contrib/forms/patient_intake_history/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_patient_intake_history';
   7 $ftitle = 'Patient intake history';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $linked = $dt['linked_ros_id'];
  17   $oldros = sqlStatement("select * from form_patient_intake_history_ros where id=$linked");
  18   $dtros = sqlFetchArray($oldros);
  19   //$dtros = formFetch("form_patient_intake_history_ros", $linked);
  20   $newid = formSubmit("form_patient_intake_history_ros", array_slice($dtros,7), $id, $userauthorized);
  21   $dt['linked_ros_id'] = $newid;
  22   $newid = formSubmit("form_patient_intake_history", array_slice($dt,7), $id, $userauthorized);
  23   addForm($encounter, "Patient intake history", $newid, "patient_intake_history", $pid, $userauthorized);
  24   $id = $newid;
  25   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  26   exit;
  27   }
  28 }
  29 ?>
  30 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  31 "http://www.w3.org/TR/html4/loose.dtd">
  32
  33 <html>
  34 <head>
  35 <?php html_header_show();?>
  36 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  37 <link rel="stylesheet" href="../../acog.css" type="text/css">
  38 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  39 <script language="JavaScript" type="text/JavaScript">
  40 window.onload = initialize;
  41 </script>
  42 </head>
  43
  44 <body class="body_top">
  45
  46 <?php
  47    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  48    if ($fres){
  49      $patient = sqlFetchArray($fres);
  50    }
  51 ?>
  52 <form action="<?php echo $rootdir;?>/forms/patient_intake_history/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  53 <?php
  54 $addmenu = <<<EOL
  55 <blockquote>
  56   <small><strong>Local sections: </strong><br>
  57   <a href="#gh">Gynecologic history</a>  |
  58   <a href="#oh">Obstetric history</a> | <a href="#cm">Current medications</a> |
  59   <a href="#fh">Family history</a> | <a href="#sh">Social history</a> |
  60   <a href="#pp">Personal profile</a> |
  61   <a href="#ih">Personal past history of illnesses</a> | <a href="#op">Operations/Hospitalizations</a> |
  62   <a href="#ii">Injuries/Illnesses</a> | <a href="#im">Immunizations/Test</a> |
  63   <a href="#ros">Review of systems</a></small>
  64 </blockquote>
  65 EOL;
  66 ?>
  67 <?php include("../../acog_menu.inc"); ?>
  68   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  69     <tr>
  70       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  71     </tr>
  72     <tr>
  73       <td align="left" valign="bottom" nowrap class="fibody3"> <input name="pih_patient" type="radio" value="0" checked>
  74       New patient </td>
  75     </tr>
  76     <tr>
  77       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_patient" type="radio" value="1">
  78       Established patient </td>
  79     </tr>
  80     <tr>
  81       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_consultation" type="checkbox" id="pih_consultation" value="1">
  82       Consultation</td>
  83     </tr>
  84     <tr>
  85       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_report_sent" type="checkbox" id="pih_report_sent" value="1">
  86       Report sent
  87       <input name="pih_report_sent_date" type="text" class="fullin" id="pih_report_sent_date" style="width:90px" value="YYYY-MM-DD"></td>
  88     </tr>
  89 </table>
  90 <?php
  91 $tip1 = <<<EOL
  92 <strong>Patient Intake History</strong> is an optional form
  93 giving practices the flexibility to have patients complete
  94 their own history at or before the visit. It uses language
  95 that a patient is likely to understand and includes ample
  96 space for physician notes. Space at the end of the form
  97 allows physicians to review the history and sign off for 4
  98 years. At year 5, the patient should be asked to complete
  99 a new Patient Intake History.
 100 EOL;
 101 $tip1 = strtr($tip1, "\n\r", "  ");
 102 ?>
 103 <div class="srvChapter">Patient Intake history <a href="#" onMouseOver="toolTip('<?php echo $tip1; ?>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
 104 <div style="border: solid 2px black; background-color: white;">
 105 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 106   <tr>
 107     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
 108       <tr align="left" valign="bottom" class="fibody">
 109         <td width="40%" class="bordR">Patient name <br>
 110           <input name="pname" type="text" class="fullin" id="pname" value="<?php
 111           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
 112           ?>"></td>
 113         <td width="20%" class="bordR">birth date
 114           <br>
 115           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
 116           echo $patient{'DOB'};
 117           ?>" size="12"> </td>
 118         <td width="20%" class="bordR">ID No<br>
 119           <input name="pih_pid" type="text" class="fullin" id="pih_pid" size="12" value="<?php
 120           echo $patient{'id'};
 121           ?>"></td>
 122         <td width="20%">date<br>
 123         <input name="pih_date" type="text" class="fullin" id="pih_date" value="<?php
 124         echo date('Y-m-d');
 125         ?>" size="12"></td>
 126       </tr>
 127     </table>
 128 </td>
 129   </tr>
 130   <tr>
 131     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 132       <tr align="left" valign="bottom">
 133         <td colspan="3" class="fibody2">Address:
 134           <input name="address" type="text" class="fullin" id="address" style="width: 90%" value="<?php echo $patient{'street'}; ?>"></td>
 135         </tr>
 136       <tr align="left" valign="bottom">
 137         <td width="50%" class="fibody2" id="bordR">City:
 138           <input name="city" type="text" class="fullin" id="city" style="width: 250px" value="<?php echo $patient{'city'}; ?>"></td>
 139         <td width="50%" colspan="2" class="fibody2">State/ZIP:
 140           <input name="state" type="text" class="fullin" id="state" style="width: 250px" value="<?php echo $patient{'state'}; ?>"></td>
 141       </tr>
 142       <tr align="left" valign="bottom">
 143         <td class="fibody2" id="bordR">Home telephone:
 144           <span style="width:auto">
 145           <input name="home_phone" type="text" class="fullin" id="home_phone" style="width: 120px" value="<?php echo $patient{'phone_home'}; ?>">
 146           </span></td>
 147         <td colspan="2" class="fibody2">Work telephone:
 148           <input name="work_phone" type="text" class="fullin" id="work_phone" style="width: 120px" value="<?php echo $patient{'phone_biz'}; ?>"></td>
 149       </tr>
 150       <tr align="left" valign="bottom">
 151         <td class="fibody2" id="bordR">Employer:
 152           <input name="employer" type="text" class="fullin" id="employer" style="width: 80%"></td>
 153         <td width="25%" class="fibody2" id="bordR">Insurance
 154           <input name="insurance" type="text" class="fullin" id="insurance" style="width: 120px"></td>
 155         <td width="25%" class="fibody2">Policy No:
 156           <input name="policy_no" type="text" class="fullin" id="policy_no" style="width: 120px"></td>
 157       </tr>
 158       <tr align="left" valign="bottom">
 159         <td class="fibody2" id="bordR">Name you would like us to use:           <input name="name_to_use" type="text" class="fullin" id="name_to_use" style="width: 50%">          </td>
 160         <td colspan="2" class="fibody2">Primary language:
 161           <input name="primary_language" type="text" class="fullin" id="primary_language" style="width: 150px"></td>
 162       </tr>
 163     </table></td>
 164   </tr>
 165   <tr>
 166     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 167       <tr align="left" valign="bottom">
 168         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 169         <td colspan="2" class="fibody2">Emergency contact:
 170           <input name="partner_emergency_contact" type="text" class="fullin" id="partner_emergency_contact" style="width: 70%" value="<?php echo $patient{'phone_contact'}; ?>"></td>
 171         </tr>
 172       <tr align="left" valign="bottom">
 173         <td rowspan="2" valign="top" class="fibody2" id="bordR"><textarea name="partner_name" rows="2" wrap="VIRTUAL" class="fullin2" id="partner_name" style="height:100%"></textarea></td>
 174         <td colspan="2" class="fibody2">Relationship:
 175           <input name="relationship" type="text" class="fullin" id="relationship" style="width:80%" value="<?php echo $patient{'contact_relationship'}; ?>"></td>
 176         </tr>
 177       <tr align="left" valign="bottom">
 178         <td width="30%" class="fibody2" id="bordR">Home telephone:
 179           <input name="partner_home_phone" type="text" class="fullin" id="partner_home_phone" style="width: 120px"></td>
 180         <td width="30%" class="fibody2">Work telephone:
 181           <input name="partner_work_phone" type="text" class="fullin" id="partner_work_phone" style="width: 120px"></td>
 182       </tr>
 183     </table></td>
 184   </tr>
 185   <tr>
 186     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 187       <tr>
 188         <td align="left" valign="bottom" class="fibody2">Referred by:
 189           <input name="referred_by" type="text" class="fullin" id="referred_by" style="width: 85%;"></td>
 190       </tr>
 191       <tr>
 192         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 193           <input name="why_come_to_office" type="text" class="fullin" id="why_come_to_office"></td>
 194       </tr>
 195       <tr>
 196         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 197           <input name="primary_care_visit" type="radio" value="1" checked>
 198           Primary care visit or
 199           <input name="primary_care_visit" type="radio" value="0">
 200           Gynecology only </td>
 201       </tr>
 202       <tr>
 203         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 204           <input name="new_problem" type="radio" value="1" checked>
 205           yes &nbsp;&nbsp;&nbsp;&nbsp;
 206           <input name="new_problem" type="radio" value="0">
 207           no</td>
 208       </tr>
 209       <tr>
 210         <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>
 211           <textarea name="problem_description" rows="6" class="fullin2" id="problem_description"></textarea></td>
 212       </tr>
 213     </table></td>
 214   </tr>
 215 </table>
 216 </div>
 217 <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>
 218 <p align="center">&nbsp;</p>
 219 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 220   </h2>
 221 <div style="border: solid 2px black; background-color: white;">
 222     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 223       <tr>
 224         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 225           <tr align="left" valign="bottom">
 226             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 227             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 228           </tr>
 229           <tr align="left" valign="bottom">
 230             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 231               <input name="last_period_date" type="text" class="fullin" id="last_period_date" style="width: 90px"></td>
 232             <td class="fibody2"><input name="gh_notes_1" type="text" class="fullin2" id="gh_notes_1"></td>
 233           </tr>
 234           <tr align="left" valign="bottom">
 235             <td nowrap class="fibody2" id="bordR">Age periods began:
 236               <input name="periods_began" type="text" class="fullin" id="periods_began" style="width: 90px"></td>
 237             <td class="fibody2"><input name="gh_notes_2" type="text" class="fullin2" id="gh_notes_2"></td>
 238           </tr>
 239           <tr align="left" valign="bottom">
 240             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 241               <input name="period_lenght" type="text" class="fullin" id="period_lenght" style="width: 90px"></td>
 242             <td class="fibody2"><input name="gh_notes_3" type="text" class="fullin2" id="gh_notes_3"></td>
 243           </tr>
 244           <tr align="left" valign="bottom">
 245             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 246               <input name="period_days_between" type="text" class="fullin" id="period_days_between" style="width: 90px"></td>
 247             <td class="fibody2"><input name="gh_notes_4" type="text" class="fullin2" id="gh_notes_4"></td>
 248           </tr>
 249           <tr align="left" valign="bottom">
 250             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 251               <input name="period_changes" type="radio" value="1">
 252 Yes
 253 <input name="pih_gh_recent_changes_periods" type="radio" value="0" checked>
 254 No</td>
 255             <td class="fibody2"><input name="gh_notes_5" type="text" class="fullin2" id="gh_notes_5"></td>
 256           </tr>
 257           <tr align="left" valign="bottom">
 258             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 259               <input name="sexually_active" type="radio" value="1" checked>
 260 Yes
 261 <input name="sexually_active" type="radio" value="0">
 262 No</td>
 263             <td class="fibody2"><input name="gh_notes_6" type="text" class="fullin2" id="gh_notes_6"></td>
 264           </tr>
 265           <tr align="left" valign="bottom">
 266             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 267               <input name="ever_had_sex" type="radio" value="1" checked>
 268 Yes
 269 <input name="ever_had_sex" type="radio" value="0">
 270 No</td>
 271             <td class="fibody2"><input name="gh_notes_7" type="text" class="fullin2" id="gh_notes_7"></td>
 272           </tr>
 273           <tr align="left" valign="bottom">
 274             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 275               <input name="number_of_partners" type="text" class="fullin" id="number_of_partners" style="width: 90px" value="not sure"></td>
 276             <td class="fibody2"><input name="gh_notes_8" type="text" class="fullin2" id="gh_notes_8"></td>
 277           </tr>
 278           <tr align="left" valign="bottom">
 279             <td nowrap class="fibody2" id="bordR">Sexual partners are
 280               <input name="partners" type="radio" value="men" checked>
 281               Men
