contrib/forms/patient_intake_history/report.php

   1 <?php
   2
   3 function patient_intake_history_report( $pid, $encounter, $cols, $id) {
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
   9    if ($fres){
  10      $patient = sqlFetchArray($fres);
  11    }
  12    $fres=sqlStatement("select * from form_patient_intake_history where id=$id");
  13    if ($fres){
  14      $fdata = sqlFetchArray($fres);
  15    }
  16    $fres=sqlStatement("select * from form_patient_intake_history_ros where id=".$fdata['linked_ros_id']);
  17    if ($fres){
  18      $fros = sqlFetchArray($fres);
  19    }
  20 ?>
  21   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  22     <tr>
  23       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  24     </tr>
  25     <tr>
  26       <td align="left" valign="bottom" nowrap class="fibody3"> <?php echo (($fdata{'pih_patient'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  27       New patient </td>
  28     </tr>
  29     <tr>
  30       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_patient'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  31       Established patient </td>
  32     </tr>
  33     <tr>
  34       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_consultation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  35       Consultation</td>
  36     </tr>
  37     <tr>
  38       <td align="left" valign="bottom" nowrap class="fibody3"><?php echo (($fdata{'pih_report_sent'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  39       Report sent: <?php echo $fdata{'pih_report_sent_date'}; ?>&nbsp</td>
  40     </tr>
  41 </table>
  42 <div class="srvChapter">Patient Intake history</div>
  43 <div style="border: solid 1.5pt black; background-color: white;">
  44 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  45   <tr>
  46     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  47       <tr align="left" valign="bottom" class="fibody">
  48         <td width="40%" class="bordR">Patient name:<?php
  49
  50           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  51           ?>&nbsp</td>
  52         <td width="20%" class="bordR">Birth date: <?php
  53
  54           echo $patient{'DOB'};
  55           ?>&nbsp</td>
  56         <td width="20%" class="bordR">ID No: <?php
  57
  58           echo $patient{'id'};
  59           ?>&nbsp</td>
  60         <td width="20%">Date: <?php
  61
  62         echo date('Y-m-d');
  63         ?>&nbsp</td>
  64       </tr>
  65     </table>
  66 </td>
  67   </tr>
  68   <tr>
  69     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  70       <tr align="left" valign="bottom">
  71         <td colspan="3" class="fibody2">Address:<?php echo $fdata{'address'}; ?>&nbsp</td></tr>
  72       <tr align="left" valign="bottom">
  73         <td width="50%" class="fibody2" id="bordR">City: <?php echo $fdata{'city'}; ?>&nbsp</td>
  74         <td width="50%" colspan="2" class="fibody2">State/ZIP: <?php echo $fdata{'state'}; ?>&nbsp</td>
  75       </tr>
  76       <tr align="left" valign="bottom">
  77         <td class="fibody2" id="bordR">Home telephone: <?php echo $fdata{'home_phone'}; ?>&nbsp</td>
  78         <td colspan="2" class="fibody2">Work telephone: <?php echo $fdata{'work_phone'}; ?>&nbsp</td>
  79       </tr>
  80       <tr align="left" valign="bottom">
  81         <td class="fibody2" id="bordR">Employer: <?php echo $fdata{'employer'}; ?>&nbsp</td>
  82         <td width="25%" class="fibody2" id="bordR">Insurance: <?php echo $fdata{'insurance'}; ?>&nbsp</td>
  83         <td width="25%" class="fibody2">Policy No: <?php echo $fdata{'policy_no'}; ?>&nbsp</td>
  84       </tr>
  85       <tr align="left" valign="bottom">
  86         <td class="fibody2" id="bordR">Name you would like us to use: <?php echo $fdata{'name_to_use'}; ?> </td>
  87         <td colspan="2" class="fibody2">Primary language: <?php echo $fdata{'primary_language'}; ?>&nbsp</td>
  88       </tr>
  89     </table></td>
  90   </tr>
  91   <tr>
  92     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  93       <tr align="left" valign="bottom">
  94         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
  95         <td colspan="2" class="fibody2">Emergency contact: <?php echo $fdata{'partner_emergency_contact'}; ?>&nbsp</td>
  96         </tr>
  97       <tr align="left" valign="bottom">
  98         <td rowspan="2" valign="top" class="fibody2" id="bordR"><?php echo $fdata{'partner_name'}; ?>&nbsp</td>
  99         <td colspan="2" class="fibody2">Relationship: <?php echo $fdata{'relationship'}; ?>&nbsp</td>
 100         </tr>
 101       <tr align="left" valign="bottom">
 102         <td width="30%" class="fibody2" id="bordR">Home telephone:
 103           <?php echo $fdata{'partner_home_phone'}; ?>&nbsp</td>
 104         <td width="30%" class="fibody2">Work telephone:
 105           <?php echo $fdata{'partner_work_phone'}; ?>&nbsp</td>
 106       </tr>
 107     </table></td>
 108   </tr>
 109   <tr>
 110     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 111       <tr>
 112         <td align="left" valign="bottom" class="fibody2">Referred by:
 113           <?php echo $fdata{'referred_by'}; ?>&nbsp</td>
 114       </tr>
 115       <tr>
 116         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 117           <?php echo $fdata{'why_come_to_office'}; ?>&nbsp</td>
 118       </tr>
 119       <tr>
 120         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 121           <?php echo (($fdata{'primary_care_visit'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 122           Primary care visit or
 123           <?php echo (($fdata{'primary_care_visit'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 124           Gynecology only </td>
 125       </tr>
 126       <tr>
 127         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 128           <?php echo (($fdata{'new_problem'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 129           yes &nbsp;&nbsp;&nbsp;&nbsp;
 130           <?php echo (($fdata{'new_problem'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 131           no</td>
 132       </tr>
 133       <tr>
 134         <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>
 135           <?php echo $fdata{'problem_description'}; ?>&nbsp</td>
 136       </tr>
 137     </table></td>
 138   </tr>
 139 </table>
 140 </div>
 141 <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>
 142 <p align="center">&nbsp;</p>
 143 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 144   </h2>
 145 <div style="border: solid 1.5pt black; background-color: white;">
 146     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 147       <tr>
 148         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 149           <tr align="left" valign="bottom">
 150             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 151             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 152           </tr>
 153           <tr align="left" valign="bottom">
 154             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 155               <?php echo $fdata{'last_period_date'}; ?>&nbsp</td>
 156             <td class="fibody2"><?php echo $fdata{'gh_notes_1'}; ?>&nbsp</td>
 157           </tr>
 158           <tr align="left" valign="bottom">
 159             <td nowrap class="fibody2" id="bordR">Age periods began:
 160               <?php echo $fdata{'periods_began'}; ?>&nbsp</td>
 161             <td class="fibody2"><?php echo $fdata{'gh_notes_2'}; ?>&nbsp</td>
 162           </tr>
 163           <tr align="left" valign="bottom">
 164             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 165               <?php echo $fdata{'period_lenght'}; ?>&nbsp</td>
 166             <td class="fibody2"><?php echo $fdata{'gh_notes_3'}; ?>&nbsp</td>
 167           </tr>
 168           <tr align="left" valign="bottom">
 169             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 170               <?php echo $fdata{'period_days_between'}; ?>&nbsp</td>
 171             <td class="fibody2"><?php echo $fdata{'gh_notes_4'}; ?>&nbsp</td>
 172           </tr>
 173           <tr align="left" valign="bottom">
 174             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 175               <?php echo (($fdata{'period_changes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 176 Yes
 177 <?php echo (($fdata{'pih_gh_recent_changes_periods'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 178 No</td>
 179             <td class="fibody2"><?php echo $fdata{'gh_notes_5'}; ?>&nbsp</td>
 180           </tr>
 181           <tr align="left" valign="bottom">
 182             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 183               <?php echo (($fdata{'sexually_active'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 184 Yes
 185 <?php echo (($fdata{'sexually_active'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 186 No</td>
 187             <td class="fibody2"><?php echo $fdata{'gh_notes_6'}; ?>&nbsp</td>
 188           </tr>
 189           <tr align="left" valign="bottom">
 190             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 191               <?php echo (($fdata{'ever_had_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 192 Yes
 193 <?php echo (($fdata{'ever_had_sex'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 194 No</td>
 195             <td class="fibody2"><?php echo $fdata{'gh_notes_7'}; ?>&nbsp</td>
 196           </tr>
 197           <tr align="left" valign="bottom">
 198             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 199               <?php echo $fdata{'number_of_partners'}; ?>&nbsp</td>
 200             <td class="fibody2"><?php echo $fdata{'gh_notes_8'}; ?>&nbsp</td>
 201           </tr>
 202           <tr align="left" valign="bottom">
 203             <td nowrap class="fibody2" id="bordR">Sexual partners are
 204               <?php echo (($fdata{'partners'} == 'men')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 205               Men
 206               <?php echo (($fdata{'partners'} == 'women')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 207               Women
 208               <?php echo (($fdata{'partners'} == 'both')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 209               Both </td>
 210             <td class="fibody2"><?php echo $fdata{'gh_notes_9'}; ?>&nbsp</td>
 211           </tr>
 212           <tr align="left" valign="bottom">
 213             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 214               <?php echo $fdata{'present_birth_control'}; ?>&nbsp</td>
 215             <td class="fibody2"><?php echo $fdata{'gh_notes_10'}; ?>&nbsp</td>
 216           </tr>
 217           <tr align="left" valign="bottom">
 218             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 219               <?php echo (($fdata{'pills_iud'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 220 Yes
 221 <?php echo (($fdata{'pills_iud'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 222 No </td>
 223             <td class="fibody2"><?php echo $fdata{'gh_notes_11'}; ?>&nbsp</td>
 224           </tr>
 225           <tr align="left" valign="bottom">
 226             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 227               <?php echo $fdata{'pills_how_long'}; ?>&nbsp</td>
 228             <td class="fibody2"><?php echo $fdata{'gh_notes_12'}; ?>&nbsp</td>
 229           </tr>
 230           <tr align="left" valign="bottom">
 231             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 232               <?php echo $fdata{'pap_test'}; ?>&nbsp</td>
 233             <td class="fibody2"><?php echo $fdata{'gh_notes_13'}; ?>&nbsp</td>
 234           </tr>
 235           <tr align="left" valign="bottom">
 236             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 237               <?php echo (($fdata{'breast_self_exam'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 238               Yes
 239               <?php echo (($fdata{'breast_self_exam'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 240               No</td>
 241             <td class="fibody2"><?php echo $fdata{'gh_notes_14'}; ?>&nbsp</td>
 242           </tr>
 243           <tr align="left" valign="bottom">
 244             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 245               <?php echo (($fdata{'des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 246 Yes
 247 <?php echo (($fdata{'des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 248 No </td>
 249             <td class="fibody2"><?php echo $fdata{'gh_notes_15'}; ?>&nbsp</td>
 250           </tr>
 251         </table></td>
 252       </tr>
 253     </table>
 254   </div>
 255   <p align="center">&nbsp;</p>
 256   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 257   </h2>
 258   <div style="border: solid 1.5pt black; background-color:#FFFFFF;">
 259     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 260       <tr>
 261         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 262             <tr align="left" valign="bottom">
 263               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 264               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 265               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 266               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 267               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 268               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 269             </tr>
