align="center">&nbsp;</p>
2037
2038   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
2039
2040   </h2>
2041
2042   <div style="border: solid 1.5pt black; background-color: white;">
2043
2044     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2045
2046       <tr>
2047
2048         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
2049
2050         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
2051
2052         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
2053
2054       </tr>
2055
2056 <?php
2057
2058 $ii = 0;
2059
2060 while ($ii<6){
2061
2062 list ($op_reason, $op_date, $op_hospital)= explode('|~', $fdata["op_rec_".$ii] );
2063
2064 print <<<EOL
2065
2066       <tr>
2067
2068         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_reason}&nbsp;</td>
2069
2070         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_date}&nbsp;</td>
2071
2072         <td align="left" valign="bottom" class="fibody2">${op_hospital}&nbsp;</td>
2073
2074       </tr>
2075
2076 EOL;
2077
2078 $ii++;
2079
2080 }
2081
2082 ?>
2083
2084     </table>
2085
2086   </div>
2087
2088   <p align="center">&nbsp;</p>
2089
2090   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
2091
2092   </h2>
2093
2094   <div style="border: solid 1.5pt black; background-color: white;">
2095
2096     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2097
2098       <tr valign="bottom">
2099
2100         <td align="left" class="ficaption2" id="bordR">Type</td>
2101
2102         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
2103
2104         <td align="left" class="ficaption2" id="bordR">Type</td>
2105
2106         <td width="90" align="center" nowrap class="ficaption2">date</td>
2107
2108       </tr>
2109
2110 <?php
2111
2112 $ii = 0;
2113
2114 while ($ii<6){
2115
2116 $ij = $ii+6;
2117
2118 list ($ii_type, $ii_date)= explode('|~', $fdata["ii_rec_".$ii] );
2119
2120 list ($ii_type1, $ii_date1)= explode('|~', $fdata["ii_rec_".$ij] );
2121
2122
2123
2124 print <<<EOL
2125
2126    <tr valign="bottom">
2127
2128      <td align="left" class="fibody2" id="bordR">${ii_type}&nbsp;</td>
2129
2130      <td align="left" nowrap class="fibody2" id="bordR">${ii_date}&nbsp;</td>
2131
2132      <td align="left" class="fibody2" id="bordR">${ii_type1}&nbsp;</td>
2133
2134      <td align="left" nowrap class="fibody2">${ii_date1}&nbsp;</td>
2135
2136    </tr>
2137
2138 EOL;
2139
2140 $ii++;
2141
2142 }
2143
2144 ?>
2145
2146     </table>
2147
2148   </div>
2149
2150   <p align="center">&nbsp;</p>
2151
2152   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
2153
2154   </h2>
2155
2156   <div style="border: solid 1.5pt black; background-color: white;">
2157
2158     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2159
2160       <tr valign="bottom">
2161
2162         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
2163
2164         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
2165
2166         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
2167
2168         <td width="90" align="center" class="ficaption2">date</td>
2169
2170       </tr>
2171
2172       <tr valign="bottom">
2173
2174         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
2175
2176         <td align="left" nowrap class="fibody2" id="bordR">
2177
2178           <?php echo $fdata{'imm_tetanus'}; ?>&nbsp;</td>
2179
2180         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
2181
2182         <td align="left" valign="bottom" nowrap class="fibody2">
2183
2184           <?php echo $fdata{'imm_influenza'}; ?>&nbsp;</td>
2185
2186       </tr>
2187
2188       <tr valign="bottom">
2189
2190         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
2191
2192         <td align="left" nowrap class="fibody2" id="bordR">
2193
2194           <?php echo $fdata{'imm_hepatitis_a'}; ?>&nbsp;</td>
2195
2196         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
2197
2198         <td align="left" valign="bottom" nowrap class="fibody2">
2199
2200           <?php echo $fdata{'imm_hepatitis_b'}; ?>&nbsp;</td>
2201
2202       </tr>
2203
2204       <tr valign="bottom">
2205
2206         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
2207
2208         <td align="left" nowrap class="fibody2" id="bordR">
2209
2210           <?php echo $fdata{'imm_varicella'}; ?>&nbsp;</td>
2211
2212         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
2213
2214         <td align="left" valign="bottom" nowrap class="fibody2">
2215
2216           <?php echo $fdata{'imm_pneumococcal'}; ?>&nbsp;</td>
2217
2218       </tr>
2219
2220       <tr valign="bottom">
2221
2222         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
2223
2224         <td align="left" nowrap class="fibody2" id="bordR">
2225
2226           <?php echo $fdata{'imm_mmr'}; ?>&nbsp;</td>
2227
2228         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
2229
2230         <?php echo $fdata{'imm_tuberculosis_skin'}; ?>&nbsp;
2231
2232         , result:
2233
2234         <?php echo $fdata{'imm_tuberculosis_result'}; ?>&nbsp</td>
2235
2236         <td align="left" valign="bottom" nowrap class="fibody2">
2237
2238           <?php echo $fdata{'imm_tuberculosis'}; ?>&nbsp;</td>
2239
2240       </tr>
2241
2242     </table>
2243
2244   </div>
2245
2246   <p align="center">&nbsp;</p>
2247
2248   <div style="border: solid 1.5pt black; background-color: white;">
2249
2250     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2251
2252       <tr>
2253
2254         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
2255
2256         <?php echo $fdata{'imm_extended_info'}; ?>&nbsp</td>
2257
2258       </tr>
2259
2260     </table>
2261
2262   </div>
2263
2264   <p align="center">&nbsp;</p>
2265
2266   <h2 align="center"><a ></a>Review of systems<br>
2267
2268     <small>Please check (x), if any of the following symptoms
2269
2270 apply to you now or since adulthood</small> </h2>
2271
2272   <div style="border: solid 2px black; background-color: white;">
2273
2274     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2275
2276       <tr>
2277
2278         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
2279
2280         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
2281
2282         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
2283
2284         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
2285
2286         <td align="center" valign="top" class="ficaption2">physician's notes </td>
2287
2288       </tr>
2289
2290       <tr valign="bottom">
2291
2292         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
2293
2294         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2295
2296         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2297
2298         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2299
2300         <td align="left" class="fibody2">&nbsp;</td>
2301
2302       </tr>
2303
2304       <tr valign="bottom">
2305
2306         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
2307
2308         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2309
2310         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2311
2312         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2313
2314         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_1'}; ?></td>
2315
2316       </tr>
2317
2318       <tr valign="bottom">
2319
2320         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
2321
2322         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2323
2324         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2325
2326         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2327