 282               <input name="partners" type="radio" value="women">
 283               Women
 284               <input name="partners" type="radio" value="both">
 285               Both </td>
 286             <td class="fibody2"><input name="gh_notes_9" type="text" class="fullin2" id="gh_notes_9"></td>
 287           </tr>
 288           <tr align="left" valign="bottom">
 289             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 290               <input name="present_birth_control" type="text" class="fullin" id="present_birth_control" style="width: 90px" value="none"></td>
 291             <td class="fibody2"><input name="gh_notes_10" type="text" class="fullin2" id="gh_notes_10"></td>
 292           </tr>
 293           <tr align="left" valign="bottom">
 294             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 295               <input name="pills_iud" type="radio" value="1">
 296 Yes
 297 <input name="pills_iud" type="radio" value="0" checked>
 298 No </td>
 299             <td class="fibody2"><input name="gh_notes_11" type="text" class="fullin2" id="gh_notes_11"></td>
 300           </tr>
 301           <tr align="left" valign="bottom">
 302             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 303               <input name="pills_how_long" type="text" class="fullin" id="pills_how_long" style="width: 90px"></td>
 304             <td class="fibody2"><input name="gh_notes_12" type="text" class="fullin2" id="gh_notes_12"></td>
 305           </tr>
 306           <tr align="left" valign="bottom">
 307             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 308               <input name="pap_test" type="text" class="fullin" id="pap_test" style="width: 90px"></td>
 309             <td class="fibody2"><input name="gh_notes_13" type="text" class="fullin2" id="gh_notes_13"></td>
 310           </tr>
 311           <tr align="left" valign="bottom">
 312             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 313               <input name="breast_self_exam" type="radio" value="1">
 314               Yes
 315               <input name="breast_self_exam" type="radio" value="0" checked>
 316               No</td>
 317             <td class="fibody2"><input name="gh_notes_14" type="text" class="fullin2" id="gh_notes_14"></td>
 318           </tr>
 319           <tr align="left" valign="bottom">
 320             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 321               <input name="des" type="radio" value="1">
 322 Yes
 323 <input name="des" type="radio" value="0">
 324 No </td>
 325             <td class="fibody2"><input name="gh_notes_15" type="text" class="fullin2" id="gh_notes_15"></td>
 326           </tr>
 327         </table></td>
 328       </tr>
 329     </table>
 330   </div>
 331   <p align="center">&nbsp;</p>
 332   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 333   </h2>
 334   <div style="border: solid 2px black; background-color:#FFFFFF;">
 335     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 336       <tr>
 337         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 338             <tr align="left" valign="bottom">
 339               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 340               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 341               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 342               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 343               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 344               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 345             </tr>
 346             <tr align="left" valign="bottom">
 347               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 348               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2" id="oh_pregnancies" value="0"></td>
 349               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 350               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2" id="gh_abortions" value="0"></td>
 351               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 352               <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2" id="oh_miscarriages" value="0"></td>
 353             </tr>
 354             <tr align="left" valign="bottom">
 355               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 356               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_premature_births" type="text" class="fullin2" value="0"></td>
 357               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 358               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_live_births" type="text" class="fullin2" value="0"></td>
 359               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 360               <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2" value="0"></td>
 361             </tr>
 362         </table></td>
 363       </tr>
 364       <tr>
 365         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 366             <tr align="center" valign="middle">
 367               <td class="ficaption2" id="bordR">No</td>
 368               <td class="ficaption2" id="bordR">birth date </td>
 369               <td class="ficaption2" id="bordR">weight at birth </td>
 370               <td class="ficaption2" id="bordR">baby's sex </td>
 371               <td class="ficaption2" id="bordR">weeks pregnant </td>
 372               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 373               <td class="ficaption2">physician's notes</td>
 374             </tr>
 375 <?php
 376   $bi = 0;
 377   while ($bi<4) {
 378     $n = $bi+1;
 379     print <<<EOL
 380         <tr align="left" valign="bottom">
 381           <td nowrap class="fibody2" id="bordR">$n.</td>
 382           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" class="fullin2"></td>
 383           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" class="fullin2"></td>
 384           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" class="fullin2"></td>
 385           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" class="fullin2"></td>
 386           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" class="fullin2"></td>
 387           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" class="fullin2"></td>
 388         </tr>
 389 EOL;
 390      $bi++;
 391   }
 392 ?>
 393         </table></td>
 394       </tr>
 395       <tr>
 396         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 397             <tr align="left" valign="bottom">
 398               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 399               <td class="fibody2"><input name="oh_complications" type="text" class="fullin2" id="oh_complications" value="n/a"></td>
 400             </tr>
 401         </table></td>
 402       </tr>
 403       <tr>
 404         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 405             <tr align="left" valign="bottom">
 406               <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox" id="oh_diabetes" value="1">
 407               diabetes
 408                 <input name="oh_hipertension" type="checkbox" id="oh_hipertension" value="1">
 409               hypertension/high blood pressure
 410               <input name="oh_preemclampsia" type="checkbox" id="oh_preemclampsia" value="1">
 411               preeclampsia/foxemia
 412               <input name="oh_complic_other" type="checkbox" id="oh_complic_other" value="1">
 413               other </td>
 414             </tr>
 415             <tr align="left" valign="bottom">
 416               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 417                   <input name="oh_depression" type="radio" value="0" checked>
 418               no
 419               <input name="oh_depression" type="radio" value="1">
 420               yes, How treated </td>
 421               <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2" id="oh_depression_treated"></td>
 422             </tr>
 423         </table></td>
 424       </tr>
 425     </table>
 426   </div>
 427   <p align="center">&nbsp;</p>
 428   <h2 align="center"><a name="cm"></a>Current medications <br>
 429     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 430   </h2>
 431   <div style="border: solid 2px black; background-color: white;">
 432     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 433       <tr align="center">
 434         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 435         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 436         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 437         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 438         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 439         <td valign="top" class="ficaption2">Who prescribed</td>
 440       </tr>
 441 <?php
 442   $bi = 0;
 443   while ($bi<5) {
 444     $bi2 = $bi+5;
 445     print <<<EOL
 446       <tr>
 447         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi}" type="text" class="fullin2"></td>
 448         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi}" type="text" class="fullin2"></td>
 449         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_who_${bi}" type="text" class="fullin2"></td>
 450         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi2}" type="text" class="fullin2"></td>
 451         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi2}" type="text" class="fullin2"></td>
 452         <td align="left" valign="top" class="fibody2"><input name="pres_who_${bi2}" type="text" class="fullin2"></td>
 453       </tr>
 454 EOL;
 455      $bi++;
 456   }
 457 ?>
 458     </table>
 459   </div>
 460   <p align="center">&nbsp;</p>
 461   <h2 align="center"><a name="fh"></a>Family history <br>
 462   </h2>
 463   <div style="border: solid 2px black; background-color: white;">
 464     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 465       <tr>
 466         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 467           <tr align="left" valign="bottom">
 468             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 469               <input name="fh_mother" type="radio" value="0" checked>
 470               living
 471               <input name="fh_mother" type="radio" value="1">
 472               deceased - cause:
 473               <input name="fh_mother_dec_cause" type="text" class="fullin" id="fh_mother_dec_cause" style="width: 20%">
 474               Age:
 475               <input name="fh_mother_dec_age" type="text" class="fullin" id="fh_mother_dec_age" style="width:40px"></td>
 476             <td width="50%" nowrap class="fibody2">father:
 477               <input name="fh_father" type="radio" value="0" checked>
 478 living
 479 <input name="fh_father" type="radio" value="1">
 480 deceased - cause:
 481 <input name="fh_father_dec_cause" type="text" class="fullin" id="fh_father_dec_cause" style="width: 20%">
 482 Age:
 483 <input name="fh_father_dec_age" type="text" class="fullin" id="fh_father_dec_age" style="width:40px"></td>
 484           </tr>
 485           <tr align="left" valign="bottom">
 486             <td nowrap class="fibody2">Siblings: Num.living:
 487               <input name="fh_sibl_living" type="text" class="fullin" id="fh_sibl_living" style="width:40px">
 488               , num.deceased:
 489               <input name="fh_sib_deceased" type="text" class="fullin" id="fh_sib_deceased" style="width:40px">
 490               , cause(s)/age(s): </td>
 491             <td nowrap class="fibody2"><input name="fh_sib_dec_cause" type="text" class="fullin" id="fh_sib_dec_cause"></td>
 492           </tr>
 493           <tr align="left" valign="bottom">
 494             <td nowrap class="fibody2">Children: Num.living:
 495               <input name="fh_children_living" type="text" class="fullin" id="fh_children_living" style="width:40px">
 496 , num.deceased:
 497 <input name="fh_children_deceased" type="text" class="fullin" id="fh_children_deceased" style="width:40px">
 498 , cause(s)/age(s):</td>
 499             <td nowrap class="fibody2"><input name="fh_children_dec_cause" type="text" class="fullin" id="fh_children_dec_cause"></td>
 500           </tr>
 501         </table></td>
 502       </tr>
 503       <tr>
 504         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 505           <tr valign="bottom">
 506             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 507             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 508             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 509             <td align="center" class="ficaption2">Physician's notes </td>
 510           </tr>
 511           <tr align="left" valign="bottom">
 512             <td nowrap class="fibody2" id="bordR">diabetes</td>
 513             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_diabetes" type="checkbox" id="fh_diabetes" value="1"></td>
 514             <td class="fibody2" id="bordR"><input name="fh_diabetes_info" type="text" class="fullin2" id="fh_diabetes_info"></td>
 515             <td class="fibody2"><input name="fh_notes_1" type="text" class="fullin2" id="fh_notes_1"></td>
 516           </tr>
 517           <tr align="left" valign="bottom">
 518             <td nowrap class="fibody2" id="bordR">Stroke</td>
 519             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_stroke" type="checkbox" id="fh_stroke" value="1"></td>
 520             <td class="fibody2" id="bordR"><input name="fh_stroke_info" type="text" class="fullin2" id="fh_stroke_info"></td>
 521             <td class="fibody2"><input name="fh_notes_2" type="text" class="fullin2" id="fh_notes_2"></td>
 522           </tr>
 523           <tr align="left" valign="bottom">
 524             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 525             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_heart_disease" type="checkbox" id="fh_heart_disease" value="1"></td>
 526             <td class="fibody2" id="bordR">              <input name="fh_heart_disease_info" type="text" class="fullin2" id="fh_heart_disease_info"></td>
 527             <td class="fibody2"><input name="fh_notes_3" type="text" class="fullin2" id="fh_notes_3"></td>
 528           </tr>
 529           <tr align="left" valign="bottom">
 530             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 531             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fhbllod_clots" type="checkbox" id="fhbllod_clots" value="1"></td>
