contrib/forms/chiro_history/preview.html

   1 <html><head>
   2 </head>
   3 <body>
   4 <form>
   5 <hr>
   6 <h1> history_exam </h1>
   7 <hr>
   8 <input type="submit" name="submit form" value="submit form" /><br>
   9 <br>
  10 <h3>History</h3>
  11
  12 <table>
  13
  14 <tr><td>
  15 <span class='text'><?php xl('Approximate onset date (yyyy-mm-dd): ','e') ?></span>
  16 </td><td>
  17 <input type='text' size='10' name='approximate_onset_date' id='approximate_onset_date' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
  18 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
  19 id='img_approximate_onset_date' border='0' alt='[?]' style='cursor:pointer'
  20 title='Click here to choose a date'>
  21 <script>
  22 Calendar.setup({inputField:'approximate_onset_date', ifFormat:'%Y-%m-%d', button:'img_approximate_onset_date'});
  23 </script>
  24 </td></tr>
  25
  26 </table>
  27
  28 <table>
  29
  30 <tr><td>Due to</td> <td><label><input type="checkbox" name="due_to[]" value="Insidious Onset" />Insidious Onset</label> <label><input type="checkbox" name="due_to[]" value="Trauma" />Trauma</label> <label><input type="checkbox" name="due_to[]" value="Work Injury" />Work Injury</label> <label><input type="checkbox" name="due_to[]" value="Personal Injury" />Personal Injury</label> <label><input type="checkbox" name="due_to[]" value="Auto Collision" />Auto Collision</label></td></tr>
  31
  32 </table>
  33
  34 <table>
  35
  36 <tr><td>Areas involved</td> <td><label><input type="checkbox" name="areas_involved[]" value="Right" />Right</label> <label><input type="checkbox" name="areas_involved[]" value="Left" />Left</label> <label><input type="checkbox" name="areas_involved[]" value="Neck" />Neck</label> <label><input type="checkbox" name="areas_involved[]" value="Mid Back" />Mid Back</label> <label><input type="checkbox" name="areas_involved[]" value="Low Back" />Low Back</label> <label><input type="checkbox" name="areas_involved[]" value="Shoulder" />Shoulder</label> <label><input type="checkbox" name="areas_involved[]" value="Elbow" />Elbow</label> <label><input type="checkbox" name="areas_involved[]" value="Hand" />Hand</label> <label><input type="checkbox" name="areas_involved[]" value="Hip" />Hip</label> <label><input type="checkbox" name="areas_involved[]" value="Knee" />Knee</label> <label><input type="checkbox" name="areas_involved[]" value="Foot" />Foot</label></td></tr>
  37
  38 </table>
  39
  40 <table>
  41
  42 <tr><td>Radiating to</td> <td><label><input type="checkbox" name="radiating_to[]" value="Right" />Right</label> <label><input type="checkbox" name="radiating_to[]" value="Left" />Left</label> <label><input type="checkbox" name="radiating_to[]" value="Shoulder" />Shoulder</label> <label><input type="checkbox" name="radiating_to[]" value="Arm" />Arm</label> <label><input type="checkbox" name="radiating_to[]" value="Hip" />Hip</label> <label><input type="checkbox" name="radiating_to[]" value="Leg" />Leg</label></td></tr>
  43
  44 </table>
  45
  46 <table>
  47
  48 <tr><td>Radiating to other</td> <td><input type="text" name="radiating_to_other"  /></td></tr>
  49
  50 </table>
  51
  52 <table>
  53
  54 <tr><td>Describe symtoms</td> <td><label><input type="checkbox" name="describe_symtoms[]" value="Constant" />Constant</label> <label><input type="checkbox" name="describe_symtoms[]" value="Intermittent" />Intermittent</label> <label><input type="checkbox" name="describe_symtoms[]" value="Dull Ache" />Dull Ache</label> <label><input type="checkbox" name="describe_symtoms[]" value="Sharp" />Sharp</label> <label><input type="checkbox" name="describe_symtoms[]" value="Burning" />Burning</label></td></tr>
