1 <!-- Form generated from formsWiz
-->
3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: reviewofs");
8 <?php
html_header_show();?
>
9 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
11 <body
class="body_top">
12 <form method
=post action
="<?php echo $rootdir;?>/forms/reviewofs/save.php?mode=new" name
="my_form">
13 <span
class="title">Review of Systems Checks
</span
><br
><br
>
15 <table
><tr
><td valign
=top
>
17 <span
class=bold
>General
</span
><br
>
18 <input type
=checkbox name
='fever' ><span
class=text
>Fever
</span
><br
>
19 <input type
=checkbox name
='chills' ><span
class=text
>Chills
</span
><br
>
20 <input type
=checkbox name
='night_sweats' ><span
class=text
>Night Sweats
</span
><br
>
21 <input type
=checkbox name
='weight_loss' ><span
class=text
>Weight Loss
</span
><br
>
22 <input type
=checkbox name
='poor_appetite' ><span
class=text
>Poor Appetite
</span
><br
>
23 <input type
=checkbox name
='insomnia' ><span
class=text
>Insomnia
</span
><br
>
24 <input type
=checkbox name
='fatigued' ><span
class=text
>Fatigued
</span
><br
>
25 <input type
=checkbox name
='depressed' ><span
class=text
>Depressed
</span
><br
>
26 <input type
=checkbox name
='hyperactive' ><span
class=text
>Hyperactive
</span
><br
>
27 <input type
=checkbox name
='exposure_to_foreign_countries' ><span
class=text
>Exposure to Foreign Countries
</span
><br
>
28 <span
class=bold
>Skin
</span
><br
>
29 <input type
=checkbox name
='rashes' ><span
class=text
>Rashes
</span
><br
>
30 <input type
=checkbox name
='infections' ><span
class=text
>Infections
</span
><br
>
31 <input type
=checkbox name
='ulcerations' ><span
class=text
>Ulcerations
</span
><br
>
32 <input type
=checkbox name
='pemphigus' ><span
class=text
>Pemphigus
</span
><br
>
33 <input type
=checkbox name
='herpes' ><span
class=text
>Herpes
</span
><br
>
37 <span
class=bold
>HEENT
</span
><br
>
38 <input type
=checkbox name
='cataracts' ><span
class=text
>Cataracts
</span
><br
>
39 <input type
=checkbox name
='cataract_surgery' ><span
class=text
>Cataract Surgery
</span
><br
>
40 <input type
=checkbox name
='glaucoma' ><span
class=text
>Glaucoma
</span
><br
>
41 <input type
=checkbox name
='double_vision' ><span
class=text
>Double Vision
</span
><br
>
42 <input type
=checkbox name
='blurred_vision' ><span
class=text
>Blurred Vision
</span
><br
>
43 <input type
=checkbox name
='poor_hearing' ><span
class=text
>Poor Hearing
</span
><br
>
44 <input type
=checkbox name
='headaches' ><span
class=text
>Headaches
</span
><br
>
45 <input type
=checkbox name
='ringing_in_ears' ><span
class=text
>Ringing in Ears
</span
><br
>
46 <input type
=checkbox name
='bloody_nose' ><span
class=text
>Bloody Nose
</span
><br
>
47 <input type
=checkbox name
='sinusitis' ><span
class=text
>Sinusitis
</span
><br
>
48 <input type
=checkbox name
='sinus_surgery' ><span
class=text
>Sinus Surgery
</span
><br
>
49 <input type
=checkbox name
='dry_mouth' ><span
class=text
>Dry Mouth
</span
><br
>
50 <input type
=checkbox name
='strep_throat' ><span
class=text
>Strep Throat
</span
><br
>
51 <input type
=checkbox name
='tonsillectomy' ><span
class=text
>Tonsillectomy
</span
><br
>
52 <input type
=checkbox name
='swollen_lymph_nodes' ><span
class=text
>Swollen Lymph Nodes
</span
><br
>
53 <input type
=checkbox name
='throat_cancer' ><span
class=text
>Throat Cancer
</span
><br
>
54 <input type
=checkbox name
='throat_cancer_surgery' ><span
class=text
>Throat Cancer Surgery
</span
><br
>
58 <span
class=bold
>Cardiovascular
</span
><br
>
59 <input type
=checkbox name
='heart_attack' ><span
class=text
>Heart Attack
</span
><br
>
60 <input type
=checkbox name
='irregular_heart_beat' ><span
class=text
>Irregular Heart Beat
</span
><br
>
61 <input type
=checkbox name
='chest_pains' ><span
class=text
>Chest Pains