 532             <td class="fibody2" id="bordR"><input name="fhbllod_clots_info" type="text" class="fullin2" id="fhbllod_clots_info"></td>
 533             <td class="fibody2"><input name="fh_notes_4" type="text" class="fullin2" id="fh_notes_4"></td>
 534           </tr>
 535           <tr align="left" valign="bottom">
 536             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 537             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_pressure" type="checkbox" id="fh_high_pressure" value="1"></td>
 538             <td class="fibody2" id="bordR"><input name="fh_high_pressure_info" type="text" class="fullin2" id="fh_high_pressure_info"></td>
 539             <td class="fibody2"><input name="fh_notes_5" type="text" class="fullin2" id="fh_notes_5"></td>
 540           </tr>
 541           <tr align="left" valign="bottom">
 542             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 543             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_cholesterol" type="checkbox" id="fh_high_cholesterol" value="1"></td>
 544             <td class="fibody2" id="bordR"><input name="fh_high_cholesterol_info" type="text" class="fullin2" id="fh_high_cholesterol_info"></td>
 545             <td class="fibody2"><input name="fh_notes_6" type="text" class="fullin2" id="fh_notes_6"></td>
 546           </tr>
 547           <tr align="left" valign="bottom">
 548             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 549             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_osteoporosis" type="checkbox" id="fh_osteoporosis" value="1"></td>
 550             <td class="fibody2" id="bordR"><input name="fh_osteoporosis_info" type="text" class="fullin2" id="fh_osteoporosis_info"></td>
 551             <td class="fibody2"><input name="fh_notes_7" type="text" class="fullin2" id="fh_notes_7"></td>
 552           </tr>
 553           <tr align="left" valign="bottom">
 554             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 555             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hepatitis" type="checkbox" id="fh_hepatitis" value="1"></td>
 556             <td class="fibody2" id="bordR"><input name="fh_hepatitis_info" type="text" class="fullin2" id="fh_hepatitis_info"></td>
 557             <td class="fibody2"><input name="fh_notes_8" type="text" class="fullin2" id="fh_notes_8"></td>
 558           </tr>
 559           <tr align="left" valign="bottom">
 560             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 561             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hiv" type="checkbox" id="fh_hiv" value="1"></td>
 562             <td class="fibody2" id="bordR"><input name="fh_hiv_info" type="text" class="fullin2" id="fh_hiv_info"></td>
 563             <td class="fibody2"><input name="fh_notes_9" type="text" class="fullin2" id="fh_notes_9"></td>
 564           </tr>
 565           <tr align="left" valign="bottom">
 566             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 567             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_tuberculosis" type="checkbox" id="fh_tuberculosis" value="1"></td>
 568             <td class="fibody2" id="bordR"><input name="fh_tuberculosis_info" type="text" class="fullin2" id="fh_tuberculosis_info"></td>
 569             <td class="fibody2"><input name="fh_notes_10" type="text" class="fullin2" id="fh_notes_10"></td>
 570           </tr>
 571           <tr align="left" valign="bottom">
 572             <td nowrap class="fibody2" id="bordR">Birth defects </td>
 573             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="dh_birth_defects" type="checkbox" id="dh_birth_defects" value="1"></td>
 574             <td class="fibody2" id="bordR"><input name="dh_birth_defects_info" type="text" class="fullin2" id="dh_birth_defects_info"></td>
 575             <td class="fibody2"><input name="fh_notes_11" type="text" class="fullin2" id="fh_notes_11"></td>
 576           </tr>
 577           <tr align="left" valign="bottom">
 578             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
 579             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alcohol_drugs" type="checkbox" id="fh_alcohol_drugs" value="1"></td>
 580             <td class="fibody2" id="bordR"><input name="fh_alcohol_drugs_info" type="text" class="fullin2" id="fh_alcohol_drugs_info"></td>
 581             <td class="fibody2"><input name="fh_notes_12" type="text" class="fullin2" id="fh_notes_12"></td>
 582           </tr>
 583           <tr align="left" valign="bottom">
 584             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
 585             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_breast_cancer" type="checkbox" id="fh_breast_cancer" value="1"></td>
 586             <td class="fibody2" id="bordR"><input name="fh_breast_cancer_info" type="text" class="fullin2" id="fh_breast_cancer_info"></td>
 587             <td class="fibody2"><input name="fh_notes_13" type="text" class="fullin2" id="fh_notes_13"></td>
 588           </tr>
 589           <tr align="left" valign="bottom">
 590             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
 591             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_colon_cancer" type="checkbox" id="fh_colon_cancer" value="1"></td>
 592             <td class="fibody2" id="bordR"><input name="fh_colon_cancer_info" type="text" class="fullin2" id="fh_colon_cancer_info"></td>
 593             <td class="fibody2"><input name="fh_notes_14" type="text" class="fullin2" id="fh_notes_14"></td>
 594           </tr>
 595           <tr align="left" valign="bottom">
 596             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
 597             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="checkbox" id="fh_ovarian_cancer" value="1"></td>
 598             <td class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="text" class="fullin2" id="fh_ovarian_cancer"></td>
 599             <td class="fibody2"><input name="fh_notes_15" type="text" class="fullin2" id="fh_notes_15"></td>
 600           </tr>
 601           <tr align="left" valign="bottom">
 602             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
 603             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_uterine_cancer" type="checkbox" id="fh_uterine_cancer" value="1"></td>
 604             <td class="fibody2" id="bordR"><input name="fh_uterine_cancer_info" type="text" class="fullin2" id="fh_uterine_cancer_info"></td>
 605             <td class="fibody2"><input name="fh_notes_16" type="text" class="fullin2" id="fh_notes_16"></td>
 606           </tr>
 607           <tr align="left" valign="bottom">
 608             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
 609             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_mental_illness" type="checkbox" id="fh_mental_illness" value="1"></td>
 610             <td class="fibody2" id="bordR"><input name="fh_mental_illness_info" type="text" class="fullin2" id="fh_mental_illness_info"></td>
 611             <td class="fibody2"><input name="fh_notes_17" type="text" class="fullin2" id="fh_notes_17"></td>
 612           </tr>
 613           <tr align="left" valign="bottom">
 614             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
 615             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alzheimer" type="checkbox" id="fh_alzheimer" value="1"></td>
 616             <td class="fibody2" id="bordR"><input name="fh_alzheimer_info" type="text" class="fullin2" id="fh_alzheimer_info"></td>
 617             <td class="fibody2"><input name="fh_notes_18" type="text" class="fullin2" id="fh_notes_18"></td>
 618           </tr>
 619           <tr align="left" valign="bottom">
 620             <td nowrap class="fibody2" id="bordR">Other</td>
 621             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_other_illness" type="checkbox" id="fh_other_illness" value="1"></td>
 622             <td class="fibody2" id="bordR"><input name="fh_other_illness_info" type="text" class="fullin2" id="fh_other_illness_info"></td>
 623             <td class="fibody2"><input name="fh_notes_19" type="text" class="fullin2" id="fh_notes_19"></td>
 624           </tr>
 625         </table></td>
 626       </tr>
 627     </table>
 628   </div>
 629   <p align="center">&nbsp;</p>
 630   <h2 align="center"><a name="sh"></a>Social history <br>
 631   </h2>
 632   <div style="border: solid 2px black; background-color: white;">
 633     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 634       <tr>
 635         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 636           <tr align="left" valign="bottom">
 637             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
 638             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 639             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 640             <td align="center" class="ficaption2">physician's notes                           </td>
 641           </tr>
 642           <tr align="left" valign="bottom">
 643             <td nowrap class="fibody2" id="bordR">Ever smoked? current smoking: packs/day:
 644               <input name="sh_smoked_packs" type="text" class="fullin" id="sh_smoked_packs" style="width: 40px">
 645               , years:
 646               <input name="sh_smoked_years" type="text" class="fullin" id="sh_smoked_years" style="width: 40px"></td>
 647             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="1"></td>
 648             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="0" checked></td>
 649             <td class="fibody2"><input name="sh_notes_1" type="text" class="fullin2" id="sh_notes_1"></td>
 650           </tr>
 651           <tr align="left" valign="bottom">
 652             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
 653               <input name="sh_alcohol_drinks_day" type="text" class="fullin" id="sh_alcohol_drinks_day" style="width: 40px">
 654               ,
 655               drinks/week:
 656               <input name="sh_alcohol_drinks_week" type="text" class="fullin" id="sh_alcohol_drinks_week" style="width: 40px">
 657               ,
 658               type of drink:
 659               <input name="sh_alcohol_drinks_type" type="text" class="fullin" id="sh_alcohol_drinks_type" style="width: 40px"></td>
 660             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="1"></td>
 661             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="0" checked></td>
 662             <td class="fibody2"><input name="sh_notes_2" type="text" class="fullin2" id="sh_notes_2"></td>
 663           </tr>
 664           <tr align="left" valign="bottom">
 665             <td nowrap class="fibody2" id="bordR">Drug use </td>
 666             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="1"></td>
 667             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="0" checked></td>
 668             <td class="fibody2"><input name="sh_notes_3" type="text" class="fullin2" id="sh_notes_3"></td>
 669           </tr>
 670           <tr align="left" valign="bottom">
 671             <td nowrap class="fibody2" id="bordR">seat belt use </td>
 672             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="1"></td>
 673             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="0" checked></td>
 674             <td class="fibody2"><input name="sh_notes_4" type="text" class="fullin2" id="sh_notes_4"></td>
 675           </tr>
 676           <tr align="left" valign="bottom">
 677             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
 678               <input name="sh_exercise_info" type="text" class="fullin" id="sh_exercise_info" style="width: 150px"></td>
 679             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="1"></td>
 680             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="0" checked></td>
 681             <td width="400" class="fibody2"><input name="sh_notes_5" type="text" class="fullin2" id="sh_notes_5"></td>
 682           </tr>
 683           <tr align="left" valign="bottom">
 684             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
 685               <input name="sh_dairy_daily" type="text" class="fullin" id="sh_dairy_daily" style="width: 40px"></td>
 686             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="1"></td>
 687             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="0" checked></td>
 688             <td width="400" class="fibody2"><input name="sh_notes_6" type="text" class="fullin2" id="sh_notes_6"></td>
 689           </tr>
 690           <tr align="left" valign="bottom">
 691             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
 692             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="1"></td>
 693             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="0" checked></td>
 694             <td width="400" class="fibody2"><input name="sh_notes_7" type="text" class="fullin2" id="sh_notes_7"></td>
 695           </tr>
 696           <tr align="left" valign="bottom">
 697             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
 698             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="1"></td>
 699             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="0" checked></td>
 700             <td width="400" class="fibody2"><input name="sh_notes_8" type="text" class="fullin2" id="sh_notes_8"></td>
 701           </tr>
 702           <tr align="left" valign="bottom">
 703             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
 704             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="1"></td>
 705             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="0" checked></td>
 706             <td class="fibody2"><input name="sh_notes_9" type="text" class="fullin2" id="sh_notes_9"></td>
 707           </tr>
 708           <tr align="left" valign="bottom">
 709             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
 710             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="1"></td>
 711             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="0" checked></td>
 712             <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2" id="sh_notes_10"></td>
 713           </tr>
 714         </table></td>
 715       </tr>
 716     </table>
 717   </div>
 718   <p align="center">&nbsp;</p>
 719   <h2 align="center"><a name="pp"></a>Personal profile <br>
 720   </h2>