  55
  56 </table>
  57
  58 <table>
  59
  60 <tr><td>Pain severity</td> <td><select name="pain_severity" >
  61 <option value=""></option>
  62 <option value="1">1</option>
  63 <option value="2">2</option>
  64 <option value="3">3</option>
  65 <option value="4">4</option>
  66 <option value="5">5</option>
  67 <option value="6">6</option>
  68 <option value="7">7</option>
  69 <option value="8">8</option>
  70 <option value="9">9</option>
  71 <option value="10">10</option>
  72 </select></td></tr>
  73
  74 </table>
  75
  76 <table>
  77
  78 <tr><td>Associated symptoms</td> <td><textarea name="associated_symptoms"  rows="4" cols="40"></textarea></td></tr>
  79
  80 </table>
  81
  82 <table>
  83
  84 <tr><td>Pain with</td> <td><label><input type="checkbox" name="pain_with[]" value="Cough" />Cough</label> <label><input type="checkbox" name="pain_with[]" value="Sneeze" />Sneeze</label> <label><input type="checkbox" name="pain_with[]" value="Deep Breath" />Deep Breath</label> <label><input type="checkbox" name="pain_with[]" value="Baring Down" />Baring Down</label></td></tr>
  85
  86 </table>
  87
  88 <table>
  89
  90 <tr><td>Describe pain</td> <td><input type="text" name="describe_pain"  /></td></tr>
  91
  92 </table>
  93
  94 <table>
  95
  96 <tr><td>Worse</td> <td><label><input type="checkbox" name="worse[]" value="Bending" />Bending</label> <label><input type="checkbox" name="worse[]" value="Sitting Rising" />Sitting Rising</label> <label><input type="checkbox" name="worse[]" value="Turning Neck" />Turning Neck</label> <label><input type="checkbox" name="worse[]" value="Turning Trunk" />Turning Trunk</label> <label><input type="checkbox" name="worse[]" value="Turning Lower Back" />Turning Lower Back</label> <label><input type="checkbox" name="worse[]" value="Standing" />Standing</label> <label><input type="checkbox" name="worse[]" value="Lying" />Lying</label> <label><input type="checkbox" name="worse[]" value="Resting" />Resting</label> <label><input type="checkbox" name="worse[]" value="AM" />AM</label> <label><input type="checkbox" name="worse[]" value="PM" />PM</label> <label><input type="checkbox" name="worse[]" value="No Effect" />No Effect</label></td></tr>
  97
  98 </table>
  99
 100 <table>
 101
 102 <tr><td>Worse other</td> <td><input type="text" name="worse_other"  /></td></tr>
 103
 104 </table>
 105
 106 <table>
 107
 108 <tr><td>Better</td> <td><label><input type="checkbox" name="better[]" value="Bending" />Bending</label> <label><input type="checkbox" name="better[]" value="Sitting Rising" />Sitting Rising</label> <label><input type="checkbox" name="better[]" value="Turning Neck" />Turning Neck</label> <label><input type="checkbox" name="better[]" value="Turning Trunk" />Turning Trunk</label> <label><input type="checkbox" name="better[]" value="Turning Lower Back" />Turning Lower Back</label> <label><input type="checkbox" name="better[]" value="Standing" />Standing</label> <label><input type="checkbox" name="better[]" value="Lying" />Lying</label> <label><input type="checkbox" name="better[]" value="Resting" />Resting</label> <label><input type="checkbox" name="better[]" value="AM" />AM</label> <label><input type="checkbox" name="better[]" value="PM" />PM</label> <label><input type="checkbox" name="better[]" value="No Effect" />No Effect</label></td></tr>
 109
 110 </table>
 111
 112 <table>
 113
 114 <tr><td>Better other</td> <td><input type="text" name="better_other"  /></td></tr>
 115
 116 </table>
 117
 118 <table>
 119