 270             <tr align="left" valign="bottom">
 271               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 272               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_pregnancies'}; ?>&nbsp</td>
 273               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 274               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_abortions'}; ?>&nbsp</td>
 275               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 276               <td width="50" nowrap class="fibody2"><?php echo $fdata{'oh_miscarriages'}; ?>&nbsp</td>
 277             </tr>
 278             <tr align="left" valign="bottom">
 279               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 280               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_premature_births'}; ?>&nbsp</td>
 281               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 282               <td width="50" nowrap class="fibody2" id="bordR"><?php echo $fdata{'oh_live_births'}; ?>&nbsp</td>
 283               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 284               <td width="50" nowrap class="fibody2"><?php echo $fdata{'oh_living_children'}; ?>&nbsp</td>
 285             </tr>
 286         </table></td>
 287       </tr>
 288       <tr>
 289         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 290             <tr align="center" valign="middle">
 291               <td class="ficaption2" id="bordR">No</td>
 292               <td class="ficaption2" id="bordR">birth date </td>
 293               <td class="ficaption2" id="bordR">weight at birth </td>
 294               <td class="ficaption2" id="bordR">baby's sex </td>
 295               <td class="ficaption2" id="bordR">weeks pregnant </td>
 296               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 297               <td class="ficaption2">physician's notes</td>
 298             </tr>
 299 <?php
 300
 301   $bi = 0;
 302   while ($bi<4) {
 303     $n = $bi+1;
 304     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 305     print <<<EOL
 306         <tr align="left" valign="bottom">
 307           <td nowrap class="fibody2" id="bordR">$n.</td>
 308           <td nowrap class="fibody2" id="bordR">${oh_ch_date}&nbsp;</td>
 309           <td nowrap class="fibody2" id="bordR">${oh_ch_width}&nbsp;</td>
 310           <td nowrap class="fibody2" id="bordR">${oh_ch_sex}&nbsp;</td>
 311           <td nowrap class="fibody2" id="bordR">${oh_ch_weeks}&nbsp;</td>
 312           <td nowrap class="fibody2" id="bordR">${oh_ch_delivery}&nbsp;</td>
 313           <td nowrap class="fibody2">${oh_ch_notes}&nbsp;</td>
 314         </tr>
 315 EOL;
 316      $bi++;
 317   }
 318 ?>
 319         </table></td>
 320       </tr>
 321       <tr>
 322         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 323             <tr align="left" valign="bottom">
 324               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 325               <td class="fibody2"><?php echo $fdata{'oh_complications'}; ?>&nbsp</td>
 326             </tr>
 327         </table></td>
 328       </tr>
 329       <tr>
 330         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 331             <tr align="left" valign="bottom">
 332               <td colspan="2" class="fibody2"><?php echo (($fdata{'oh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 333               diabetes
 334                 <?php echo (($fdata{'oh_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 335               hypertension/high blood pressure
 336               <?php echo (($fdata{'oh_preemclampsia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 337               preeclampsia/foxemia
 338               <?php echo (($fdata{'oh_complic_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 339               other </td>
 340             </tr>
 341             <tr align="left" valign="bottom">
 342               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 343                   <?php echo (($fdata{'oh_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 344               no
 345               <?php echo (($fdata{'oh_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 346               yes, How treated </td>
 347               <td class="fibody2"><?php echo $fdata{'oh_depression_treated'}; ?>&nbsp</td>
 348             </tr>
 349         </table></td>
 350       </tr>
 351     </table>
 352   </div>
 353   <p align="center">&nbsp;</p>
 354   <h2 align="center"><a name="cm"></a>Current medications <br>
 355     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 356   </h2>
 357   <div style="border: solid 1.5pt black; background-color: white;">
 358     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 359       <tr align="center">
 360         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 361         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 362         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 363         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 364         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 365         <td valign="top" class="ficaption2">Who prescribed</td>
 366       </tr>
 367 <?php
 368
 369   $bi = 0;
 370   while ($bi<5) {
 371   $bi2 = $bi+5;
 372       list ($pres_drug, $pres_dosage, $pres_who) = explode('|~', $fdata["pres_drug_rec_".$bi] );
 373       list ($pres_drug1, $pres_dosage1, $pres_who1) = explode('|~', $fdata["pres_drug_rec_".$bi2] );
 374     print <<<EOL
 375       <tr>
 376         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage}&nbsp;</td>
 377         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug}&nbsp;</td>
 378         <td align="left" valign="top" class="fibody2" id="bordR">${pres_who}&nbsp;</td>
 379         <td align="left" valign="top" class="fibody2" id="bordR">${pres_drug1}&nbsp;</td>
 380         <td align="left" valign="top" class="fibody2" id="bordR">${pres_dosage1}&nbsp;</td>
 381         <td align="left" valign="top" class="fibody2">${pres_who1}&nbsp;</td>
 382       </tr>
 383 EOL;
 384      $bi++;
 385   }
 386 ?>
 387     </table>
 388   </div>
 389   <p align="center">&nbsp;</p>
 390   <h2 align="center"><a name="fh"></a>Family history <br>
 391   </h2>
 392   <div style="border: solid 1.5pt black; background-color: white;">
 393     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 394       <tr>
 395         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 396           <tr align="left" valign="bottom">
 397             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 398               <?php echo (($fdata{'fh_mother'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 399               living
 400               <?php echo (($fdata{'fh_mother'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 401               deceased - cause:
 402               <?php echo $fdata{'fh_mother_dec_cause'}; ?>
 403               Age:
 404               <?php echo $fdata{'fh_mother_dec_age'}; ?>&nbsp</td>
 405             <td width="50%" nowrap class="fibody2">father:
 406               <?php echo (($fdata{'fh_father'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 407 living
 408 <?php echo (($fdata{'fh_father'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 409 deceased - cause:
 410 <?php echo $fdata{'fh_father_dec_cause'}; ?>
 411 Age:
 412 <?php echo $fdata{'fh_father_dec_age'}; ?>&nbsp</td>
 413           </tr>
 414           <tr align="left" valign="bottom">
 415             <td nowrap class="fibody2">Siblings: Num.living:
 416               <?php echo $fdata{'fh_sibl_living'}; ?>
 417               , num.deceased:
 418               <?php echo $fdata{'fh_sib_deceased'}; ?>
 419               , cause(s)/age(s): </td>
 420             <td nowrap class="fibody2"><?php echo $fdata{'fh_sib_dec_cause'}; ?>&nbsp</td>
 421           </tr>
 422           <tr align="left" valign="bottom">
 423             <td nowrap class="fibody2">Children: Num.living:
 424               <?php echo $fdata{'fh_children_living'}; ?>
 425 , num.deceased:
 426 <?php echo $fdata{'fh_children_deceased'}; ?>
 427 , cause(s)/age(s):</td>
 428             <td nowrap class="fibody2"><?php echo $fdata{'fh_children_dec_cause'}; ?>&nbsp</td>
 429           </tr>
 430         </table></td>
 431       </tr>
 432       <tr>
 433         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 434           <tr valign="bottom">
 435             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 436             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 437             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 438             <td align="center" class="ficaption2">Physician's notes </td>
 439           </tr>
 440           <tr align="left" valign="bottom">
 441             <td nowrap class="fibody2" id="bordR">diabetes</td>
 442             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 443             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_diabetes_info'}; ?>&nbsp</td>
 444             <td class="fibody2"><?php echo $fdata{'fh_notes_1'}; ?>&nbsp</td>
 445           </tr>
 446           <tr align="left" valign="bottom">
 447             <td nowrap class="fibody2" id="bordR">Stroke</td>
 448             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 449             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_stroke_info'}; ?>&nbsp</td>
 450             <td class="fibody2"><?php echo $fdata{'fh_notes_2'}; ?>&nbsp</td>
 451           </tr>
 452           <tr align="left" valign="bottom">
 453             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 454             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_heart_disease'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 455             <td class="fibody2" id="bordR"> <?php echo $fdata{'fh_heart_disease_info'}; ?>&nbsp</td>
 456             <td class="fibody2"><?php echo $fdata{'fh_notes_3'}; ?>&nbsp</td>
 457           </tr>
 458           <tr align="left" valign="bottom">
 459             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 460             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fhbllod_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 461             <td class="fibody2" id="bordR"><?php echo $fdata{'fhbllod_clots_info'}; ?>&nbsp</td>
 462             <td class="fibody2"><?php echo $fdata{'fh_notes_4'}; ?>&nbsp</td>
 463           </tr>
 464           <tr align="left" valign="bottom">
 465             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 466             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 467             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_high_pressure_info'}; ?>&nbsp</td>
 468             <td class="fibody2"><?php echo $fdata{'fh_notes_5'}; ?>&nbsp</td>
 469           </tr>
 470           <tr align="left" valign="bottom">
 471             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 472             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_high_cholesterol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 473             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_high_cholesterol_info'}; ?>&nbsp</td>
 474             <td class="fibody2"><?php echo $fdata{'fh_notes_6'}; ?>&nbsp</td>
 475           </tr>
 476           <tr align="left" valign="bottom">
 477             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 478             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_osteoporosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 479             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_osteoporosis_info'}; ?>&nbsp</td>
 480             <td class="fibody2"><?php echo $fdata{'fh_notes_7'}; ?>&nbsp</td>
 481           </tr>
 482           <tr align="left" valign="bottom">
 483             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 484             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 485             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_hepatitis_info'}; ?>&nbsp</td>
 486             <td class="fibody2"><?php echo $fdata{'fh_notes_8'}; ?>&nbsp</td>
 487           </tr>
 488           <tr align="left" valign="bottom">
 489             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 490             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 491             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_hiv_info'}; ?>&nbsp</td>
 492             <td class="fibody2"><?php echo $fdata{'fh_notes_9'}; ?>&nbsp</td>
 493           </tr>
 494           <tr align="left" valign="bottom">
 495             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 496             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_tuberculosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 497             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_tuberculosis_info'}; ?>&nbsp</td>
 498             <td class="fibody2"><?php echo $fdata{'fh_notes_10'}; ?>&nbsp</td>
 499           </tr>
 500           <tr align="left" valign="bottom">
 501             <td nowrap class="fibody2" id="bordR">Birth defects </td>
 502             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'dh_birth_defects'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 503             <td class="fibody2" id="bordR"><?php echo $fdata{'dh_birth_defects_info'}; ?>&nbsp</td>
 504             <td class="fibody2"><?php echo $fdata{'fh_notes_11'}; ?>&nbsp</td>
 505           </tr>
 506           <tr align="left" valign="bottom">
 507             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