 721   <div style="border: solid 2px black; background-color: white;">
 722     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 723       <tr>
 724         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
 725           <input name="pih_pp_orientation" type="radio" value="hetero" checked>
 726         heterosexual
 727         <input name="pih_pp_orientation" type="radio" value="homo">
 728         homosexual
 729         <input name="pih_pp_orientation" type="radio" value="bi">
 730         bisexual </td>
 731       </tr>
 732       <tr>
 733         <td align="left" valign="bottom" class="fibody2">Marital status:
 734           <input name="pih_pp_status" type="radio" value="married">
 735         married
 736         &nbsp;&nbsp;
 737         <input name="pih_pp_status" type="radio" value="partner">
 738         living with partner&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="single" checked>
 739         single
 740         &nbsp;&nbsp;
 741         <input name="pih_pp_status" type="radio" value="widowed">
 742         widowed&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="divorced">
 743         divorced </td>
 744       </tr>
 745       <tr>
 746         <td align="left" valign="bottom" class="fibody2">Number of living children:
 747         <input name="pp_living_children" type="text" class="fullin" id="pp_living_children" style="width: 70px" value="0"></td>
 748       </tr>
 749       <tr>
 750         <td align="left" valign="bottom" class="fibody2">Number of people in household:
 751         <input name="pp_number_household" type="text" class="fullin" id="pp_number_household" style="width: 70px" value="1"></td>
 752       </tr>
 753       <tr>
 754         <td align="left" valign="bottom" class="fibody2">School completed:
 755           <input name="pih_pp_education" type="radio" id="pih_pp_education" value="highschool">
 756         high school
 757         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="aadegree">
 758         some college/AA degree
 759         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="college">
 760         college
 761         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="gdegree">
 762         graduate degree
 763         <input name="pih_pp_education" type="radio" id="pih_pp_education" value="other" checked>
 764         other </td>
 765       </tr>
 766       <tr>
 767         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
 768         <input name="pp_current_job" type="text" class="fullin" id="pp_current_job" style="width: 77%" value="none"></td>
 769       </tr>
 770       <tr>
 771         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
 772           <input name="pp_travel_outside_us" type="radio" value="1">
 773           yes
 774           <input name="pp_travel_outside_us" type="radio" value="0" checked>
 775           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
 776           <input name="pp_travel_outside_locations" type="text" class="fullin" id="pp_travel_outside_locations" style="width:50%">
 777         </span></td>
 778       </tr>
 779     </table>
 780   </div>
 781   <p align="center">&nbsp;</p>
 782   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
 783   </h2>
 784   <div style="border: solid 2px black; background-color: white;">
 785     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 786       <tr>
 787         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 788             <tr align="left" valign="bottom">
 789               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
 790               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
 791               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 792               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
 793               <td align="center" class="ficaption2">Physician's notes </td>
 794             </tr>
 795             <tr align="left" valign="bottom">
 796               <td nowrap class="fibody2" id="bordR">Asthma</td>
 797               <td class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="1">
 798                   <input name="pih_ih_asthma_date" type="text" class="fullin" id="pih_ih_asthma_date" style="width: 70px"></td>
 799               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="0" checked></td>
 800               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="2"></td>
 801               <td class="fibody2"><input name="ih_notes_1" type="text" class="fullin2" id="ih_notes_1"></td>
 802             </tr>
 803             <tr align="left" valign="bottom">
 804               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
 805               <td class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="1">
 806                   <input name="pih_ih_pneumonia_date" type="text" class="fullin" id="pih_ih_pneumonia_date" style="width: 70px"></td>
 807               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="0" checked></td>
 808               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="2"></td>
 809               <td class="fibody2"><input name="ih_notes_2" type="text" class="fullin2" id="ih_notes_2"></td>
 810             </tr>
 811             <tr align="left" valign="bottom">
 812               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
 813               <td class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="1">
 814                   <input name="pih_ih_kidney_date" type="text" class="fullin" id="pih_ih_kidney_date" style="width: 70px"></td>
 815               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="0" checked></td>
 816               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="2"></td>
 817               <td class="fibody2"><input name="ih_notes_3" type="text" class="fullin2" id="ih_notes_3"></td>
 818             </tr>
 819             <tr align="left" valign="bottom">
 820               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 821               <td class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="1">
 822                   <input name="pih_ih_tuber_date" type="text" class="fullin" id="pih_ih_tuber_date" style="width: 70px"></td>
 823               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="0" checked></td>
 824               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="2"></td>
 825               <td class="fibody2"><input name="ih_notes_4" type="text" class="fullin2" id="ih_notes_4"></td>
 826             </tr>
 827             <tr align="left" valign="bottom">
 828               <td nowrap class="fibody2" id="bordR">Fibroids</td>
 829               <td class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="1">
 830                   <input name="pih_ih_fibroids_date" type="text" class="fullin" id="pih_ih_fibroids_date" style="width: 70px"></td>
 831               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="0" checked></td>
 832               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="2"></td>
 833               <td class="fibody2"><input name="ih_notes_5" type="text" class="fullin2" id="ih_notes_5"></td>
 834             </tr>
 835             <tr align="left" valign="bottom">
 836               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
 837               <td class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="1">
 838                   <input name="pih_ih_sexually_date" type="text" class="fullin" id="pih_ih_sexually_date" style="width: 70px"></td>
 839               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="0" checked></td>
 840               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="2"></td>
 841               <td class="fibody2"><input name="ih_notes_6" type="text" class="fullin2" id="ih_notes_6"></td>
 842             </tr>
 843             <tr align="left" valign="bottom">
 844               <td nowrap class="fibody2" id="bordR">Infertility</td>
 845               <td class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="1">
 846                   <input name="pih_ih_infertil_date" type="text" class="fullin" id="pih_ih_infertil_date" style="width: 70px"></td>
 847               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="0" checked></td>
 848               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="2"></td>
 849               <td class="fibody2"><input name="ih_notes_7" type="text" class="fullin2" id="ih_notes_7"></td>
 850             </tr>
 851             <tr align="left" valign="bottom">
 852               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
 853               <td class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="1">
 854                   <input name="pih_ih_hiv_date" type="text" class="fullin" id="pih_ih_hiv_date" style="width: 70px"></td>
 855               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="0" checked></td>
 856               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="2"></td>
 857               <td class="fibody2"><input name="ih_notes_8" type="text" class="fullin2" id="ih_notes_8"></td>
 858             </tr>
 859             <tr align="left" valign="bottom">
 860               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
 861               <td class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="1">
 862                   <input name="pih_ih_heart_date" type="text" class="fullin" id="pih_ih_heart_date" style="width: 70px"></td>
 863               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="0" checked></td>
 864               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="2"></td>
 865               <td class="fibody2"><input name="ih_notes_9" type="text" class="fullin2" id="ih_notes_9"></td>
 866             </tr>
 867             <tr align="left" valign="bottom">
 868               <td nowrap class="fibody2" id="bordR">Diabetes</td>
 869               <td class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="1">
 870                   <input name="pih_ih_diabetes_date" type="text" class="fullin" id="pih_ih_diabetes_date" style="width: 70px"></td>
 871               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="0" checked></td>
 872               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="2"></td>
 873               <td class="fibody2"><input name="ih_notes_10" type="text" class="fullin2" id="ih_notes_10"></td>
 874             </tr>
 875             <tr align="left" valign="bottom">
 876               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 877               <td class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="1">
 878                   <input name="pih_ih_high_pressure_date" type="text" class="fullin" id="pih_ih_high_pressure_date" style="width: 70px"></td>
 879               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="0" checked></td>
 880               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="2"></td>
 881               <td class="fibody2"><input name="ih_notes_11" type="text" class="fullin2" id="ih_notes_11"></td>
 882             </tr>
 883             <tr align="left" valign="bottom">
 884               <td nowrap class="fibody2" id="bordR">Stroke</td>
 885               <td class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="1">
 886                   <input name="pih_ih_stroke_date" type="text" class="fullin" id="pih_ih_stroke_date" style="width: 70px"></td>
 887               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="0" checked></td>
 888               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="2"></td>
 889               <td class="fibody2"><input name="ih_notes_12" type="text" class="fullin2" id="ih_notes_12"></td>
 890             </tr>
 891             <tr align="left" valign="bottom">
 892               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
 893               <td class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="1">
 894                   <input name="pih_ih_rheumatic_date" type="text" class="fullin" id="pih_ih_rheumatic_date" style="width: 70px"></td>
 895               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="0" checked></td>
 896               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="2"></td>
 897               <td class="fibody2"><input name="ih_notes_13" type="text" class="fullin2" id="ih_notes_13"></td>
 898             </tr>
 899             <tr align="left" valign="bottom">
 900               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 901               <td class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="1">
 902                   <input name="pih_ih_blood_clots_date" type="text" class="fullin" id="pih_ih_blood_clots_date" style="width: 70px"></td>
 903               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="0" checked></td>
 904               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="2"></td>
 905               <td class="fibody2"><input name="ih_notes_14" type="text" class="fullin2" id="ih_notes_14"></td>
 906             </tr>
 907             <tr align="left" valign="bottom">
 908               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
 909               <td class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="1">
 910                   <input name="pih_ih_eating_disorder_date" type="text" class="fullin" id="pih_ih_eating_disorder_date" style="width: 70px"></td>
 911               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="0" checked></td>
 912               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="2"></td>
 913               <td class="fibody2"><input name="ih_notes_15" type="text" class="fullin2" id="ih_notes_15"></td>
 914             </tr>
 915             <tr align="left" valign="bottom">
 916               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
 917               <td class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="1">
 918                   <input name="pih_ih_autoimmune_date" type="text" class="fullin" id="pih_ih_autoimmune_date" style="width: 70px"></td>
 919               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="0" checked></td>
 920               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="2"></td>
 921               <td class="fibody2"><input name="ih_notes_16" type="text" class="fullin2" id="ih_notes_16"></td>
 922             </tr>
 923             <tr align="left" valign="bottom">
 924               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