2328         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_2'}; ?></td>
2329
2330       </tr>
2331
2332       <tr valign="bottom">
2333
2334         <td align="left" class="fibody4"  id="bordR" >Fever</td>
2335
2336         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2337
2338         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2339
2340         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2341
2342         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_3'}; ?></td>
2343
2344       </tr>
2345
2346       <tr valign="bottom">
2347
2348         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
2349
2350         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2351
2352         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2353
2354         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2355
2356         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_4'}; ?></td>
2357
2358       </tr>
2359
2360       <tr valign="bottom">
2361
2362         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
2363
2364         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2365
2366         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2367
2368         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2369
2370         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_5'}; ?></td>
2371
2372       </tr>
2373
2374       <tr valign="bottom">
2375
2376         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
2377
2378         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2379
2380         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2381
2382         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2383
2384         <td align="left" class="fibody2">&nbsp;</td>
2385
2386       </tr>
2387
2388       <tr valign="bottom">
2389
2390         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
2391
2392         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2393
2394         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2395
2396         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2397
2398         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_6'}; ?></td>
2399
2400       </tr>
2401
2402       <tr valign="bottom">
2403
2404         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
2405
2406         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2407
2408         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2409
2410         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2411
2412         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_7'}; ?></td>
2413
2414       </tr>
2415
2416       <tr valign="bottom">
2417
2418         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
2419
2420         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2421
2422         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2423
2424         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2425
2426         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_8'}; ?></td>
2427
2428       </tr>
2429
2430       <tr valign="bottom">
2431
2432         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
2433
2434         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2435
2436         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2437
2438         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2439
2440         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_9'}; ?></td>
2441
2442       </tr>
2443
2444       <tr valign="bottom">
2445
2446         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
2447
2448         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2449
2450         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2451
2452         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2453
2454         <td align="left" class="fibody2">&nbsp;</td>
2455
2456       </tr>
2457
2458       <tr valign="bottom">
2459
2460         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
2461
2462         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2463
2464         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2465
2466         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2467
2468         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_10'}; ?></td>
2469
2470       </tr>
2471
2472       <tr valign="bottom">
2473
2474         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
2475
2476         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2477
2478         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2479
2480         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2481
2482         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_11'}; ?></td>
2483
2484       </tr>
2485
2486       <tr valign="bottom">
2487
2488         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
2489
2490         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2491
2492         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2493
2494         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2495
2496         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_12'}; ?></td>
2497
2498       </tr>
2499
2500       <tr valign="bottom">
2501
2502         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
2503
2504         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2505
2506         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2507
2508         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2509
2510         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_13'}; ?></td>
2511
2512       </tr>
2513
2514       <tr valign="bottom">
2515
2516         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
2517
2518         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2519
2520         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2521
2522         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2523
2524         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_14'}; ?></td>
2525
2526       </tr>
2527
2528       <tr valign="bottom">
2529
2530         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
2531
2532         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2533
2534         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2535
2536         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2537
2538         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_15'}; ?></td>
2539
2540       </tr>
2541
2542       <tr valign="bottom">
2543
2544         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
2545
2546         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2547
2548         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2549
2550         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2551
2552         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_16'}; ?></td>
2553
2554       </tr>
2555
2556       <tr valign="bottom">
2557
2558         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
2559
2560         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2561
2562         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2563
2564         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2565
2566         <td align="left" class="fibody2">&nbsp;</td>
2567
2568       </tr>
2569
2570       <tr valign="bottom">
2571
2572         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
2573
2574         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2575
2576         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2577
2578         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2579