 508             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_alcohol_drugs'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 509             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_alcohol_drugs_info'}; ?>&nbsp</td>
 510             <td class="fibody2"><?php echo $fdata{'fh_notes_12'}; ?>&nbsp</td>
 511           </tr>
 512           <tr align="left" valign="bottom">
 513             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
 514             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_breast_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 515             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_breast_cancer_info'}; ?>&nbsp</td>
 516             <td class="fibody2"><?php echo $fdata{'fh_notes_13'}; ?>&nbsp</td>
 517           </tr>
 518           <tr align="left" valign="bottom">
 519             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
 520             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_colon_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 521             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_colon_cancer_info'}; ?>&nbsp</td>
 522             <td class="fibody2"><?php echo $fdata{'fh_notes_14'}; ?>&nbsp</td>
 523           </tr>
 524           <tr align="left" valign="bottom">
 525             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
 526             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_ovarian_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 527             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_ovarian_cancer'}; ?>&nbsp</td>
 528             <td class="fibody2"><?php echo $fdata{'fh_notes_15'}; ?>&nbsp</td>
 529           </tr>
 530           <tr align="left" valign="bottom">
 531             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
 532             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_uterine_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 533             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_uterine_cancer_info'}; ?>&nbsp</td>
 534             <td class="fibody2"><?php echo $fdata{'fh_notes_16'}; ?>&nbsp</td>
 535           </tr>
 536           <tr align="left" valign="bottom">
 537             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
 538             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_mental_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 539             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_mental_illness_info'}; ?>&nbsp</td>
 540             <td class="fibody2"><?php echo $fdata{'fh_notes_17'}; ?>&nbsp</td>
 541           </tr>
 542           <tr align="left" valign="bottom">
 543             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
 544             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_alzheimer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 545             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_alzheimer_info'}; ?>&nbsp</td>
 546             <td class="fibody2"><?php echo $fdata{'fh_notes_18'}; ?>&nbsp</td>
 547           </tr>
 548           <tr align="left" valign="bottom">
 549             <td nowrap class="fibody2" id="bordR">Other</td>
 550             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'fh_other_illness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 551             <td class="fibody2" id="bordR"><?php echo $fdata{'fh_other_illness_info'}; ?>&nbsp</td>
 552             <td class="fibody2"><?php echo $fdata{'fh_notes_19'}; ?>&nbsp</td>
 553           </tr>
 554         </table></td>
 555       </tr>
 556     </table>
 557   </div>
 558   <p align="center">&nbsp;</p>
 559   <h2 align="center"><a name="sh"></a>Social history <br>
 560   </h2>
 561   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
 562     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 563       <tr>
 564         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 565           <tr align="left" valign="bottom">
 566             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
 567             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 568             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 569             <td align="center" class="ficaption2">physician's notes                           </td>
 570           </tr>
 571           <tr align="left" valign="bottom">
 572             <td nowrap class="fibody2" id="bordR">Ever smoked? Current smoking: packs/day:
 573               <?php echo $fdata{'sh_smoked_packs'}; ?>
 574               , years:
 575               <?php echo $fdata{'sh_smoked_years'}; ?>&nbsp</td>
 576             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_smoked'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 577             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_smoked'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 578             <td class="fibody2"><?php echo $fdata{'sh_notes_1'}; ?>&nbsp</td>
 579           </tr>
 580           <tr align="left" valign="bottom">
 581             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
 582               <?php echo $fdata{'sh_alcohol_drinks_day'}; ?>
 583               ,
 584               drinks/week:
 585               <?php echo $fdata{'sh_alcohol_drinks_week'}; ?>
 586               ,
 587               type of drink:
 588               <?php echo $fdata{'sh_alcohol_drinks_type'}; ?>&nbsp</td>
 589             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_alcohol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 590             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_alcohol'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 591             <td class="fibody2"><?php echo $fdata{'sh_notes_2'}; ?>&nbsp</td>
 592           </tr>
 593           <tr align="left" valign="bottom">
 594             <td nowrap class="fibody2" id="bordR">Drug use </td>
 595             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_drug'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 596             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_drug'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 597             <td class="fibody2"><?php echo $fdata{'sh_notes_3'}; ?>&nbsp</td>
 598           </tr>
 599           <tr align="left" valign="bottom">
 600             <td nowrap class="fibody2" id="bordR">seat belt use </td>
 601             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_seat_belt'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 602             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_seat_belt'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 603             <td class="fibody2"><?php echo $fdata{'sh_notes_4'}; ?>&nbsp</td>
 604           </tr>
 605           <tr align="left" valign="bottom">
 606             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
 607               <?php echo $fdata{'sh_exercise_info'}; ?>&nbsp</td>
 608             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 609             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_exercise'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 610             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_5'}; ?>&nbsp</td>
 611           </tr>
 612           <tr align="left" valign="bottom">
 613             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
 614               <?php echo $fdata{'sh_dairy_daily'}; ?>&nbsp</td>
 615             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_dairy'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 616             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_dairy'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 617             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_6'}; ?>&nbsp</td>
 618           </tr>
 619           <tr align="left" valign="bottom">
 620             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
 621             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_hazards'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 622             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_hazards'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 623             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_7'}; ?>&nbsp</td>
 624           </tr>
 625           <tr align="left" valign="bottom">
 626             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
 627             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_abuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 628             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_abuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 629             <td width="400" class="fibody2"><?php echo $fdata{'sh_notes_8'}; ?>&nbsp</td>
 630           </tr>
 631           <tr align="left" valign="bottom">
 632             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
 633             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_living_will'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 634             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_living_will'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 635             <td class="fibody2"><?php echo $fdata{'sh_notes_9'}; ?>&nbsp</td>
 636           </tr>
 637           <tr align="left" valign="bottom">
 638             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
 639             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_donor'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 640             <td align="center" valign="middle" class="fibody2" id="bordR"><?php echo (($fdata{'pih_donor'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 641             <td class="fibody2"><?php echo $fdata{'sh_notes_10'}; ?>&nbsp</td>
 642           </tr>
 643         </table></td>
 644       </tr>
 645     </table>
 646   </div>
 647   <p align="center">&nbsp;</p>
 648   <h2 align="center"><a name="pp"></a>Personal profile <br>
 649   </h2>
 650   <div style="border: solid 1.5pt black; background-color: white;">
 651     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 652       <tr>
 653         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
 654           <?php echo (($fdata{'pih_pp_orientation'} == 'hetero')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 655         heterosexual
 656         <?php echo (($fdata{'pih_pp_orientation'} == 'homo')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 657         homosexual
 658         <?php echo (($fdata{'pih_pp_orientation'} == 'bi')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 659         bisexual </td>
 660       </tr>
 661       <tr>
 662         <td align="left" valign="bottom" class="fibody2">Marital status:
 663           <?php echo (($fdata{'pih_pp_status'} == 'married')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 664         married
 665         &nbsp;&nbsp;
 666         <?php echo (($fdata{'pih_pp_status'} == 'partner')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 667         living with partner&nbsp;&nbsp;        <?php echo (($fdata{'pih_pp_status'} == 'single')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 668         single
 669         &nbsp;&nbsp;
 670         <?php echo (($fdata{'pih_pp_status'} == 'widowed')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 671         widowed&nbsp;&nbsp;        <?php echo (($fdata{'pih_pp_status'} == 'divorced')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 672         divorced </td>
 673       </tr>
 674       <tr>
 675         <td align="left" valign="bottom" class="fibody2">Number of living children:
 676         <?php echo $fdata{'pp_living_children'}; ?>&nbsp</td>
 677       </tr>
 678       <tr>
 679         <td align="left" valign="bottom" class="fibody2">Number of people in household:
 680         <?php echo $fdata{'pp_number_household'}; ?>&nbsp</td>
 681       </tr>
 682       <tr>
 683         <td align="left" valign="bottom" class="fibody2">School completed:
 684           <?php echo (($fdata{'pih_pp_education'} == 'highschool')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 685         high school
 686         <?php echo (($fdata{'pih_pp_education'} == 'aadegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 687         some college/AA degree
 688         <?php echo (($fdata{'pih_pp_education'} == 'college')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 689         college
 690         <?php echo (($fdata{'pih_pp_education'} == 'gdegree')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 691         graduate degree
 692         <?php echo (($fdata{'pih_pp_education'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 693         other </td>
 694       </tr>
 695       <tr>
 696         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
 697         <?php echo $fdata{'pp_current_job'}; ?>&nbsp</td>
 698       </tr>
 699       <tr>
 700         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
 701           <?php echo (($fdata{'pp_travel_outside_us'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 702           yes
 703           <?php echo (($fdata{'pp_travel_outside_us'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 704           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
 705           <?php echo $fdata{'pp_travel_outside_locations'}; ?>
 706         </span></td>
 707       </tr>
 708     </table>
 709   </div>
 710   <p align="center">&nbsp;</p>
 711   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