 120 <tr><td>Pain effected</td> <td><label><input type="checkbox" name="pain_effected[]" value="NA" />NA</label> <label><input type="checkbox" name="pain_effected[]" value="Job" />Job</label> <label><input type="checkbox" name="pain_effected[]" value="Home" />Home</label> <label><input type="checkbox" name="pain_effected[]" value="Recreational Activities" />Recreational Activities</label></td></tr>
 121
 122 </table>
 123
 124 <table>
 125
 126 <tr><td>Effected other</td> <td><input type="text" name="effected_other"  /></td></tr>
 127
 128 </table>
 129
 130 <table>
 131
 132 <tr><td>Previous history</td> <td><label><input type="checkbox" name="previous_history[]" value="No" />No</label> <label><input type="checkbox" name="previous_history[]" value="Yes" />Yes</label></td></tr>
 133
 134 </table>
 135
 136 <table>
 137
 138 <tr><td>Previous history explain</td> <td><input type="text" name="previous_history_explain"  /></td></tr>
 139
 140 </table>
 141
 142 <table>
 143
 144 <tr><td>Previous treatment</td> <td><label><input type="checkbox" name="previous_treatment[]" value="DC" />DC</label> <label><input type="checkbox" name="previous_treatment[]" value="MD" />MD</label> <label><input type="checkbox" name="previous_treatment[]" value="PT" />PT</label></td></tr>
 145
 146 </table>
 147
 148 <table>
 149
 150 <tr><td>Previous treatment other</td> <td><input type="text" name="previous_treatment_other"  /></td></tr>
 151
 152 </table>
 153
 154 <table>
 155
 156 <tr><td>Current treatment</td> <td><label><input type="checkbox" name="current_treatment[]" value="DC" />DC</label> <label><input type="checkbox" name="current_treatment[]" value="MD" />MD</label> <label><input type="checkbox" name="current_treatment[]" value="PT" />PT</label></td></tr>
 157
 158 </table>
 159
 160 <table>
 161
 162 <tr><td>Current treatment other</td> <td><input type="text" name="current_treatment_other"  /></td></tr>
 163
 164 </table>
 165
 166 <table>
 167
 168 <tr><td>Recent scans</td> <td><label><input type="checkbox" name="recent_scans[]" value="X-Rays" />X-Rays</label> <label><input type="checkbox" name="recent_scans[]" value="MRI" />MRI</label> <label><input type="checkbox" name="recent_scans[]" value="CT" />CT</label></td></tr>
 169
 170 </table>
 171
 172 <table>
 173
 174 <tr><td>
 175 <span class='text'><?php xl('Scan date (yyyy-mm-dd): ','e') ?></span>
 176 </td><td>
 177 <input type='text' size='10' name='scan_date' id='scan_date' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 178 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 179 id='img_scan_date' border='0' alt='[?]' style='cursor:pointer'
 180 title='Click here to choose a date'>
 181 <script>
 182 Calendar.setup({inputField:'scan_date', ifFormat:'%Y-%m-%d', button:'img_scan_date'});
 183 </script>
 184 </td></tr>
 185
 186 </table>
 187
 188 <table>
 189
 190 <tr><td>Scan location</td> <td><input type="text" name="scan_location"  /></td></tr>
 191
 192 </table>
 193
 194 <table>
 195
 196 <tr><td>Medications</td> <td><label><input type="checkbox" name="medications[]" value="NSAIDS" />NSAIDS</label> <label><input type="checkbox" name="medications[]" value="Muscle Relaxer" />Muscle Relaxer</label></td></tr>
 197
 198 </table>
 199
 200 <table>
 201
 202 <tr><td>Medications other</td> <td><input type="text" name="medications_other"  /></td></tr>
 203
 204 </table>
 205
 206 <table>
 207
 208 <tr><td>Vitamins supplements</td> <td><label><input type="checkbox" name="vitamins_supplements[]" value="Mulivitamin" />Mulivitamin</label> <label><input type="checkbox" name="vitamins_supplements[]" value="Calcium" />Calcium</label> <label><input type="checkbox" name="vitamins_supplements[]" value="Fish Oil" />Fish Oil</label></td></tr>
