3 #######################################################
5 # Progress Notes Form created by Kam Sharifi #
9 #######################################################
11 include_once("../../globals.php");
13 include_once("$srcdir/api.inc");
15 formHeader("Form: progressnotes");
20 <?php
html_header_show();?
>
22 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
26 <body
class="body_top">
28 <form method
=post action
="<?php echo $rootdir;?>/forms/progressnotes/save.php?mode=new" name
="my_form">
30 <span
class="title">Progress Notes
</span
><br
><br
>
38 <span
class=text
>P
: </span
><input size
=3 type
=entry name
="prog_p" value
="" >
40 <span
class=text
>R
: </span
><input size
=3 type
=entry name
="prog_r" value
="" >
42 <span
class=text
>BP
: </span
><input size
=3 type
=entry name
="prog_bp" value
="" >
44 <span
class=text
>HT
: </span
><input size
=3 type
=entry name
="prog_ht" value
="" >
46 <span
class=text
>WT
: </span
><input size
=3 type
=entry name
="prog_wt" value
="" >
48 <span
class=text
>TEMP
: </span
><input size
=3 type
=entry name
="prog_temp" value
="" >
50 <span
class=text
>LMP
: </span
><input size
=3 type
=entry name
="prog_lmp" value
="" >
52 <br
><span
class=text
>Last Pap Smear
: </span
><input size
=3 type
=entry name
="prog_last_pap_smear" value
="" >
54 <span
class=text
>Last Td
. Booster
: </span
><input size
=3 type
=entry name
="prog_last_td_booster" value
="" >
56 <span
class=text
>Allergies
: </span
><input size
=3 type
=entry name
="prog_allergies" value
="" >
58 <span
class=text
>Last Mammogram
: </span
><input size
=3 type
=entry name
="prog_last_mammogram" value
="" >
68 <span
class=text
><b
>Present Complaint
*:</b
> </span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="prog_present_complaint" ></textarea
>
74 <b
>Past Medical History
</b
>
78 <TABLE ID
="Table1" BORDER
=1 CELLSPACING
=2 CELLPADDING
=1 WIDTH
="100%" >
84 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
90 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>ABN
</B
></FONT
><B
></B
></P
>
96 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>NE
</B
></FONT
><B
></B
></P
>
102 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>PHYSICAL EXAMINATION
-Comments
</B
></FONT
><B
></B
></P
>
112 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
118 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
120 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
124 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox2" TYPE
=CHECKBOX NAME
="prog_skin_abn" VALUE
=""></TD
>
130 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
134 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
136 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
140 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox8" TYPE
=CHECKBOX NAME
="prog_skin_ne" VALUE
=""></TD
>
146 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
150 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>SKIN
: no significant lesions
</B
></FONT
><B
></B
></P
>
160 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
166 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
168 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
172 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox7" TYPE
=CHECKBOX NAME
="prog_head_abn" VALUE
=""></TD
>
178 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
182 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
184 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
188 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox9" TYPE
=CHECKBOX NAME
="prog_head_ne" VALUE
=""></TD
>
194 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
198 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>HEAD
: normocephalic
. no headache
</B
></FONT
><B
></B
></P
>
208 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
214 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
216 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
220 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox10" TYPE
=CHECKBOX NAME
="prog_eyes_abn" VALUE
=""></TD
>
226 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
230 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
232 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
236 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox11" TYPE
=CHECKBOX NAME
="prog_eyes_ne" VALUE
=""></TD
>
242 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
246 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>EYES
: perla
. eom satisfactory
</B
></FONT
><B
></B
></P
>
256 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
262 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
264 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
268 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox12" TYPE
=CHECKBOX NAME
="prog_ears_abn" VALUE
=""></TD
>
274 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
278 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
280 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
284 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox13" TYPE
=CHECKBOX NAME
="prog_ears_ne" VALUE
=""></TD
>
290 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
294 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>EARS
: drums intact
</B
></FONT
><B
></B
></P
>
304 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
310 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
312 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
316 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox14" TYPE
=CHECKBOX NAME
="prog_nose_abn" VALUE
=""></TD
>
322 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
326 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
328 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
332 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox16" TYPE
=CHECKBOX NAME
="prog_nose_ne" VALUE
=""></TD
>
338 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
342 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>NOSE
: no abnormality
</B
></FONT
><B
></B
></P
>
352 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
358 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