 712   </h2>
 713   <div style="border: solid 1.5pt black; background-color: white; page-break-after: always;">
 714     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 715       <tr>
 716         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 717             <tr align="left" valign="bottom">
 718               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
 719               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
 720               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 721               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
 722               <td align="center" class="ficaption2">Physician's notes </td>
 723             </tr>
 724             <tr align="left" valign="bottom">
 725               <td nowrap class="fibody2" id="bordR">Asthma</td>
 726               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 727                   <?php echo $fdata{'pih_ih_asthma_date'}; ?>&nbsp</td>
 728               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 729               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_asthma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 730               <td class="fibody2"><?php echo $fdata{'ih_notes_1'}; ?>&nbsp</td>
 731             </tr>
 732             <tr align="left" valign="bottom">
 733               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
 734               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 735                   <?php echo $fdata{'pih_ih_pneumonia_date'}; ?>&nbsp</td>
 736               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 737               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_pneumonia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 738               <td class="fibody2"><?php echo $fdata{'ih_notes_2'}; ?>&nbsp</td>
 739             </tr>
 740             <tr align="left" valign="bottom">
 741               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
 742               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 743                   <?php echo $fdata{'pih_ih_kidney_date'}; ?>&nbsp</td>
 744               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 745               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_kidney'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 746               <td class="fibody2"><?php echo $fdata{'ih_notes_3'}; ?>&nbsp</td>
 747             </tr>
 748             <tr align="left" valign="bottom">
 749               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 750               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 751                   <?php echo $fdata{'pih_ih_tuber_date'}; ?>&nbsp</td>
 752               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 753               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_tuber'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 754               <td class="fibody2"><?php echo $fdata{'ih_notes_4'}; ?>&nbsp</td>
 755             </tr>
 756             <tr align="left" valign="bottom">
 757               <td nowrap class="fibody2" id="bordR">Fibroids</td>
 758               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 759                   <?php echo $fdata{'pih_ih_fibroids_date'}; ?>&nbsp</td>
 760               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 761               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_fibroids'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 762               <td class="fibody2"><?php echo $fdata{'ih_notes_5'}; ?>&nbsp</td>
 763             </tr>
 764             <tr align="left" valign="bottom">
 765               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
 766               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 767                   <?php echo $fdata{'pih_ih_sexually_date'}; ?>&nbsp</td>
 768               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 769               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_sexually'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 770               <td class="fibody2"><?php echo $fdata{'ih_notes_6'}; ?>&nbsp</td>
 771             </tr>
 772             <tr align="left" valign="bottom">
 773               <td nowrap class="fibody2" id="bordR">Infertility</td>
 774               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 775                   <?php echo $fdata{'pih_ih_infertil_date'}; ?>&nbsp</td>
 776               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 777               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_infertil'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 778               <td class="fibody2"><?php echo $fdata{'ih_notes_7'}; ?>&nbsp</td>
 779             </tr>
 780             <tr align="left" valign="bottom">
 781               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
 782               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 783                   <?php echo $fdata{'pih_ih_hiv_date'}; ?>&nbsp</td>
 784               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 785               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hiv'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 786               <td class="fibody2"><?php echo $fdata{'ih_notes_8'}; ?>&nbsp</td>
 787             </tr>
 788             <tr align="left" valign="bottom">
 789               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
 790               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 791                   <?php echo $fdata{'pih_ih_heart_date'}; ?>&nbsp</td>
 792               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 793               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_heart'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 794               <td class="fibody2"><?php echo $fdata{'ih_notes_9'}; ?>&nbsp</td>
 795             </tr>
 796             <tr align="left" valign="bottom">
 797               <td nowrap class="fibody2" id="bordR">Diabetes</td>
 798               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 799                   <?php echo $fdata{'pih_ih_diabetes_date'}; ?>&nbsp</td>
 800               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 801               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_diabetes'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 802               <td class="fibody2"><?php echo $fdata{'ih_notes_10'}; ?>&nbsp</td>
 803             </tr>
 804             <tr align="left" valign="bottom">
 805               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 806               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 807                   <?php echo $fdata{'pih_ih_high_pressure_date'}; ?>&nbsp</td>
 808               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 809               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_high_pressure'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 810               <td class="fibody2"><?php echo $fdata{'ih_notes_11'}; ?>&nbsp</td>
 811             </tr>
 812             <tr align="left" valign="bottom">
 813               <td nowrap class="fibody2" id="bordR">Stroke</td>
 814               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 815                   <?php echo $fdata{'pih_ih_stroke_date'}; ?>&nbsp</td>
 816               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 817               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_stroke'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 818               <td class="fibody2"><?php echo $fdata{'ih_notes_12'}; ?>&nbsp</td>
 819             </tr>
 820             <tr align="left" valign="bottom">
 821               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
 822               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 823                   <?php echo $fdata{'pih_ih_rheumatic_date'}; ?>&nbsp</td>
 824               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 825               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_rheumatic'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 826               <td class="fibody2"><?php echo $fdata{'ih_notes_13'}; ?>&nbsp</td>
 827             </tr>
 828             <tr align="left" valign="bottom">
 829               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 830               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 831                   <?php echo $fdata{'pih_ih_blood_clots_date'}; ?>&nbsp</td>
 832               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 833               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_clots'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 834               <td class="fibody2"><?php echo $fdata{'ih_notes_14'}; ?>&nbsp</td>
 835             </tr>
 836             <tr align="left" valign="bottom">
 837               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
 838               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 839                   <?php echo $fdata{'pih_ih_eating_disorder_date'}; ?>&nbsp</td>
 840               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 841               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_eating_disorder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 842               <td class="fibody2"><?php echo $fdata{'ih_notes_15'}; ?>&nbsp</td>
 843             </tr>
 844             <tr align="left" valign="bottom">
 845               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
 846               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 847                   <?php echo $fdata{'pih_ih_autoimmune_date'}; ?>&nbsp</td>
 848               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 849               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_autoimmune'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 850               <td class="fibody2"><?php echo $fdata{'ih_notes_16'}; ?>&nbsp</td>
 851             </tr>
 852             <tr align="left" valign="bottom">
 853               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
 854               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 855                   <?php echo $fdata{'pih_ih_chickenpox_date'}; ?>&nbsp</td>
 856               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 857               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_chickenpox'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 858               <td class="fibody2"><?php echo $fdata{'ih_notes_17'}; ?>&nbsp</td>
 859             </tr>
 860             <tr align="left" valign="bottom">
 861               <td nowrap class="fibody2" id="bordR">Cancer</td>
 862               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 863                   <?php echo $fdata{'pih_ih_cancer_date'}; ?>&nbsp</td>
 864               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 865               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cancer'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 866               <td class="fibody2"><?php echo $fdata{'ih_notes_18'}; ?>&nbsp</td>
 867             </tr>
 868             <tr align="left" valign="bottom">
 869               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
 870               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 871                   <?php echo $fdata{'pih_ih_reflux_date'}; ?>&nbsp</td>
 872               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 873               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_reflux'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 874               <td class="fibody2"><?php echo $fdata{'ih_notes_19'}; ?>&nbsp</td>
 875             </tr>
 876             <tr align="left" valign="bottom">
 877               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
 878               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 879                   <?php echo $fdata{'pih_ih_depression_date'}; ?>&nbsp</td>
 880               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 881               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_depression'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 882               <td class="fibody2"><?php echo $fdata{'ih_notes_20'}; ?>&nbsp</td>
 883             </tr>
 884             <tr align="left" valign="bottom">
 885               <td nowrap class="fibody2" id="bordR">Anemia</td>
 886               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 887                   <?php echo $fdata{'pih_ih_anemia_date'}; ?>&nbsp</td>
 888               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 889               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_anemia'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 890               <td class="fibody2"><?php echo $fdata{'ih_notes_21'}; ?>&nbsp</td>
 891             </tr>
 892             <tr align="left" valign="bottom">
 893               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
 894               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 895                   <?php echo $fdata{'pih_ih_blood_transf_date'}; ?>&nbsp</td>
 896               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 897               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_blood_transf'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 898               <td class="fibody2"><?php echo $fdata{'ih_notes_22'}; ?>&nbsp</td>