 925               <td class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="1">
 926                   <input name="pih_ih_chickenpox_date" type="text" class="fullin" id="pih_ih_chickenpox_date" style="width: 70px"></td>
 927               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="0" checked></td>
 928               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="2"></td>
 929               <td class="fibody2"><input name="ih_notes_17" type="text" class="fullin2" id="ih_notes_17"></td>
 930             </tr>
 931             <tr align="left" valign="bottom">
 932               <td nowrap class="fibody2" id="bordR">Cancer</td>
 933               <td class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="1">
 934                   <input name="pih_ih_cancer_date" type="text" class="fullin" id="pih_ih_cancer_date" style="width: 70px"></td>
 935               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="0" checked></td>
 936               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="2"></td>
 937               <td class="fibody2"><input name="ih_notes_18" type="text" class="fullin2" id="ih_notes_18"></td>
 938             </tr>
 939             <tr align="left" valign="bottom">
 940               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
 941               <td class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="1">
 942                   <input name="pih_ih_reflux_date" type="text" class="fullin" id="pih_ih_reflux_date" style="width: 70px"></td>
 943               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="0" checked></td>
 944               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="2"></td>
 945               <td class="fibody2"><input name="ih_notes_19" type="text" class="fullin2" id="ih_notes_19"></td>
 946             </tr>
 947             <tr align="left" valign="bottom">
 948               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
 949               <td class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="1">
 950                   <input name="pih_ih_depression_date" type="text" class="fullin" id="pih_ih_depression_date" style="width: 70px"></td>
 951               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="0" checked></td>
 952               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="2"></td>
 953               <td class="fibody2"><input name="ih_notes_20" type="text" class="fullin2" id="ih_notes_20"></td>
 954             </tr>
 955             <tr align="left" valign="bottom">
 956               <td nowrap class="fibody2" id="bordR">Anemia</td>
 957               <td class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="1">
 958                   <input name="pih_ih_anemia_date" type="text" class="fullin" id="pih_ih_anemia_date" style="width: 70px"></td>
 959               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="0" checked></td>
 960               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="2"></td>
 961               <td class="fibody2"><input name="ih_notes_21" type="text" class="fullin2" id="ih_notes_21"></td>
 962             </tr>
 963             <tr align="left" valign="bottom">
 964               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
 965               <td class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="1">
 966                   <input name="pih_ih_blood_transf_date" type="text" class="fullin" id="pih_ih_blood_transf_date" style="width: 70px"></td>
 967               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="0" checked></td>
 968               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="2"></td>
 969               <td class="fibody2"><input name="ih_notes_22" type="text" class="fullin2" id="ih_notes_22"></td>
 970             </tr>
 971             <tr align="left" valign="bottom">
 972               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
 973               <td class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="1">
 974                   <input name="pih_ih_seizures_date" type="text" class="fullin" id="pih_ih_seizures_date" style="width: 70px"></td>
 975               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="0" checked></td>
 976               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="2"></td>
 977               <td class="fibody2"><input name="ih_notes_23" type="text" class="fullin2" id="ih_notes_23"></td>
 978             </tr>
 979             <tr align="left" valign="bottom">
 980               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
 981               <td class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="1">
 982                   <input name="pih_ih_bowel_problems_date" type="text" class="fullin" id="pih_ih_bowel_problems_date" style="width: 70px"></td>
 983               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="0" checked></td>
 984               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="2"></td>
 985               <td class="fibody2"><input name="ih_notes_24" type="text" class="fullin2" id="ih_notes_24"></td>
 986             </tr>
 987             <tr align="left" valign="bottom">
 988               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
 989               <td class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="1">
 990                   <input name="pih_ih_glaucoma_date" type="text" class="fullin" id="pih_ih_glaucoma_date" style="width: 70px"></td>
 991               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="0" checked></td>
 992               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="2"></td>
 993               <td class="fibody2"><input name="ih_notes_25" type="text" class="fullin2" id="ih_notes_25"></td>
 994             </tr>
 995             <tr align="left" valign="bottom">
 996               <td nowrap class="fibody2" id="bordR">Cataracts</td>
 997               <td class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="1">
 998                   <input name="pih_ih_cataracts_date" type="text" class="fullin" id="pih_ih_cataracts_date" style="width: 70px"></td>
 999               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="0" checked></td>
1000               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="2"></td>
1001               <td class="fibody2"><input name="ih_notes_26" type="text" class="fullin2" id="ih_notes_26"></td>
1002             </tr>
1003             <tr align="left" valign="bottom">
1004               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
1005               <td class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="1">
1006                   <input name="pih_ih_joint_pain_date" type="text" class="fullin" id="pih_ih_joint_pain_date" style="width: 70px"></td>
1007               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="0" checked></td>
1008               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="2"></td>
1009               <td class="fibody2"><input name="ih_notes_27" type="text" class="fullin2" id="ih_notes_27"></td>
1010             </tr>
1011             <tr align="left" valign="bottom">
1012               <td nowrap class="fibody2" id="bordR">Broken bones </td>
1013               <td class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="1">
1014                   <input name="pih_ih_broken_bones_date" type="text" class="fullin" id="pih_ih_broken_bones_date" style="width: 70px"></td>
1015               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="0" checked></td>
1016               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="2"></td>
1017               <td class="fibody2"><input name="ih_notes_28" type="text" class="fullin2" id="ih_notes_28"></td>
1018             </tr>
1019             <tr align="left" valign="bottom">
1020               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
1021               <td class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="1">
1022                   <input name="pih_ih_hepatitis_date" type="text" class="fullin" id="pih_ih_hepatitis_date" style="width: 70px"></td>
1023               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="0" checked></td>
1024               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="2"></td>
1025               <td class="fibody2"><input name="ih_notes_29" type="text" class="fullin2" id="ih_notes_29"></td>
1026             </tr>
1027             <tr align="left" valign="bottom">
1028               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
1029               <td class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="1">
1030                   <input name="pih_ih_thyroid_date" type="text" class="fullin" id="pih_ih_thyroid_date" style="width: 70px"></td>
1031               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="0" checked></td>
1032               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="2"></td>
1033               <td class="fibody2"><input name="ih_notes_30" type="text" class="fullin2" id="ih_notes_30"></td>
1034             </tr>
1035             <tr align="left" valign="bottom">
1036               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
1037               <td class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="1">
1038                   <input name="pih_ih_galibladder_date" type="text" class="fullin" id="pih_ih_galibladder_date" style="width: 70px"></td>
1039               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="0" checked></td>
1040               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="2"></td>
1041               <td class="fibody2"><input name="ih_notes_31" type="text" class="fullin2" id="ih_notes_31"></td>
1042             </tr>
1043             <tr align="left" valign="bottom">
1044               <td nowrap class="fibody2" id="bordR">Headaches</td>
1045               <td class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="1">
1046                   <input name="pih_ih_headaches_date" type="text" class="fullin" id="pih_ih_headaches_date" style="width: 70px"></td>
1047               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="0" checked></td>
1048               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="2"></td>
1049               <td class="fibody2"><input name="ih_notes_32" type="text" class="fullin2" id="ih_notes_32"></td>
1050             </tr>
1051             <tr align="left" valign="bottom">
1052               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
1053               <td class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="1">
1054                   <input name="pih_ih_des_date" type="text" class="fullin" id="pih_ih_des_date" style="width: 70px"></td>
1055               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="0" checked></td>
1056               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="2"></td>
1057               <td class="fibody2"><input name="ih_notes_33" type="text" class="fullin2" id="ih_notes_33"></td>
1058             </tr>
1059             <tr align="left" valign="bottom">
1060               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
1061               <td class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="1">
1062                   <input name="pih_ih_bleeding_disorders_date" type="text" class="fullin" id="pih_ih_bleeding_disorders_date" style="width: 70px"></td>
1063               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="0" checked></td>
1064               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="2"></td>
1065               <td class="fibody2"><input name="ih_notes_34" type="text" class="fullin2" id="ih_notes_34"></td>
1066             </tr>
1067             <tr align="left" valign="bottom">
1068               <td nowrap class="fibody2" id="bordR">other</td>
1069               <td class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="1">
1070                   <input name="pih_ih_other_date" type="text" class="fullin" id="pih_ih_other_date" style="width: 70px"></td>
1071               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="0" checked></td>
1072               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="2"></td>
1073               <td class="fibody2"><input name="ih_notes_35" type="text" class="fullin2" id="ih_notes_35"></td>
1074             </tr>
1075             <tr align="left" valign="bottom">
1076               <td colspan="5" nowrap class="fibody3"><textarea name="pih_ih_extended_info" rows="4" wrap="VIRTUAL" class="fullin2" id="pih_ih_extended_info"></textarea></td>
1077             </tr>
1078         </table></td>
1079       </tr>
1080     </table>
1081   </div>
1082   <p align="center">&nbsp;</p>
1083   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
1084   </h2>
1085   <div style="border: solid 2px black; background-color: white;">
1086     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1087       <tr>
1088         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
1089         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
1090         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
1091       </tr>
1092 <?php
1093 $ii = 0;
1094 while ($ii<6){
1095 print <<<EOL
1096       <tr>
1097         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_reason_${ii}" type="text" class="fullin2"></td>
1098         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_date_${ii}" type="text" class="fullin2"></td>
1099         <td align="left" valign="bottom" class="fibody2"><input name="op_hospital_${ii}" type="text" class="fullin2"></td>
1100       </tr>
1101 EOL;
1102 $ii++;
1103 }
1104 ?>
1105     </table>
1106   </div>
1107   <p align="center">&nbsp;</p>
1108   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
1109   </h2>
1110   <div style="border: solid 2px black; background-color: white;">
1111     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1112       <tr valign="bottom">
1113         <td align="left" class="ficaption2" id="bordR">Type</td>
1114         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
1115         <td align="left" class="ficaption2" id="bordR">Type</td>
1116         <td width="90" align="center" nowrap class="ficaption2">date</td>
1117       </tr>
1118 <?php
1119 $ii = 0;
1120 while ($ii<6){
1121 $ij = $ii+6;
1122 print <<<EOL
1123       <tr valign="bottom">