2580         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_17'}; ?></td>
2581
2582       </tr>
2583
2584       <tr valign="bottom">
2585
2586         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
2587
2588         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2589
2590         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2591
2592         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2593
2594         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_18'}; ?></td>
2595
2596       </tr>
2597
2598       <tr valign="bottom">
2599
2600         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
2601
2602         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2603
2604         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2605
2606         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2607
2608         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_19'}; ?></td>
2609
2610       </tr>
2611
2612       <tr valign="bottom">
2613
2614         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
2615
2616         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2617
2618         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2619
2620         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2621
2622         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_20'}; ?></td>
2623
2624       </tr>
2625
2626       <tr valign="bottom">
2627
2628         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
2629
2630         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2631
2632         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2633
2634         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2635
2636         <td align="left" class="fibody2">&nbsp;</td>
2637
2638       </tr>
2639
2640       <tr valign="bottom">
2641
2642         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
2643
2644         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2645
2646         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2647
2648         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2649
2650         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_21'}; ?></td>
2651
2652       </tr>
2653
2654       <tr valign="bottom">
2655
2656         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
2657
2658         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2659
2660         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2661
2662         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2663
2664         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_22'}; ?></td>
2665
2666       </tr>
2667
2668       <tr valign="bottom">
2669
2670         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
2671
2672         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2673
2674         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2675
2676         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2677
2678         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_23'}; ?></td>
2679
2680       </tr>
2681
2682       <tr valign="bottom">
2683
2684         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
2685
2686         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2687
2688         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2689
2690         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2691
2692         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_24'}; ?></td>
2693
2694       </tr>
2695
2696       <tr valign="bottom">
2697
2698         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
2699
2700         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2701
2702         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2703
2704         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2705
2706         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_25'}; ?></td>
2707
2708       </tr>
2709
2710       <tr valign="bottom">
2711
2712         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
2713
2714         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2715
2716         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2717
2718         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2719
2720         <td align="left" class="fibody2">&nbsp;</td>
2721
2722       </tr>
2723
2724       <tr valign="bottom">
2725
2726         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
2727
2728         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2729
2730         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2731
2732         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2733
2734         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_26'}; ?></td>
2735
2736       </tr>
2737
2738       <tr valign="bottom">
2739
2740         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
2741
2742         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2743
2744         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2745
2746         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2747
2748         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_27'}; ?></td>
2749
2750       </tr>
2751
2752       <tr valign="bottom">
2753
2754         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
2755
2756         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2757
2758         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2759
2760         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2761
2762         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_28'}; ?></td>
2763
2764       </tr>
2765
2766       <tr valign="bottom">
2767
2768         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
2769
2770         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2771
2772         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2773
2774         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2775
2776         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_29'}; ?></td>
2777
2778       </tr>
2779
2780       <tr valign="bottom">
2781
2782         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
2783
2784         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2785
2786         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2787
2788         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2789
2790         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_30'}; ?></td>
2791
2792       </tr>
2793
2794       <tr valign="bottom">
2795
2796         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
2797
2798         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2799
2800         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2801
2802         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2803
2804         <td align="left" class="fibody2">&nbsp;</td>
2805
2806       </tr>
2807
2808       <tr valign="bottom">
2809
2810         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
2811
2812         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2813
2814         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2815
2816         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2817
2818         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_31'}; ?></td>
2819
2820       </tr>
2821
2822       <tr valign="bottom">
2823
2824         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
2825
2826         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2827
2828         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2829
2830         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2831