 899             </tr>
 900             <tr align="left" valign="bottom">
 901               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
 902               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 903                   <?php echo $fdata{'pih_ih_seizures_date'}; ?>&nbsp</td>
 904               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 905               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_seizures'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 906               <td class="fibody2"><?php echo $fdata{'ih_notes_23'}; ?>&nbsp</td>
 907             </tr>
 908             <tr align="left" valign="bottom">
 909               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
 910               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 911                   <?php echo $fdata{'pih_ih_bowel_problems_date'}; ?>&nbsp</td>
 912               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 913               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bowel_problems'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 914               <td class="fibody2"><?php echo $fdata{'ih_notes_24'}; ?>&nbsp</td>
 915             </tr>
 916             <tr align="left" valign="bottom">
 917               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
 918               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 919                   <?php echo $fdata{'pih_ih_glaucoma_date'}; ?>&nbsp</td>
 920               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 921               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_glaucoma'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 922               <td class="fibody2"><?php echo $fdata{'ih_notes_25'}; ?>&nbsp</td>
 923             </tr>
 924             <tr align="left" valign="bottom">
 925               <td nowrap class="fibody2" id="bordR">Cataracts</td>
 926               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 927                   <?php echo $fdata{'pih_ih_cataracts_date'}; ?>&nbsp</td>
 928               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 929               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_cataracts'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 930               <td class="fibody2"><?php echo $fdata{'ih_notes_26'}; ?>&nbsp</td>
 931             </tr>
 932             <tr align="left" valign="bottom">
 933               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
 934               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 935                   <?php echo $fdata{'pih_ih_joint_pain_date'}; ?>&nbsp</td>
 936               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 937               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_joint_pain'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 938               <td class="fibody2"><?php echo $fdata{'ih_notes_27'}; ?>&nbsp</td>
 939             </tr>
 940             <tr align="left" valign="bottom">
 941               <td nowrap class="fibody2" id="bordR">Broken bones </td>
 942               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 943                   <?php echo $fdata{'pih_ih_broken_bones_date'}; ?>&nbsp</td>
 944               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 945               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_broken_bones'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 946               <td class="fibody2"><?php echo $fdata{'ih_notes_28'}; ?>&nbsp</td>
 947             </tr>
 948             <tr align="left" valign="bottom">
 949               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
 950               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 951                   <?php echo $fdata{'pih_ih_hepatitis_date'}; ?>&nbsp</td>
 952               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 953               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_hepatitis'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 954               <td class="fibody2"><?php echo $fdata{'ih_notes_29'}; ?>&nbsp</td>
 955             </tr>
 956             <tr align="left" valign="bottom">
 957               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
 958               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 959                   <?php echo $fdata{'pih_ih_thyroid_date'}; ?>&nbsp</td>
 960               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 961               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_thyroid'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 962               <td class="fibody2"><?php echo $fdata{'ih_notes_30'}; ?>&nbsp</td>
 963             </tr>
 964             <tr align="left" valign="bottom">
 965               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
 966               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 967                   <?php echo $fdata{'pih_ih_galibladder_date'}; ?>&nbsp</td>
 968               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 969               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_galibladder'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 970               <td class="fibody2"><?php echo $fdata{'ih_notes_31'}; ?>&nbsp</td>
 971             </tr>
 972             <tr align="left" valign="bottom">
 973               <td nowrap class="fibody2" id="bordR">Headaches</td>
 974               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 975                   <?php echo $fdata{'pih_ih_headaches_date'}; ?>&nbsp</td>
 976               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 977               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_headaches'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 978               <td class="fibody2"><?php echo $fdata{'ih_notes_32'}; ?>&nbsp</td>
 979             </tr>
 980             <tr align="left" valign="bottom">
 981               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
 982               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 983                   <?php echo $fdata{'pih_ih_des_date'}; ?>&nbsp</td>
 984               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 985               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_des'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 986               <td class="fibody2"><?php echo $fdata{'ih_notes_33'}; ?>&nbsp</td>
 987             </tr>
 988             <tr align="left" valign="bottom">
 989               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
 990               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 991                   <?php echo $fdata{'pih_ih_bleeding_disorders_date'}; ?>&nbsp</td>
 992               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 993               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_bleeding_disorders'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
 994               <td class="fibody2"><?php echo $fdata{'ih_notes_34'}; ?>&nbsp</td>
 995             </tr>
 996             <tr align="left" valign="bottom">
 997               <td nowrap class="fibody2" id="bordR">other</td>
 998               <td class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 999                   <?php echo $fdata{'pih_ih_other_date'}; ?>&nbsp</td>
1000               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1001               <td align="center" class="fibody2" id="bordR"><?php echo (($fdata{'pih_ih_other'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp</td>
1002               <td class="fibody2"><?php echo $fdata{'ih_notes_35'}; ?>&nbsp</td>
1003             </tr>
1004             <tr align="left" valign="bottom">
1005               <td colspan="5" nowrap class="fibody3"><?php echo $fdata{'pih_ih_extended_info'}; ?>&nbsp</td>
1006             </tr>
1007         </table></td>
1008       </tr>
1009     </table>
1010   </div>
1011   <p align="center">&nbsp;</p>
1012   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
1013   </h2>
1014   <div style="border: solid 1.5pt black; background-color: white;">
1015     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1016       <tr>
1017         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
1018         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
1019         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
1020       </tr>
1021 <?
1022 $ii = 0;
1023 while ($ii<6){
1024 list ($op_reason, $op_date, $op_hospital)= explode('|~', $fdata["op_rec_".$ii] );
1025 print <<<EOL
1026       <tr>
1027         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_reason}&nbsp;</td>
1028         <td align="left" valign="bottom" class="fibody2" id="bordR">${op_date}&nbsp;</td>
1029         <td align="left" valign="bottom" class="fibody2">${op_hospital}&nbsp;</td>
1030       </tr>
1031 EOL;
1032 $ii++;
1033 }
1034 ?>
1035     </table>
1036   </div>
1037   <p align="center">&nbsp;</p>
1038   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
1039   </h2>
1040   <div style="border: solid 1.5pt black; background-color: white;">
1041     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1042       <tr valign="bottom">
1043         <td align="left" class="ficaption2" id="bordR">Type</td>
1044         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
1045         <td align="left" class="ficaption2" id="bordR">Type</td>
1046         <td width="90" align="center" nowrap class="ficaption2">date</td>
1047       </tr>
1048 <?
1049 $ii = 0;
1050 while ($ii<6){
1051 $ij = $ii+6;
1052 list ($ii_type, $ii_date)= explode('|~', $fdata["ii_rec_".$ii] );
1053 list ($ii_type1, $ii_date1)= explode('|~', $fdata["ii_rec_".$ij] );
1054
1055 print <<<EOL
1056    <tr valign="bottom">
1057      <td align="left" class="fibody2" id="bordR">${ii_type}&nbsp;</td>
1058      <td align="left" nowrap class="fibody2" id="bordR">${ii_date}&nbsp;</td>
1059      <td align="left" class="fibody2" id="bordR">${ii_type1}&nbsp;</td>
1060      <td align="left" nowrap class="fibody2">${ii_date1}&nbsp;</td>
1061    </tr>
1062 EOL;
1063 $ii++;
1064 }
1065 ?>
1066     </table>
1067   </div>
1068   <p align="center">&nbsp;</p>
1069   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
1070   </h2>
1071   <div style="border: solid 1.5pt black; background-color: white;">
1072     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1073       <tr valign="bottom">
1074         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
1075         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
1076         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
1077         <td width="90" align="center" class="ficaption2">date</td>
1078       </tr>
1079       <tr valign="bottom">
1080         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
1081         <td align="left" nowrap class="fibody2" id="bordR">
1082           <?php echo $fdata{'imm_tetanus'}; ?>&nbsp;</td>
1083         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
1084         <td align="left" valign="bottom" nowrap class="fibody2">
1085           <?php echo $fdata{'imm_influenza'}; ?>&nbsp;</td>
1086       </tr>
1087       <tr valign="bottom">
1088         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
1089         <td align="left" nowrap class="fibody2" id="bordR">
1090           <?php echo $fdata{'imm_hepatitis_a'}; ?>&nbsp;</td>
1091         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
1092         <td align="left" valign="bottom" nowrap class="fibody2">
1093           <?php echo $fdata{'imm_hepatitis_b'}; ?>&nbsp;</td>
1094       </tr>
1095       <tr valign="bottom">
1096         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
1097         <td align="left" nowrap class="fibody2" id="bordR">
1098           <?php echo $fdata{'imm_varicella'}; ?>&nbsp;</td>
1099         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
1100         <td align="left" valign="bottom" nowrap class="fibody2">
1101           <?php echo $fdata{'imm_pneumococcal'}; ?>&nbsp;</td>
1102       </tr>
1103       <tr valign="bottom">
1104         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
1105         <td align="left" nowrap class="fibody2" id="bordR">
1106           <?php echo $fdata{'imm_mmr'}; ?>&nbsp;</td>
1107         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
1108         <?php echo $fdata{'imm_tuberculosis_skin'}; ?>&nbsp;
1109         , result:
1110         <?php echo $fdata{'imm_tuberculosis_result'}; ?>&nbsp</td>
1111         <td align="left" valign="bottom" nowrap class="fibody2">
1112           <?php echo $fdata{'imm_tuberculosis'}; ?>&nbsp;</td>
1113       </tr>
1114     </table>
1115   </div>
1116   <p align="center">&nbsp;</p>
1117   <div style="border: solid 1.5pt black; background-color: white;">
1118     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1119       <tr>
1120         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
1121         <?php echo $fdata{'imm_extended_info'}; ?>&nbsp</td>
1122       </tr>
1123     </table>
1124   </div>
1125   <p align="center">&nbsp;</p>
1126   <h2 align="center"><a ></a>Review of systems<br>
1127     <small>Please check (x), if any of the following symptoms
1128 apply to you now or since adulthood</small> </h2>
1129   <div style="border: solid 2px black; background-color: white;">
1130     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1131       <tr>
1132         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