 209
 210 </table>
 211
 212 <table>
 213
 214 <tr><td>Vitamins supplements other</td> <td><input type="text" name="vitamins_supplements_other"  /></td></tr>
 215
 216 </table>
 217
 218 <table>
 219
 220 <tr><td>Recent or major surgeries</td> <td><input type="text" name="recent_or_major_surgeries"  /></td></tr>
 221
 222 </table>
 223
 224 <table>
 225
 226 <tr><td>Current or past health problems</td> <td><input type="text" name="current_or_past_health_problems"  /></td></tr>
 227
 228 </table>
 229
 230 <table>
 231
 232 <tr><td>Family history of major illness</td> <td><input type="text" name="family_history_of_major_illness"  /></td></tr>
 233
 234 </table>
 235 <br>
 236 <h3>Musculosketal Exam</h3>
 237 <br>
 238 <h3>Constitutional</h3>
 239
 240 <table>
 241
 242 <tr><td>Ht</td> <td><input type="text" name="ht"  /></td></tr>
 243
 244 </table>
 245
 246 <table>
 247
 248 <tr><td>Wt</td> <td><input type="text" name="wt"  /></td></tr>
 249
 250 </table>
 251
 252 <table>
 253
 254 <tr><td>Bp</td> <td><input type="text" name="bp"  /></td></tr>
 255
 256 </table>
 257
 258 <table>
 259
 260 <tr><td>General appearance</td> <td><label><input type="checkbox" name="general_appearance[]" value="Normal" />Normal</label> <label><input type="checkbox" name="general_appearance[]" value="Other" />Other</label></td></tr>
 261
 262 </table>
 263
 264 <table>
 265
 266 <tr><td>General appearance other</td> <td><input type="text" name="general_appearance_other"  /></td></tr>
 267
 268 </table>
 269
 270 <table>
 271
 272 <tr><td>Current symptoms</td> <td><label><input type="checkbox" name="current_symptoms[]" value="Cervical" />Cervical</label> <label><input type="checkbox" name="current_symptoms[]" value="Thoracic" />Thoracic</label> <label><input type="checkbox" name="current_symptoms[]" value="Lumbar" />Lumbar</label> <label><input type="checkbox" name="current_symptoms[]" value="SI" />SI</label> <label><input type="checkbox" name="current_symptoms[]" value="Other" />Other</label></td></tr>
 273
 274 </table>
 275
 276 <table>
 277
 278 <tr><td>Symptoms other</td> <td><input type="text" name="symptoms_other"  /></td></tr>
 279
 280 </table>
 281 <br>
 282 <h3>Mechanical MecKenzie Exam</h3>
 283
 284 <table>
 285
 286 <tr><td>Cervical</td> <td><label><input type="checkbox" name="cervical" value="yes" /></label></td></tr>
 287
 288 </table>
 289
 290 <table>
 291
 292 <tr><td>Cervical wnl</td> <td><input type="text" name="cervical_wnl"  /></td></tr>
 293
 294 </table>
 295
 296 <table>
 297
 298 <tr><td>Thoracic</td> <td><label><input type="checkbox" name="thoracic" value="yes" /></label></td></tr>
 299
 300 </table>
 301
 302 <table>
 303
 304 <tr><td>Thoracic wnl</td> <td><input type="text" name="thoracic_wnl"  /></td></tr>
 305
 306 </table>
 307
 308 <table>
 309
 310 <tr><td>Lumbar</td> <td><label><input type="checkbox" name="lumbar" value="yes" /></label></td></tr>
 311
 312 </table>
 313
 314 <table>
 315
 316 <tr><td>Lumbar wnl</td> <td><input type="text" name="lumbar_wnl"  /></td></tr>
 317
 318 </table>
 319
 320 <table>
 321
 322 <tr><td>Cerv rom</td> <td><label><input type="checkbox" name="cerv_rom[]" value="Subject" />Subject</label> <label><input type="checkbox" name="cerv_rom[]" value="Object" />Object</label> <label><input type="checkbox" name="cerv_rom[]" value="WNL" />WNL</label></td></tr>
 323
 324 </table>
 325
 326 <table>
 327
 328 <tr><td>Cerv flexion rom</td> <td><input type="text" name="cerv_flexion_rom"  /></td></tr>