360 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
364 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox17" TYPE
=CHECKBOX NAME
="prog_throat_abn" VALUE
=""></TD
>
370 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
374 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
376 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
380 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox15" TYPE
=CHECKBOX NAME
="prog_throat_ne" VALUE
=""></TD
>
386 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
390 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>THROAT
: dear
, no infection
</B
></FONT
><B
></B
></P
>
400 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
406 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
408 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
412 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox19" TYPE
=CHECKBOX NAME
="prog_teeth_abn" VALUE
=""></TD
>
418 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
422 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
424 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
428 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox20" TYPE
=CHECKBOX NAME
="prog_teeth_ne" VALUE
=""></TD
>
434 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
438 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>TEETH
: good repair
, no dentures
</B
></FONT
><B
></B
></P
>
448 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
454 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
456 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
460 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox18" TYPE
=CHECKBOX NAME
="prog_neck_abn" VALUE
=""></TD
>
466 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
470 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
472 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
476 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox21" TYPE
=CHECKBOX NAME
="prog_neck_ne" VALUE
=""></TD
>
482 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
486 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>NECK
: supple
, no adenopathy
</B
></FONT
><B
></B
></P
>
496 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
502 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
504 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
508 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox22" TYPE
=CHECKBOX NAME
="prog_chest_abn" VALUE
=""></TD
>
514 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
518 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
520 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
524 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox23" TYPE
=CHECKBOX NAME
="prog_chest_ne" VALUE
=""></TD
>
530 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
534 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>CHEST
: symmetrical
, no pain
</B
></FONT
><B
></B
></P
>
544 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
550 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
552 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
556 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox24" TYPE
=CHECKBOX NAME
="prog_breast_abn" VALUE
=""></TD
>
562 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
566 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
568 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
572 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox25" TYPE
=CHECKBOX NAME
="prog_breast_ne" VALUE
=""></TD
>
578 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
582 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>BREAST
: no masses
</B
></FONT
><B
></B
></P
>
592 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
598 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
600 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
604 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox26" TYPE
=CHECKBOX NAME
="prog_lungs_abn" VALUE
=""></TD
>
610 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
614 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
616 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
620 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox27" TYPE
=CHECKBOX NAME
="prog_lungs_ne" VALUE
=""></TD
>
626 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
630 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>LUNGS
: dear to P
&
;a
. no mono
, no rales
</B
></FONT
><B
></B
></P
>
640 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
646 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
648 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
652 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox28" TYPE
=CHECKBOX NAME
="prog_heart_abn" VALUE
=""></TD
>
658 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
662 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
664 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
668 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox29" TYPE
=CHECKBOX NAME
="prog_heart_ne" VALUE
=""></TD
>
674 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
678 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>HEART
: rsr
. no cardiomegaly
</B
></FONT
><B
></B
></P
>
688 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
694 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
696 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
700 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox30" TYPE
=CHECKBOX NAME
="prog_abdomen_abn" VALUE
=""></TD
>
706 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
710 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
712 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
716 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox31" TYPE
=CHECKBOX NAME
="prog_abdomen_ne" VALUE
=""></TD
>
722 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
726 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>ABDOMEN
: non
-tender
, soft
, no masses
</B
></FONT
><B
></B
></P
>
736 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
742 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
744 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