1133         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
1134         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
1135         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
1136         <td align="center" valign="top" class="ficaption2">physician's notes </td>
1137       </tr>
1138       <tr valign="bottom">
1139         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
1140         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1141         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1142         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1143         <td align="left" class="fibody2">&nbsp;</td>
1144       </tr>
1145       <tr valign="bottom">
1146         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
1147         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1148         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1149         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1150         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_1'}; ?></td>
1151       </tr>
1152       <tr valign="bottom">
1153         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
1154         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1155         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1156         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_weight_gain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1157         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_2'}; ?></td>
1158       </tr>
1159       <tr valign="bottom">
1160         <td align="left" class="fibody4"  id="bordR" >Fever</td>
1161         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1162         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1163         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fever_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1164         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_3'}; ?></td>
1165       </tr>
1166       <tr valign="bottom">
1167         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
1168         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1169         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1170         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_fatigue_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1171         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_4'}; ?></td>
1172       </tr>
1173       <tr valign="bottom">
1174         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
1175         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1176         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1177         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_height_change_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1178         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_5'}; ?></td>
1179       </tr>
1180       <tr valign="bottom">
1181         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
1182         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1183         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1184         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1185         <td align="left" class="fibody2">&nbsp;</td>
1186       </tr>
1187       <tr valign="bottom">
1188         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
1189         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1190         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1191         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dvision_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1192         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_6'}; ?></td>
1193       </tr>
1194       <tr valign="bottom">
1195         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
1196         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1197         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1198         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spots_eyes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1199         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_7'}; ?></td>
1200       </tr>
1201       <tr valign="bottom">
1202         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
1203         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1204         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1205         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vis_changes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1206         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_8'}; ?></td>
1207       </tr>
1208       <tr valign="bottom">
1209         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
1210         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1211         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1212         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_glasses_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1213         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_9'}; ?></td>
1214       </tr>
1215       <tr valign="bottom">
1216         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
1217         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1218         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1219         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1220         <td align="left" class="fibody2">&nbsp;</td>
1221       </tr>
1222       <tr valign="bottom">
1223         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
1224         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1225         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1226         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_earaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1227         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_10'}; ?></td>
1228       </tr>
1229       <tr valign="bottom">
1230         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
1231         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1232         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1233         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_ringing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1234         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_11'}; ?></td>
1235       </tr>
1236       <tr valign="bottom">
1237         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
1238         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1239         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1240         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hearing_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1241         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_12'}; ?></td>
1242       </tr>
1243       <tr valign="bottom">
1244         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
1245         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1246         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1247         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sinus_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1248         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_13'}; ?></td>
1249       </tr>
1250       <tr valign="bottom">
1251         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
1252         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1253         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1254         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sore_throat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1255         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_14'}; ?></td>
1256       </tr>
1257       <tr valign="bottom">
1258         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
1259         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1260         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1261         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_mouth_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1262         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_15'}; ?></td>
1263       </tr>
1264       <tr valign="bottom">
1265         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
1266         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1267         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1268         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dental_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1269         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_16'}; ?></td>
1270       </tr>
1271       <tr valign="bottom">
1272         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
1273         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1274         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1275         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1276         <td align="left" class="fibody2">&nbsp;</td>
1277       </tr>
1278       <tr valign="bottom">
1279         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
1280         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1281         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1282         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chest_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1283         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_17'}; ?></td>
1284       </tr>
1285       <tr valign="bottom">
1286         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
1287         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1288         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1289         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_difficulty_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1290         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_18'}; ?></td>
1291       </tr>
1292       <tr valign="bottom">
1293         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
1294         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1295         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1296         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_swelling_legs_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1297         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_19'}; ?></td>
1298       </tr>
1299       <tr valign="bottom">
1300         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
1301         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1302         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1303         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rapid_heartbeat_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1304         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_20'}; ?></td>
1305       </tr>
1306       <tr valign="bottom">
1307         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
1308         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1309         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1310         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1311         <td align="left" class="fibody2">&nbsp;</td>
1312       </tr>
1313       <tr valign="bottom">
1314         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
1315         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1316         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1317         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_breathing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1318         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_21'}; ?></td>
1319       </tr>
1320       <tr valign="bottom">
1321         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
1322         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1323         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1324         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_wheezing_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1325         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_22'}; ?></td>
1326       </tr>
1327       <tr valign="bottom">
1328         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
1329         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1330         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1331         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_spitting_blood_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1332         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_23'}; ?></td>
1333       </tr>
1334       <tr valign="bottom">
1335         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
1336         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1337         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1338         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_breath_shortness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1339         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_24'}; ?></td>
1340       </tr>
1341       <tr valign="bottom">
1342         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
1343         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1344         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1345         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_chronic_cough_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1346         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_25'}; ?></td>
1347       </tr>
1348       <tr valign="bottom">