2832         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_32'}; ?></td>
2833
2834       </tr>
2835
2836       <tr valign="bottom">
2837
2838         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
2839
2840         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2841
2842         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2843
2844         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2845
2846         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_33'}; ?></td>
2847
2848       </tr>
2849
2850       <tr valign="bottom">
2851
2852         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
2853
2854         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2855
2856         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2857
2858         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2859
2860         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_34'}; ?></td>
2861
2862       </tr>
2863
2864       <tr valign="bottom">
2865
2866         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
2867
2868         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2869
2870         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2871
2872         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2873
2874         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_35'}; ?></td>
2875
2876       </tr>
2877
2878       <tr valign="bottom">
2879
2880         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
2881
2882         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2883
2884         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2885
2886         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2887
2888         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_36'}; ?></td>
2889
2890       </tr>
2891
2892       <tr valign="bottom">
2893
2894         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
2895
2896         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2897
2898         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2899
2900         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2901
2902         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_37'}; ?></td>
2903
2904       </tr>
2905
2906       <tr valign="bottom">
2907
2908         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
2909
2910         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2911
2912         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2913
2914         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2915
2916         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_38'}; ?></td>
2917
2918       </tr>
2919
2920       <tr valign="bottom">
2921
2922         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
2923
2924         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2925
2926         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2927
2928         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2929
2930         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_39'}; ?></td>
2931
2932       </tr>
2933
2934       <tr valign="bottom">
2935
2936         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
2937
2938         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2939
2940         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2941
2942         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2943
2944         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_40'}; ?></td>
2945
2946       </tr>
2947
2948       <tr valign="bottom">
2949
2950         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
2951
2952         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2953
2954         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2955
2956         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2957
2958         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_41'}; ?></td>
2959
2960       </tr>
2961
2962       <tr valign="bottom">
2963
2964         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
2965
2966         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2967
2968         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2969
2970         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2971
2972         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_42'}; ?></td>
2973
2974       </tr>
2975
2976       <tr valign="bottom">
2977
2978         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
2979
2980         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2981
2982         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2983
2984         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2985
2986         <td align="left" class="fibody2">&nbsp;</td>
2987
2988       </tr>
2989
2990       <tr valign="bottom">
2991
2992         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
2993
2994         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2995
2996         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2997
2998         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
2999
3000         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_43'}; ?></td>
3001
3002       </tr>
3003
3004       <tr valign="bottom">
3005
3006         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
3007
3008         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3009
3010         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3011
3012         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3013
3014         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_44'}; ?></td>
3015
3016       </tr>
3017
3018       <tr valign="bottom">
3019
3020         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
3021
3022         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3023
3024         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3025
3026         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3027
3028         <td align="left" class="fibody2">&nbsp;</td>
3029
3030       </tr>
3031
3032       <tr valign="bottom">
3033
3034         <td align="left" class="fibody4"  id="bordR" >Rash</td>
3035
3036         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3037
3038         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3039
3040         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3041
3042         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_45'}; ?></td>
3043
3044       </tr>
3045
3046       <tr valign="bottom">
3047
3048         <td align="left" class="fibody4"  id="bordR" >Sores</td>
3049
3050         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3051
3052         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3053
3054         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3055
3056         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_46'}; ?></td>
3057
3058       </tr>
3059
3060       <tr valign="bottom">
3061
3062         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
3063
3064         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3065
3066         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3067
3068         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3069
3070         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_47'}; ?></td>
3071
3072       </tr>
3073
3074       <tr valign="bottom">
3075
3076         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
3077
3078         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3079
3080         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3081