</span
><br
>
62 <input type
=checkbox name
='shortness_of_breath' ><span
class=text
>Shortness of Breath
</span
><br
>
63 <input type
=checkbox name
='high_blood_pressure' ><span
class=text
>High Blood Pressure
</span
><br
>
64 <input type
=checkbox name
='heart_failure' ><span
class=text
>Heart Failure
</span
><br
>
65 <input type
=checkbox name
='poor_circulation' ><span
class=text
>Poor Circulation
</span
><br
>
66 <input type
=checkbox name
='vascular_surgery' ><span
class=text
>Vascular Surgery
</span
><br
>
67 <input type
=checkbox name
='cardiac_catheterization' ><span
class=text
>Cardiac Catheterization
</span
><br
>
68 <input type
=checkbox name
='coronary_artery_bypass' ><span
class=text
>Coronary Artery Bypass
</span
><br
>
69 <input type
=checkbox name
='heart_transplant' ><span
class=text
>Heart Transplant
</span
><br
>
70 <input type
=checkbox name
='stress_test' ><span
class=text
>Stress Test
</span
><br
>
71 <span
class=bold
>Endocrine
</span
><br
>
72 <input type
=checkbox name
='insulin_dependent_diabetes' ><span
class=text
>Insulin Dependent Diabetes
</span
><br
>
73 <input type
=checkbox name
='noninsulin_dependent_diabetes' ><span
class=text
>Non
-Insulin Dependent Diabetes
</span
><br
>
74 <input type
=checkbox name
='hypothyroidism' ><span
class=text
>Hypothyroidism
</span
><br
>
75 <input type
=checkbox name
='hyperthyroidism' ><span
class=text
>Hyperthyroidism
</span
><br
>
76 <input type
=checkbox name
='cushing_syndrom' ><span
class=text
>Cushing Syndrom
</span
><br
>
77 <input type
=checkbox name
='addison_syndrom' ><span
class=text
>Addison Syndrom
</span
><br
>
81 <span
class=bold
>Pulmonary
</span
><br
>
82 <input type
=checkbox name
='emphysema' ><span
class=text
>Emphysema
</span
><br
>
83 <input type
=checkbox name
='chronic_bronchitis' ><span
class=text
>Chronic Bronchitis
</span
><br
>
84 <input type
=checkbox name
='interstitial_lung_disease' ><span
class=text
>Interstitial Lung Disease
</span
><br
>
85 <input type
=checkbox name
='shortness_of_breath_2' ><span
class=text
>Shortness of Breath
</span
><br
>
86 <input type
=checkbox name
='lung_cancer' ><span
class=text
>Lung Cancer
</span
><br
>
87 <input type
=checkbox name
='lung_cancer_surgery' ><span
class=text
>Lung Cancer Surgery
</span
><br
>
88 <input type
=checkbox name
='pheumothorax' ><span
class=text
>Pheumothorax
</span
><br
>
89 <span
class=bold
>Genitourinary
</span
><br
>
90 <input type
=checkbox name
='kidney_failure' ><span
class=text
>Kidney Failure
</span
><br
>
91 <input type
=checkbox name
='kidney_stones' ><span
class=text
>Kidney Stones
</span
><br
>
92 <input type
=checkbox name
='kidney_cancer' ><span
class=text
>Kidney Cancer
</span
><br
>
93 <input type
=checkbox name
='kidney_infections' ><span
class=text
>Kidney Infections
</span
><br
>
94 <input type
=checkbox name
='bladder_infections' ><span
class=text
>Bladder Infections
</span
><br
>
95 <input type
=checkbox name
='bladder_cancer' ><span
class=text
>Bladder Cancer
</span
><br
>
96 <input type
=checkbox name
='prostate_problems' ><span
class=text
>Prostate Problems
</span
><br
>
97 <input type
=checkbox name
='prostate_cancer' ><span
class=text
>Prostate Cancer
</span
><br
>
98 <input type
=checkbox name
='kidney_transplant' ><span
class=text
>Kidney Transplant
</span
><br
>
99 <input type
=checkbox name
='sexually_transmitted_disease' ><span
class=text
>Sexually Transmitted Disease
</span
><br
>
100 <input type
=checkbox name
='burning_with_urination' ><span
class=text
>Burning with Urination
</span
><br
>
101 <input type
=checkbox name
='discharge_from_urethra' ><span
class=text
>Discharge From Urethra
</span
><br
>
105 <span
class=bold
>Gastrointestinal
</span
><br
>
106 <input type
=checkbox name
='stomach_pains' ><span
class=text
>Stomach Pains
</span