1349         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
1350         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1351         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1352         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1353         <td align="left" class="fibody2">&nbsp;</td>
1354       </tr>
1355       <tr valign="bottom">
1356         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
1357         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1358         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1359         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_diarrhea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1360         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_26'}; ?></td>
1361       </tr>
1362       <tr valign="bottom">
1363         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
1364         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1365         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1366         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_bloody_stool_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1367         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_27'}; ?></td>
1368       </tr>
1369       <tr valign="bottom">
1370         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
1371         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1372         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1373         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nausea_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1374         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_28'}; ?></td>
1375       </tr>
1376       <tr valign="bottom">
1377         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
1378         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1379         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1380         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_constipation_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1381         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_29'}; ?></td>
1382       </tr>
1383       <tr valign="bottom">
1384         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
1385         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1386         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1387         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_gas_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1388         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_30'}; ?></td>
1389       </tr>
1390       <tr valign="bottom">
1391         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
1392         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1393         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1394         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1395         <td align="left" class="fibody2">&nbsp;</td>
1396       </tr>
1397       <tr valign="bottom">
1398         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
1399         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1400         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1401         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_blood_urine_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1402         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_31'}; ?></td>
1403       </tr>
1404       <tr valign="bottom">
1405         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
1406         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1407         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1408         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1409         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_32'}; ?></td>
1410       </tr>
1411       <tr valign="bottom">
1412         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
1413         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1414         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1415         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_urgency_urinate_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1416         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_33'}; ?></td>
1417       </tr>
1418       <tr valign="bottom">
1419         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
1420         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1421         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1422         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_urination_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1423         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_34'}; ?></td>
1424       </tr>
1425       <tr valign="bottom">
1426         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
1427         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1428         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1429         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_incomplete_emptying_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1430         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_35'}; ?></td>
1431       </tr>
1432       <tr valign="bottom">
1433         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
1434         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1435         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1436         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_unint_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1437         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_36'}; ?></td>
1438       </tr>
1439       <tr valign="bottom">
1440         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
1441         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1442         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1443         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lifting_urine_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1444         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_37'}; ?></td>
1445       </tr>
1446       <tr valign="bottom">
1447         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
1448         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1449         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1450         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1451         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_38'}; ?></td>
1452       </tr>
1453       <tr valign="bottom">
1454         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
1455         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1456         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1457         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_periods_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1458         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_39'}; ?></td>
1459       </tr>
1460       <tr valign="bottom">
1461         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
1462         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1463         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1464         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pms_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1465         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_40'}; ?></td>
1466       </tr>
1467       <tr valign="bottom">
1468         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
1469         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1470         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1471         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_painful_intercourse_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1472         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_41'}; ?></td>
1473       </tr>
1474       <tr valign="bottom">
1475         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
1476         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1477         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1478         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_vaginal_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1479         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_42'}; ?></td>
1480       </tr>
1481       <tr valign="bottom">
1482         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
1483         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1484         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1485         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1486         <td align="left" class="fibody2">&nbsp;</td>
1487       </tr>
1488       <tr valign="bottom">
1489         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
1490         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1491         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1492         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_weakness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1493         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_43'}; ?></td>
1494       </tr>
1495       <tr valign="bottom">
1496         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
1497         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1498         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1499         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_muscle_pain_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1500         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_44'}; ?></td>
1501       </tr>
1502       <tr valign="bottom">
1503         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
1504         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1505         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1506         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1507         <td align="left" class="fibody2">&nbsp;</td>
1508       </tr>
1509       <tr valign="bottom">
1510         <td align="left" class="fibody4"  id="bordR" >Rash</td>
1511         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1512         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1513         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_rash_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1514         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_45'}; ?></td>
1515       </tr>
1516       <tr valign="bottom">
1517         <td align="left" class="fibody4"  id="bordR" >Sores</td>
1518         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1519         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1520         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_sores_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1521         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_46'}; ?></td>
1522       </tr>
1523       <tr valign="bottom">
1524         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
1525         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1526         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1527         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dry_skin_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1528         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_47'}; ?></td>
1529       </tr>
1530       <tr valign="bottom">
1531         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
1532         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1533         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1534         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_moles_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1535         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_48'}; ?></td>
1536       </tr>
1537       <tr valign="bottom">
1538         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
1539         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1540         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1541         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1542         <td align="left" class="fibody2">&nbsp;</td>
1543       </tr>
1544       <tr valign="bottom">
1545         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
1546         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1547         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1548         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_pain_breast_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1549         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_49'}; ?></td>
1550       </tr>
1551       <tr valign="bottom">
1552         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
1553         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1554         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1555         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_nipple_discharge_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1556         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_50'}; ?></td>
1557       </tr>
1558       <tr valign="bottom">
1559         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
1560         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1561         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1562         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_lumps_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1563         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_51'}; ?></td>