1124         <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ii}" type="text" class="fullin2"></td>
1125         <td align="left" nowrap class="fibody2" id="bordR"><input name="ii_date_${ii}" type="text" class="fullin2"></td>
1126         <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ij}" type="text" class="fullin2"></td>
1127         <td align="left" nowrap class="fibody2"><input name="ii_date_${ij}" type="text" class="fullin2"></td>
1128       </tr>
1129 EOL;
1130 $ii++;
1131 }
1132 ?>
1133     </table>
1134   </div>
1135   <p align="center">&nbsp;</p>
1136   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
1137   </h2>
1138   <div style="border: solid 2px black; background-color: white;">
1139     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1140       <tr valign="bottom">
1141         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
1142         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
1143         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
1144         <td width="90" align="center" class="ficaption2">date</td>
1145       </tr>
1146       <tr valign="bottom">
1147         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
1148         <td align="left" nowrap class="fibody2" id="bordR">
1149           <input name="imm_tetanus" type="text" class="fullin2" id="imm_tetanus">
1150         </td>
1151         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
1152         <td align="left" valign="bottom" nowrap class="fibody2">
1153           <input name="imm_influenza" type="text" class="fullin2" id="imm_influenza">
1154         </td>
1155       </tr>
1156       <tr valign="bottom">
1157         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
1158         <td align="left" nowrap class="fibody2" id="bordR">
1159           <input name="imm_hepatitis_a" type="text" class="fullin2" id="imm_hepatitis_a">
1160         </td>
1161         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
1162         <td align="left" valign="bottom" nowrap class="fibody2">
1163           <input name="imm_hepatitis_b" type="text" class="fullin2" id="imm_hepatitis_b">
1164         </td>
1165       </tr>
1166       <tr valign="bottom">
1167         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
1168         <td align="left" nowrap class="fibody2" id="bordR">
1169           <input name="imm_varicella" type="text" class="fullin2" id="imm_varicella">
1170         </td>
1171         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
1172         <td align="left" valign="bottom" nowrap class="fibody2">
1173           <input name="imm_pneumococcal" type="text" class="fullin2" id="imm_pneumococcal">
1174         </td>
1175       </tr>
1176       <tr valign="bottom">
1177         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
1178         <td align="left" nowrap class="fibody2" id="bordR">
1179           <input name="imm_mmr" type="text" class="fullin2" id="imm_mmr">
1180         </td>
1181         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
1182         <input name="imm_tuberculosis_skin" type="text" class="fullin" id="imm_tuberculosis_skin" style="width:40px">
1183         , result:
1184         <input name="imm_tuberculosis_result" type="text" class="fullin" id="imm_tuberculosis_result" style="width:40px"></td>
1185         <td align="left" valign="bottom" nowrap class="fibody2">
1186           <input name="imm_tuberculosis" type="text" class="fullin2" id="imm_tuberculosis">
1187         </td>
1188       </tr>
1189     </table>
1190   </div>
1191   <p align="center">&nbsp;</p>
1192   <div style="border: solid 2px black; background-color: white;">
1193     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1194       <tr>
1195         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
1196         <textarea name="imm_extended_info" rows="6" wrap="VIRTUAL" class="fullin2" id="imm_extended_info"></textarea></td>
1197       </tr>
1198     </table>
1199   </div>
1200   <p align="center">&nbsp;</p>
1201   <a name="ros">
1202   <h2 align="center"><a ></a>Review of systems<br>
1203     <small>Please check (x), if any of the following symptoms
1204 apply to you now or since adulthood</small> </h2>
1205   <div style="border: solid 2px black; background-color: white;">
1206     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1207       <tr>
1208         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
1209         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
1210         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
1211         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
1212         <td align="center" valign="top" class="ficaption2">physician's notes </td>
1213       </tr>
1214       <tr valign="bottom">
1215         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
1216         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1217         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1218         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1219         <td align="left" class="fibody2">&nbsp;</td>
1220       </tr>
1221       <tr valign="bottom">
1222         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
1223         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="1"></td>
1224         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="2"></td>
1225         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="3"></td>
1226         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_1"  ></td>
1227       </tr>
1228       <tr valign="bottom">
1229         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
1230         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="1"></td>
1231         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="2"></td>
1232         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="3"></td>
1233         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_2"  ></td>
1234       </tr>
1235       <tr valign="bottom">
1236         <td align="left" class="fibody4"  id="bordR" >Fever</td>
1237         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="1"></td>
1238         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="2"></td>
1239         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="3"></td>
1240         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_3"  ></td>
1241       </tr>
1242       <tr valign="bottom">
1243         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
1244         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="1"></td>
1245         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="2"></td>
1246         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="3"></td>
1247         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_4"  ></td>
1248       </tr>
1249       <tr valign="bottom">
1250         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
1251         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="1"></td>
1252         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="2"></td>
1253         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="3"></td>
1254         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_5"  ></td>
1255       </tr>
1256       <tr valign="bottom">
1257         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
1258         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1259         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1260         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1261         <td align="left" class="fibody2">&nbsp;</td>
1262       </tr>
1263       <tr valign="bottom">
1264         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
1265         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="1"></td>
1266         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="2"></td>
1267         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="3"></td>
1268         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_6"  ></td>
1269       </tr>
1270       <tr valign="bottom">
1271         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
1272         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="1"></td>
1273         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="2"></td>
1274         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="3"></td>
1275         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_7"  ></td>
1276       </tr>
1277       <tr valign="bottom">
1278         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
1279         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="1"></td>
1280         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="2"></td>
1281         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="3"></td>
1282         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_8"  ></td>
1283       </tr>
1284       <tr valign="bottom">
1285         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
1286         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="1"></td>
1287         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="2"></td>
1288         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="3"></td>
1289         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_9"  ></td>
1290       </tr>
1291       <tr valign="bottom">
1292         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
1293         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1294         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1295         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1296         <td align="left" class="fibody2">&nbsp;</td>
1297       </tr>
1298       <tr valign="bottom">
1299         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
1300         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="1"></td>
1301         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="2"></td>
1302         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="3"></td>
1303         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_10"  ></td>
1304       </tr>
1305       <tr valign="bottom">
1306         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
1307         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="1"></td>
1308         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="2"></td>
1309         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="3"></td>
1310         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_11"  ></td>
1311       </tr>
1312       <tr valign="bottom">
1313         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
1314         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="1"></td>
1315         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="2"></td>
1316         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="3"></td>
1317         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_12"  ></td>
1318       </tr>
1319       <tr valign="bottom">
1320         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
1321         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="1"></td>
1322         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="2"></td>
1323         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="3"></td>
1324         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_13"  ></td>
1325       </tr>
1326       <tr valign="bottom">
1327         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
1328         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="1"></td>
1329         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="2"></td>
1330         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="3"></td>
1331         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_14"  ></td>
1332       </tr>
1333       <tr valign="bottom">
1334         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
1335         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="1"></td>
1336         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="2"></td>
1337         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="3"></td>
1338         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_15"  ></td>
1339       </tr>
1340       <tr valign="bottom">
1341         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
1342         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="1"></td>
1343         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="2"></td>
1344         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="3"></td>
1345         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_16"  ></td>
1346       </tr>
1347       <tr valign="bottom">
1348         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
1349         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1350         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1351         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1352         <td align="left" class="fibody2">&nbsp;</td>
1353       </tr>
1354       <tr valign="bottom">
1355         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
1356         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="1"></td>
1357         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="2"></td>
1358         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="3"></td>
1359         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_17"  ></td>
1360       </tr>
1361       <tr valign="bottom">
1362         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
1363         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="1"></td>
1364         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="2"></td>
1365         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="3"></td>
1366         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_18"  ></td>
1367       </tr>
1368       <tr valign="bottom">
1369         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
1370         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="1"></td>
1371         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="2"></td>
1372         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="3"></td>
1373         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_19"  ></td>
1374       </tr>
1375       <tr valign="bottom">
1376         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
1377         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="1"></td>
1378         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="2"></td>