748 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox32" TYPE
=CHECKBOX NAME
="prog_spine_abn" VALUE
=""></TD
>
754 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
758 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
760 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
764 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox33" TYPE
=CHECKBOX NAME
="prog_spine_ne" VALUE
=""></TD
>
770 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
774 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>SPINE
: no abnormalities
</B
></FONT
><B
></B
></P
>
784 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
790 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
792 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
796 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox34" TYPE
=CHECKBOX NAME
="prog_extremeities_abn" VALUE
=""></TD
>
802 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
806 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
808 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
812 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox35" TYPE
=CHECKBOX NAME
="prog_extremeities_ne" VALUE
=""></TD
>
818 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
822 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>EXTREMEITIES
: no abnormalities
</B
></FONT
><B
></B
></P
>
832 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
838 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
840 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
844 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox36" TYPE
=CHECKBOX NAME
="prog_lowback_abn" VALUE
=""></TD
>
850 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
854 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
856 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
860 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox37" TYPE
=CHECKBOX NAME
="prog_lowback_ne" VALUE
=""></TD
>
866 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
870 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>LOW BACK
: rom normal
</B
></FONT
><B
></B
></P
>
880 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
886 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
888 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
892 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox38" TYPE
=CHECKBOX NAME
="prog_neuro_abn" VALUE
=""></TD
>
898 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
902 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
904 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
908 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox39" TYPE
=CHECKBOX NAME
="prog_neuro_ne" VALUE
=""></TD
>
914 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
918 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>NEURO
: d(r
>
;>
;2>
;>
;. no abnormal findings
</B
></FONT
><B
></B
></P
>
928 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
934 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
936 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
940 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox40" TYPE
=CHECKBOX NAME
="prog_rectal_abn" VALUE
=""></TD
>
946 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
950 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
952 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
956 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox41" TYPE
=CHECKBOX NAME
="prog_rectal_ne" VALUE
=""></TD
>
962 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
966 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>RECTAL
: no abnormalities
</B
></FONT
><B
></B
></P
>
976 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"> 
;</FONT
></P
>
982 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
984 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
988 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox42" TYPE
=CHECKBOX NAME
="prog_pelvic_abn" VALUE
=""></TD
>
994 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
998 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
>
1000 <TABLE WIDTH
="100%" BORDER
=0 CELLSPACING
=0 CELLPADDING
=0 NOF
=TE
>
1004 <TD ALIGN
="CENTER"><INPUT ID
="Forms Checkbox43" TYPE
=CHECKBOX NAME
="prog_pelvic_ne" VALUE
=""></TD
>
1010 <FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"></FONT
></TD
>
1014 <P
><FONT FACE
="Arial,Helvetica,Geneva,Sans-serif,sans-serif"><B
>PELVIC
:</B
></FONT
><B
></B
></P
>
1030 <span
class=text
><b
>HEALTH EDUCATION PROVIDED
<br
>ASSESSMENT
:</b
></span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="prog_assessment" ></textarea
>
1038 <span
class=text
><b
>Plan
:</b
></span
><br
><textarea cols
=40 rows
=8 wrap
=virtual name
="prog_plan" ></textarea
>
1044 <td
><input size
=3 type
=entry name
="prog_breast_se" value
="" > 
;<span
class=text
><b
>Breast Self Examination
</span
></td
><br
></b
>
1046 <td
><input size
=3 type
=entry name
="prog_dental_h" value
="" > 
;<span
class=text
><b
>Dental Health
</span
></td
><br
></b
>
1048 <td
><input size
=3 type
=entry name
="prog_diagnosis" value
="" > 
;<span
class=text
><b
>Diagnosis
/Prognosis
</span
></td
><br
></b
>
1050 <td
><input size
=3 type
:entry name
="prog_injur_p" value
="" > 
;<span
class=text
><b
>Injury Prevention
</span
></td
><br
></b
>
1052 <td
><input size
=3 type
=entry name
="prog_new_treat" value
="" > 
;<span
class=text
><b
>New Treatment
/Medication
</span
></td
><br
></b
>
1054 <td
><input size
=3 type
=entry name
="prog_nutrition_e" value
="" > 
;<span
class=text
><b
>Nutrition
/Exercise
</span
></td
><br
></b
>
1056 <td
><input size
=3 type
=entry name
="prog_sexual_p" value
="" > 
;<span
class=text
><b
>Sexual Practice
</span
></td
><br
></b
>
1058 <td
><input size
=3 type
=entry name
="prog_substance_a" value
="" > 
;<span
class=text
><b
>Substance Abuse
</span
></td
><br
></b
>
1066 <a href
="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save
]</a
>
1068  
; 
; 
; 
; 
; 
; 
; 
; 
; 
; 
;
1070 <a href
="<?php echo $GLOBALS['form_exit_url']; ?>" class="link"
1072 onclick
="top.restoreSession()">[Don
't Save]</a>