1564       </tr>
1565       <tr valign="bottom">
1566         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
1567         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1568         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1569         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1570         <td align="left" class="fibody2">&nbsp;</td>
1571       </tr>
1572       <tr valign="bottom">
1573         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
1574         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1575         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1576         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_dizziness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1577         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_52'}; ?></td>
1578       </tr>
1579       <tr valign="bottom">
1580         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
1581         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1582         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1583         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_seizures_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1584         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_53'}; ?></td>
1585       </tr>
1586       <tr valign="bottom">
1587         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
1588         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1589         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1590         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_numbness_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1591         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_54'}; ?></td>
1592       </tr>
1593       <tr valign="bottom">
1594         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
1595         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1596         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1597         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_trouble_walking_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1598         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_55'}; ?></td>
1599       </tr>
1600       <tr valign="bottom">
1601         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
1602         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1603         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1604         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_memory_problems_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1605         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_56'}; ?></td>
1606       </tr>
1607       <tr valign="bottom">
1608         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
1609         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1610         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1611         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_freq_headaches_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1612         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_57'}; ?></td>
1613       </tr>
1614       <tr valign="bottom">
1615         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
1616         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1617         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1618         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1619         <td align="left" class="fibody2">&nbsp;</td>
1620       </tr>
1621       <tr valign="bottom">
1622         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
1623         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1624         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1625         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_depression_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1626         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_58'}; ?></td>
1627       </tr>
1628       <tr valign="bottom">
1629         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
1630         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1631         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1632         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_anxiety_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1633         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_59'}; ?></td>
1634       </tr>
1635       <tr valign="bottom">
1636         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
1637         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1638         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1639         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1640         <td align="left" class="fibody2">&nbsp;</td>
1641       </tr>
1642       <tr valign="bottom">
1643         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
1644         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1645         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1646         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hair_loss_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1647         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_60'}; ?></td>
1648       </tr>
1649       <tr valign="bottom">
1650         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
1651         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1652         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1653         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_heat_cold_intolerance_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1654         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_61'}; ?></td>
1655       </tr>
1656       <tr valign="bottom">
1657         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
1658         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1659         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1660         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_abnormal_thirst_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1661         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_62'}; ?></td>
1662       </tr>
1663       <tr valign="bottom">
1664         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
1665         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1666         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1667         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_hot_flashes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1668         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_63'}; ?></td>
1669       </tr>
1670       <tr valign="bottom">
1671         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
1672         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1673         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1674         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1675         <td align="left" class="fibody2">&nbsp;</td>
1676       </tr>
1677       <tr valign="bottom">
1678         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
1679         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1680         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1681         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_frequent_bruises_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1682         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_64'}; ?></td>
1683       </tr>
1684       <tr valign="bottom">
1685         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
1686         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1687         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1688         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_cuts_bleeding_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1689         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_65'}; ?></td>
1690       </tr>
1691       <tr valign="bottom">
1692         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
1693         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1694         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1695         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_enlarged_nodes_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1696         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_66'}; ?></td>
1697       </tr>
1698       <tr valign="bottom">
1699         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
1700         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1701         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1702         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1703         <td align="left" class="fibody2">&nbsp;</td>
1704       </tr>
1705       <tr valign="bottom">
1706         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
1707         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1708         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1709         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_med_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1710         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_68'}; ?></td>
1711       </tr>
1712       <tr valign="bottom">
1713         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
1714         <td colspan="4" align="left" class="fibody2"><?php echo $fros{'ros_med_allergy_reaction'}; ?></td>
1715       </tr>
1716       <tr valign="bottom">
1717         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
1718         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1719         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1720         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_latex_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1721         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_69'}; ?></td>
1722       </tr>
1723       <tr valign="bottom">
1724         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
1725         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1726         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '2')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1727         <td align="center" class="fibody2"  id="bordR" ><?php echo (($fros{'ros_other_allergy_now'} == '3')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
1728         <td align="left" class="fibody2"><?php echo $fros{'ros_notes_70'}; ?></td>
1729       </tr>
1730       <tr valign="bottom">
1731         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
1732         <td colspan="4" align="left" class="fibody2"><?php echo $fros{'ros_other_allergy_reaction_'}; ?></td>
1733       </tr>
1734     </table>
1735   </div>
1736   <p align="center">&nbsp;</p>
1737   <div style="border: solid 2px black; background-color: white;">
1738     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1739       <tr valign="bottom">
1740         <td colspan="2" align="left" class="fibody2">Form completed by
1741           <?php echo (($fdata{'pih_completed_by'} == 'patient')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1742         patient
1743         <?php echo (($fdata{'pih_completed_by'} == 'nurse')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1744         office nurse
1745         <?php echo (($fdata{'pih_completed_by'} == 'physician')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1746         physician
1747         <?php echo (($fdata{'pih_completed_by'} == 'other')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
1748         other:
1749         <?php echo $fdata{'pih_completed_by_other'}; ?>&nbsp</td>
1750       </tr>
1751       <tr valign="bottom">
1752         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
1753       </tr>
1754       <tr valign="bottom">
1755         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
1756         <?php echo $fdata{'pih_date_reviewed_1'}; ?>&nbsp</td>
1757         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
1758       </tr>
1759       <tr valign="bottom">
1760         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
1761       </tr>
1762       <tr valign="bottom">
1763         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1764           <?php echo $fdata{'pih_date_reviewed_2'}; ?>
1765         </span></td>
1766         <td height="46" align="left" class="fibody2">Physician signature: </td>
1767       </tr>
1768       <tr valign="bottom">
1769         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1770           <?php echo $fdata{'pih_date_reviewed_3'}; ?>
1771         </span> </td>
1772         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1773       </tr>
1774       <tr valign="bottom">
1775         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1776           <?php echo $fdata{'pih_date_reviewed_4'}; ?>
1777         </span> </td>
1778         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1779       </tr>
1780       <tr valign="bottom">
1781         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1782           <?php echo $fdata{'pih_date_reviewed_5'}; ?>
1783         </span> </td>
1784         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1785       </tr>
1786       <tr valign="bottom">
1787         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1788           <?php echo $fdata{'pih_date_reviewed_6'}; ?>
1789         </span> </td>
1790         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1791       </tr>
1792     </table>
1793   </div>
1794   <p align="center">&nbsp;</p>
1795 <?php } ?>