1379         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="3"></td>
1380         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_20"  ></td>
1381       </tr>
1382       <tr valign="bottom">
1383         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
1384         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1385         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1386         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1387         <td align="left" class="fibody2">&nbsp;</td>
1388       </tr>
1389       <tr valign="bottom">
1390         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
1391         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="1"></td>
1392         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="2"></td>
1393         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="3"></td>
1394         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_21"  ></td>
1395       </tr>
1396       <tr valign="bottom">
1397         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
1398         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="1"></td>
1399         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="2"></td>
1400         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="3"></td>
1401         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_22"  ></td>
1402       </tr>
1403       <tr valign="bottom">
1404         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
1405         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="1"></td>
1406         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="2"></td>
1407         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="3"></td>
1408         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_23"  ></td>
1409       </tr>
1410       <tr valign="bottom">
1411         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
1412         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="1"></td>
1413         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="2"></td>
1414         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="3"></td>
1415         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_24"  ></td>
1416       </tr>
1417       <tr valign="bottom">
1418         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
1419         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="1"></td>
1420         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="2"></td>
1421         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="3"></td>
1422         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_25"  ></td>
1423       </tr>
1424       <tr valign="bottom">
1425         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
1426         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1427         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1428         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1429         <td align="left" class="fibody2">&nbsp;</td>
1430       </tr>
1431       <tr valign="bottom">
1432         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
1433         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="1"></td>
1434         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="2"></td>
1435         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="3"></td>
1436         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_26"  ></td>
1437       </tr>
1438       <tr valign="bottom">
1439         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
1440         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="1"></td>
1441         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="2"></td>
1442         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="3"></td>
1443         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_27"  ></td>
1444       </tr>
1445       <tr valign="bottom">
1446         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
1447         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="1"></td>
1448         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="2"></td>
1449         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="3"></td>
1450         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_28"  ></td>
1451       </tr>
1452       <tr valign="bottom">
1453         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
1454         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="1"></td>
1455         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="2"></td>
1456         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="3"></td>
1457         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_29"  ></td>
1458       </tr>
1459       <tr valign="bottom">
1460         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
1461         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="1"></td>
1462         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="2"></td>
1463         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="3"></td>
1464         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_30"  ></td>
1465       </tr>
1466       <tr valign="bottom">
1467         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
1468         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1469         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1470         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1471         <td align="left" class="fibody2">&nbsp;</td>
1472       </tr>
1473       <tr valign="bottom">
1474         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
1475         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="1"></td>
1476         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="2"></td>
1477         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="3"></td>
1478         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_31"  ></td>
1479       </tr>
1480       <tr valign="bottom">
1481         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
1482         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="1"></td>
1483         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="2"></td>
1484         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="3"></td>
1485         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_32"  ></td>
1486       </tr>
1487       <tr valign="bottom">
1488         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
1489         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="1"></td>
1490         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="2"></td>
1491         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="3"></td>
1492         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_33"  ></td>
1493       </tr>
1494       <tr valign="bottom">
1495         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
1496         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="1"></td>
1497         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="2"></td>
1498         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="3"></td>
1499         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_34"  ></td>
1500       </tr>
1501       <tr valign="bottom">
1502         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
1503         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="1"></td>
1504         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="2"></td>
1505         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="3"></td>
1506         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_35"  ></td>
1507       </tr>
1508       <tr valign="bottom">
1509         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
1510         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="1"></td>
1511         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="2"></td>
1512         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="3"></td>
1513         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_36"  ></td>
1514       </tr>
1515       <tr valign="bottom">
1516         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
1517         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="1"></td>
1518         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="2"></td>
1519         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="3"></td>
1520         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_37"  ></td>
1521       </tr>
1522       <tr valign="bottom">
1523         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
1524         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="1"></td>
1525         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="2"></td>
1526         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="3"></td>
1527         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_38"  ></td>
1528       </tr>
1529       <tr valign="bottom">
1530         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
1531         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="1"></td>
1532         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="2"></td>
1533         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="3"></td>
1534         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_39"  ></td>
1535       </tr>
1536       <tr valign="bottom">
1537         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
1538         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="1"></td>
1539         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="2"></td>
1540         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="3"></td>
1541         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_40"  ></td>
1542       </tr>
1543       <tr valign="bottom">
1544         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
1545         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="1"></td>
1546         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="2"></td>
1547         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="3"></td>
1548         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_41"  ></td>
1549       </tr>
1550       <tr valign="bottom">
1551         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
1552         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="1"></td>
1553         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="2"></td>
1554         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="3"></td>
1555         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_42"  ></td>
1556       </tr>
1557       <tr valign="bottom">
1558         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
1559         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1560         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1561         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1562         <td align="left" class="fibody2">&nbsp;</td>
1563       </tr>
1564       <tr valign="bottom">
1565         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
1566         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="1"></td>
1567         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="2"></td>
1568         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="3"></td>
1569         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_43"  ></td>
1570       </tr>
1571       <tr valign="bottom">
1572         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
1573         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="1"></td>
1574         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="2"></td>
1575         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="3"></td>
1576         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_44"  ></td>
1577       </tr>
1578       <tr valign="bottom">
1579         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
1580         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1581         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1582         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1583         <td align="left" class="fibody2">&nbsp;</td>
1584       </tr>
1585       <tr valign="bottom">
1586         <td align="left" class="fibody4"  id="bordR" >Rash</td>
1587         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="1"></td>
1588         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="2"></td>
1589         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="3"></td>
1590         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_45"  ></td>
1591       </tr>
1592       <tr valign="bottom">
1593         <td align="left" class="fibody4"  id="bordR" >Sores</td>
1594         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="1"></td>
1595         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="2"></td>
1596         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="3"></td>
1597         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_46"  ></td>
1598       </tr>
1599       <tr valign="bottom">
1600         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
1601         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="1"></td>
1602         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="2"></td>
1603         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="3"></td>
1604         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_47"  ></td>
1605       </tr>
1606       <tr valign="bottom">
1607         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
1608         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="1"></td>
1609         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="2"></td>
1610         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="3"></td>
1611         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_48"  ></td>
1612       </tr>
1613       <tr valign="bottom">
1614         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
1615         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1616         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1617         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1618         <td align="left" class="fibody2">&nbsp;</td>
1619       </tr>
1620       <tr valign="bottom">
1621         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
1622         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="1"></td>
1623         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="2"></td>