><br
>
107 <input type
=checkbox name
='peptic_ulcer_disease' ><span
class=text
>Peptic Ulcer Disease
</span
><br
>
108 <input type
=checkbox name
='gastritis' ><span
class=text
>Gastritis
</span
><br
>
109 <input type
=checkbox name
='endoscopy' ><span
class=text
>Endoscopy
</span
><br
>
110 <input type
=checkbox name
='polyps' ><span
class=text
>Polyps
</span
><br
>
111 <input type
=checkbox name
='colonoscopy' ><span
class=text
>colonoscopy
</span
><br
>
112 <input type
=checkbox name
='colon_cancer' ><span
class=text
>Colon Cancer
</span
><br
>
113 <input type
=checkbox name
='colon_cancer_surgery' ><span
class=text
>Colon Cancer Surgery
</span
><br
>
114 <input type
=checkbox name
='ulcerative_colitis' ><span
class=text
>Ulcerative Colitis
</span
><br
>
115 <input type
=checkbox name
='crohns_disease' ><span
class=text
>Crohn
's Disease</span><br>
116 <input type=checkbox name='appendectomy
' ><span class=text>Appendectomy</span><br>
117 <input type=checkbox name='divirticulitis
' ><span class=text>Divirticulitis</span><br>
118 <input type=checkbox name='divirticulitis_surgery
' ><span class=text>Divirticulitis Surgery</span><br>
119 <input type=checkbox name='gall_stones
' ><span class=text>Gall Stones</span><br>
120 <input type=checkbox name='cholecystectomy
' ><span class=text>Cholecystectomy</span><br>
121 <input type=checkbox name='hepatitis
' ><span class=text>Hepatitis</span><br>
122 <input type=checkbox name='cirrhosis_of_the_liver
' ><span class=text>Cirrhosis of the Liver</span><br>
123 <input type=checkbox name='splenectomy
' ><span class=text>Splenectomy</span><br>
127 <span class=bold>Musculoskeletal</span><br>
128 <input type=checkbox name='osetoarthritis
' ><span class=text>Osetoarthritis</span><br>
129 <input type=checkbox name='rheumotoid_arthritis
' ><span class=text>Rheumotoid Arthritis</span><br>
130 <input type=checkbox name='lupus
' ><span class=text>Lupus</span><br>
131 <input type=checkbox name='ankylosing_sondlilitis
' ><span class=text>Ankylosing Sondlilitis</span><br>
132 <input type=checkbox name='swollen_joints
' ><span class=text>Swollen Joints</span><br>
133 <input type=checkbox name='stiff_joints
' ><span class=text>Stiff Joints</span><br>
134 <input type=checkbox name='broken_bones
' ><span class=text>Broken Bones</span><br>
135 <input type=checkbox name='neck_problems
' ><span class=text>Neck Problems</span><br>
136 <input type=checkbox name='back_problems
' ><span class=text>Back Problems</span><br>
137 <input type=checkbox name='back_surgery
' ><span class=text>Back Surgery</span><br>
138 <input type=checkbox name='scoliosis
' ><span class=text>Scoliosis</span><br>
139 <input type=checkbox name='herniated_disc
' ><span class=text>Herniated Disc</span><br>
140 <input type=checkbox name='shoulder_problems
' ><span class=text>Shoulder Problems</span><br>
141 <input type=checkbox name='elbow_problems
' ><span class=text>Elbow Problems</span><br>
142 <input type=checkbox name='wrist_problems
' ><span class=text>Wrist Problems</span><br>
143 <input type=checkbox name='hand_problems
' ><span class=text>Hand Problems</span><br>
144 <input type=checkbox name='hip_problems
' ><span class=text>Hip Problems</span><br>
145 <input type=checkbox name='knee_problems
' ><span class=text>Knee Problems</span><br>
146 <input type=checkbox name='ankle_problems
' ><span class=text>Ankle Problems</span><br>
147 <input type=checkbox name='foot_problems
' ><span class=text>Foot Problems</span><br>
152 <span class=text>Additional Notes: </span><br><textarea cols=40 rows=8 wrap=virtual name="additional_notes" ></textarea><br>
154 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save]</a>
156 <a href="<?php echo $GLOBALS['form_exit_url
']; ?>" class="link" onclick="top.restoreSession()">[Don't Save
]</a
>