3082         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3083
3084         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_48'}; ?></td>
3085
3086       </tr>
3087
3088       <tr valign="bottom">
3089
3090         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
3091
3092         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3093
3094         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3095
3096         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3097
3098         <td align="left" class="fibody2">&nbsp;</td>
3099
3100       </tr>
3101
3102       <tr valign="bottom">
3103
3104         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
3105
3106         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3107
3108         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3109
3110         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3111
3112         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_49'}; ?></td>
3113
3114       </tr>
3115
3116       <tr valign="bottom">
3117
3118         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
3119
3120         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3121
3122         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3123
3124         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3125
3126         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_50'}; ?></td>
3127
3128       </tr>
3129
3130       <tr valign="bottom">
3131
3132         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
3133
3134         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3135
3136         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3137
3138         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3139
3140         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_51'}; ?></td>
3141
3142       </tr>
3143
3144       <tr valign="bottom">
3145
3146         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
3147
3148         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3149
3150         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3151
3152         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3153
3154         <td align="left" class="fibody2">&nbsp;</td>
3155
3156       </tr>
3157
3158       <tr valign="bottom">
3159
3160         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
3161
3162         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3163
3164         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3165
3166         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3167
3168         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_52'}; ?></td>
3169
3170       </tr>
3171
3172       <tr valign="bottom">
3173
3174         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
3175
3176         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3177
3178         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3179
3180         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3181
3182         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_53'}; ?></td>
3183
3184       </tr>
3185
3186       <tr valign="bottom">
3187
3188         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
3189
3190         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3191
3192         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3193
3194         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3195
3196         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_54'}; ?></td>
3197
3198       </tr>
3199
3200       <tr valign="bottom">
3201
3202         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
3203
3204         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3205
3206         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3207
3208         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3209
3210         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_55'}; ?></td>
3211
3212       </tr>
3213
3214       <tr valign="bottom">
3215
3216         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
3217
3218         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3219
3220         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3221
3222         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3223
3224         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_56'}; ?></td>
3225
3226       </tr>
3227
3228       <tr valign="bottom">
3229
3230         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
3231
3232         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3233
3234         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3235
3236         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3237
3238         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_57'}; ?></td>
3239
3240       </tr>
3241
3242       <tr valign="bottom">
3243
3244         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
3245
3246         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3247
3248         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3249
3250         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3251
3252         <td align="left" class="fibody2">&nbsp;</td>
3253
3254       </tr>
3255
3256       <tr valign="bottom">
3257
3258         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
3259
3260         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3261
3262         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3263
3264         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3265
3266         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_58'}; ?></td>
3267
3268       </tr>
3269
3270       <tr valign="bottom">
3271
3272         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
3273
3274         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3275
3276         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3277
3278         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3279
3280         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_59'}; ?></td>
3281
3282       </tr>
3283
3284       <tr valign="bottom">
3285
3286         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
3287
3288         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3289
3290         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3291
3292         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3293
3294         <td align="left" class="fibody2">&nbsp;</td>
3295
3296       </tr>
3297
3298       <tr valign="bottom">
3299
3300         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
3301
3302         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3303
3304         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3305
3306         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3307
3308         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_60'}; ?></td>
3309
3310       </tr>
3311
3312       <tr valign="bottom">
3313
3314         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
3315
3316         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3317
3318         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3319
3320         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3321
3322         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_61'}; ?></td>
3323
3324       </tr>
3325
3326       <tr valign="bottom">
3327
3328         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
3329
3330         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3331
3332         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3333
3334         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3335