1624         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="3"></td>
1625         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_49"  ></td>
1626       </tr>
1627       <tr valign="bottom">
1628         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
1629         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="1"></td>
1630         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="2"></td>
1631         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="3"></td>
1632         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_50"  ></td>
1633       </tr>
1634       <tr valign="bottom">
1635         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
1636         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="1"></td>
1637         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="2"></td>
1638         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="3"></td>
1639         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_51"  ></td>
1640       </tr>
1641       <tr valign="bottom">
1642         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
1643         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1644         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1645         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1646         <td align="left" class="fibody2">&nbsp;</td>
1647       </tr>
1648       <tr valign="bottom">
1649         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
1650         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="1"></td>
1651         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="2"></td>
1652         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="3"></td>
1653         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_52"  ></td>
1654       </tr>
1655       <tr valign="bottom">
1656         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
1657         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="1"></td>
1658         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="2"></td>
1659         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="3"></td>
1660         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_53"  ></td>
1661       </tr>
1662       <tr valign="bottom">
1663         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
1664         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="1"></td>
1665         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="2"></td>
1666         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="3"></td>
1667         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_54"  ></td>
1668       </tr>
1669       <tr valign="bottom">
1670         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
1671         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="1"></td>
1672         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="2"></td>
1673         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="3"></td>
1674         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_55"  ></td>
1675       </tr>
1676       <tr valign="bottom">
1677         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
1678         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="1"></td>
1679         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="2"></td>
1680         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="3"></td>
1681         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_56"  ></td>
1682       </tr>
1683       <tr valign="bottom">
1684         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
1685         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="1"></td>
1686         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="2"></td>
1687         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="3"></td>
1688         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_57"  ></td>
1689       </tr>
1690       <tr valign="bottom">
1691         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
1692         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1693         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1694         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1695         <td align="left" class="fibody2">&nbsp;</td>
1696       </tr>
1697       <tr valign="bottom">
1698         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
1699         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="1"></td>
1700         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="2"></td>
1701         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="3"></td>
1702         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_58"  ></td>
1703       </tr>
1704       <tr valign="bottom">
1705         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
1706         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="1"></td>
1707         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="2"></td>
1708         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="3"></td>
1709         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_59"  ></td>
1710       </tr>
1711       <tr valign="bottom">
1712         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
1713         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1714         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1715         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1716         <td align="left" class="fibody2">&nbsp;</td>
1717       </tr>
1718       <tr valign="bottom">
1719         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
1720         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="1"></td>
1721         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="2"></td>
1722         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="3"></td>
1723         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_60"  ></td>
1724       </tr>
1725       <tr valign="bottom">
1726         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
1727         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="1"></td>
1728         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="2"></td>
1729         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="3"></td>
1730         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_61"  ></td>
1731       </tr>
1732       <tr valign="bottom">
1733         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
1734         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="1"></td>
1735         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="2"></td>
1736         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="3"></td>
1737         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_62"  ></td>
1738       </tr>
1739       <tr valign="bottom">
1740         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
1741         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="1"></td>
1742         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="2"></td>
1743         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="3"></td>
1744         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_63"  ></td>
1745       </tr>
1746       <tr valign="bottom">
1747         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
1748         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1749         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1750         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1751         <td align="left" class="fibody2">&nbsp;</td>
1752       </tr>
1753       <tr valign="bottom">
1754         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
1755         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="1"></td>
1756         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="2"></td>
1757         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="3"></td>
1758         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_64"  ></td>
1759       </tr>
1760       <tr valign="bottom">
1761         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
1762         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="1"></td>
1763         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="2"></td>
1764         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="3"></td>
1765         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_65"  ></td>
1766       </tr>
1767       <tr valign="bottom">
1768         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
1769         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="1"></td>
1770         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="2"></td>
1771         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="3"></td>
1772         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_66"  ></td>
1773       </tr>
1774       <tr valign="bottom">
1775         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
1776         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1777         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1778         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1779         <td align="left" class="fibody2">&nbsp;</td>
1780       </tr>
1781       <tr valign="bottom">
1782         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
1783         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="1"></td>
1784         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="2"></td>
1785         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="3"></td>
1786         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_68"  ></td>
1787       </tr>
1788       <tr valign="bottom">
1789         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
1790         <td colspan="4" align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_med_allergy_reaction"  ></td>
1791       </tr>
1792       <tr valign="bottom">
1793         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
1794         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="1"></td>
1795         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="2"></td>
1796         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="3"></td>
1797         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_69"  ></td>
1798       </tr>
1799       <tr valign="bottom">
1800         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
1801         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="1"></td>
1802         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="2"></td>
1803         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="3"></td>
1804         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_70"  ></td>
1805       </tr>
1806       <tr valign="bottom">
1807         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
1808         <td colspan="4" align="left" class="fibody2"><input type="text" class="fullin2"   name="ros_other_allergy_reaction_"  ></td>
1809       </tr>
1810     </table>
1811   </div>
1812   <p align="center">&nbsp;</p>
1813   <div style="border: solid 2px black; background-color: white;">
1814     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1815       <tr valign="bottom">
1816         <td colspan="2" align="left" class="fibody2">Form completed by
1817           <input name="pih_completed_by" type="radio" value="patient" checked>
1818         patient
1819         <input name="pih_completed_by" type="radio" value="nurse">
1820         office nurse
1821         <input name="pih_completed_by" type="radio" value="physician">
1822         physician
1823         <input name="pih_completed_by" type="radio" value="other">
1824         other:
1825         <input name="pih_completed_by_other" type="text" class="fullin" id="pih_completed_by_other" style="width: 40%"></td>
1826       </tr>
1827       <tr valign="bottom">
1828         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
1829       </tr>
1830       <tr valign="bottom">
1831         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
1832         <input name="pih_date_reviewed_1" type="text" class="fullin" id="pih_date_reviewed_1" style="width:70px"></td>
1833         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
1834       </tr>
1835       <tr valign="bottom">
1836         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
1837       </tr>
1838       <tr valign="bottom">
1839         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1840           <input name="pih_date_reviewed_2" type="text" class="fullin" id="pih_date_reviewed_2" style="width:70px">
1841         </span></td>
1842         <td height="46" align="left" class="fibody2">Physician signature: </td>
1843       </tr>
1844       <tr valign="bottom">
1845         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1846           <input name="pih_date_reviewed_3" type="text" class="fullin" id="pih_date_reviewed_3" style="width:70px">
1847         </span> </td>
1848         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1849       </tr>
1850       <tr valign="bottom">
1851         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1852           <input name="pih_date_reviewed_4" type="text" class="fullin" id="pih_date_reviewed_4" style="width:70px">
1853         </span> </td>
1854         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1855       </tr>
1856       <tr valign="bottom">
1857         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1858           <input name="pih_date_reviewed_5" type="text" class="fullin" id="pih_date_reviewed_5" style="width:70px">
1859         </span> </td>
1860         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1861       </tr>
1862       <tr valign="bottom">
1863         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1864           <input name="pih_date_reviewed_6" type="text" class="fullin" id="pih_date_reviewed_6" style="width:70px">
1865         </span> </td>
1866         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1867       </tr>
1868     </table>
1869   </div>
1870   <p align="center">&nbsp;</p>
1871   <table width="100%" border="0">
1872     <tr>
1873       <td align="left"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
1874       <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
1875        onclick="top.restoreSession()">[Don't Save]</a> </td>
1876     </tr>
1877   </table>
1878 </form>
1879 <?php
1880 formFooter();
1881 ?>
1882 </body>
1883 </html>