3336         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_62'}; ?></td>
3337
3338       </tr>
3339
3340       <tr valign="bottom">
3341
3342         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
3343
3344         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3345
3346         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3347
3348         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3349
3350         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_63'}; ?></td>
3351
3352       </tr>
3353
3354       <tr valign="bottom">
3355
3356         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
3357
3358         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3359
3360         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3361
3362         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3363
3364         <td align="left" class="fibody2">&nbsp;</td>
3365
3366       </tr>
3367
3368       <tr valign="bottom">
3369
3370         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
3371
3372         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3373
3374         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3375
3376         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3377
3378         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_64'}; ?></td>
3379
3380       </tr>
3381
3382       <tr valign="bottom">
3383
3384         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
3385
3386         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3387
3388         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3389
3390         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3391
3392         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_65'}; ?></td>
3393
3394       </tr>
3395
3396       <tr valign="bottom">
3397
3398         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
3399
3400         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3401
3402         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3403
3404         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3405
3406         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_66'}; ?></td>
3407
3408       </tr>
3409
3410       <tr valign="bottom">
3411
3412         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
3413
3414         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3415
3416         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3417
3418         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3419
3420         <td align="left" class="fibody2">&nbsp;</td>
3421
3422       </tr>
3423
3424       <tr valign="bottom">
3425
3426         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
3427
3428         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3429
3430         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3431
3432         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3433
3434         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_68'}; ?></td>
3435
3436       </tr>
3437
3438       <tr valign="bottom">
3439
3440         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
3441
3442         <td colspan="4" align="left" class="fibody2"><?php echo $fros{'ros_med_allergy_reaction'}; ?></td>
3443
3444       </tr>
3445
3446       <tr valign="bottom">
3447
3448         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
3449
3450         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3451
3452         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3453
3454         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3455
3456         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_69'}; ?></td>
3457
3458       </tr>
3459
3460       <tr valign="bottom">
3461
3462         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
3463
3464         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3465
3466         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3467
3468         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
3469
3470         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_70'}; ?></td>
3471
3472       </tr>
3473
3474       <tr valign="bottom">
3475
3476         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
3477
3478         <td colspan="4" align="left" class="fibody2"><?php echo $fros{'ros_other_allergy_reaction_'}; ?></td>
3479
3480       </tr>
3481
3482     </table>
3483
3484   </div>
3485
3486   <p align="center">&nbsp;</p>
3487
3488   <div style="border: solid 2px black; background-color: white;">
3489
3490     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
3491
3492       <tr valign="bottom">
3493
3494         <td colspan="2" align="left" class="fibody2">Form completed by
3495
3496           <?php echo (($fdata{'pih_completed_by'} == 'patient')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
3497
3498         patient
3499
3500         <?php echo (($fdata{'pih_completed_by'} == 'nurse')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
3501
3502         office nurse
3503
3504         <?php echo (($fdata{'pih_completed_by'} == 'physician')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
3505
3506         physician
3507
3508         <?php echo (($fdata{'pih_completed_by'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
3509
3510         other:
3511
3512         <?php echo $fdata{'pih_completed_by_other'}; ?>&nbsp</td>
3513
3514       </tr>
3515
3516       <tr valign="bottom">
3517
3518         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
3519
3520       </tr>
3521
3522       <tr valign="bottom">
3523
3524         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
3525
3526         <?php echo $fdata{'pih_date_reviewed_1'}; ?>&nbsp</td>
3527
3528         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
3529
3530       </tr>
3531
3532       <tr valign="bottom">
3533
3534         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
3535
3536       </tr>
3537
3538       <tr valign="bottom">
3539
3540         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3541
3542           <?php echo $fdata{'pih_date_reviewed_2'}; ?>
3543
3544         </span></td>
3545
3546         <td height="46" align="left" class="fibody2">Physician signature: </td>
3547
3548       </tr>
3549
3550       <tr valign="bottom">
3551
3552         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3553
3554           <?php echo $fdata{'pih_date_reviewed_3'}; ?>
3555
3556         </span> </td>
3557
3558         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3559
3560       </tr>
3561
3562       <tr valign="bottom">
3563
3564         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3565
3566           <?php echo $fdata{'pih_date_reviewed_4'}; ?>
3567
3568         </span> </td>
3569
3570         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3571
3572       </tr>
3573
3574       <tr valign="bottom">
3575
3576         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3577
3578           <?php echo $fdata{'pih_date_reviewed_5'}; ?>
3579
3580         </span> </td>
3581
3582         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3583
3584       </tr>
3585
3586       <tr valign="bottom">
3587
3588         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3589
3590           <?php echo $fdata{'pih_date_reviewed_6'}; ?>
3591
3592         </span> </td>
3593
3594         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3595
3596       </tr>
3597
3598     </table>
3599
3600   </div>
3601
3602   <p align="center">&nbsp;</p>
3603
3604 </body>
3605
3606 </html>