 329
 330 </table>
 331
 332 <table>
 333
 334 <tr><td>Cerv flexion pain</td> <td><label><input type="checkbox" name="cerv_flexion_pain" value="yes" /></label></td></tr>
 335
 336 </table>
 337
 338 <table>
 339
 340 <tr><td>Cerv flexion response</td> <td><input type="text" name="cerv_flexion_response"  /></td></tr>
 341
 342 </table>
 343
 344 <table>
 345
 346 <tr><td>Cerv extension rom</td> <td><input type="text" name="cerv_extension_rom"  /></td></tr>
 347
 348 </table>
 349
 350 <table>
 351
 352 <tr><td>Cerv extension pain</td> <td><label><input type="checkbox" name="cerv_extension_pain" value="yes" /></label></td></tr>
 353
 354 </table>
 355
 356 <table>
 357
 358 <tr><td>Cerv extension response</td> <td><input type="text" name="cerv_extension_response"  /></td></tr>
 359
 360 </table>
 361
 362 <table>
 363
 364 <tr><td>Cerv lt lat flex rom</td> <td><input type="text" name="cerv_lt_lat_flex_rom"  /></td></tr>
 365
 366 </table>
 367
 368 <table>
 369
 370 <tr><td>Cerv lt lat flex pain</td> <td><label><input type="checkbox" name="cerv_lt_lat_flex_pain" value="yes" /></label></td></tr>
 371
 372 </table>
 373
 374 <table>
 375
 376 <tr><td>Cerv lt lat flex response</td> <td><input type="text" name="cerv_lt_lat_flex_response"  /></td></tr>
 377
 378 </table>
 379
 380 <table>
 381
 382 <tr><td>Cerv rt lat flex rom</td> <td><input type="text" name="cerv_rt_lat_flex_rom"  /></td></tr>
 383
 384 </table>
 385
 386 <table>
 387
 388 <tr><td>Cerv rt lat flex pain</td> <td><label><input type="checkbox" name="cerv_rt_lat_flex_pain" value="yes" /></label></td></tr>
 389
 390 </table>
 391
 392 <table>
 393
 394 <tr><td>Cerv rt lat flex response</td> <td><input type="text" name="cerv_rt_lat_flex_response"  /></td></tr>
 395
 396 </table>
 397
 398 <table>
 399
 400 <tr><td>Cerv lt rotation rom</td> <td><input type="text" name="cerv_lt_rotation_rom"  /></td></tr>
 401
 402 </table>
 403
 404 <table>
 405
 406 <tr><td>Cerv lt rotation pain</td> <td><label><input type="checkbox" name="cerv_lt_rotation_pain" value="yes" /></label></td></tr>
 407
 408 </table>
 409
 410 <table>
 411
 412 <tr><td>Cerv lt rotation response</td> <td><input type="text" name="cerv_lt_rotation_response"  /></td></tr>
 413
 414 </table>
 415
 416 <table>
 417
 418 <tr><td>Cerv rt rotation rom</td> <td><input type="text" name="cerv_rt_rotation_rom"  /></td></tr>
 419
 420 </table>
 421
 422 <table>
 423
 424 <tr><td>Cerv rt rotation pain</td> <td><label><input type="checkbox" name="cerv_rt_rotation_pain" value="yes" /></label></td></tr>
 425
 426 </table>
 427
 428 <table>
 429
 430 <tr><td>Cerv rt rotation response</td> <td><input type="text" name="cerv_rt_rotation_response"  /></td></tr>
 431
 432 </table>
 433
 434 <table>
 435
 436 <tr><td>Thor rom</td> <td><label><input type="checkbox" name="thor_rom[]" value="Subject" />Subject</label> <label><input type="checkbox" name="thor_rom[]" value="Object" />Object</label> <label><input type="checkbox" name="thor_rom[]" value="WNL" />WNL</label></td></tr>
 437
 438 </table>
 439
 440 <table>
 441
 442 <tr><td>Thor flexion rom</td> <td><input type="text" name="thor_flexion_rom"  /></td></tr>
 443
 444 </table>
 445
 446 <table>
 447
 448 <tr><td>Thor flexion pain</td> <td><label><input type="checkbox" name="thor_flexion_pain" value="yes" /></label></td></tr>
 449
 450 </table>
 451
 452 <table>
 453
 454 <tr><td>Thor flexion response</td> <td><input type="text" name="thor_flexion_response"  /></td></tr>
 455
 456 </table>
 457
 458 <table>
 459
 460 <tr><td>Thor extension rom</td> <td><input type="text" name="thor_extension_rom"  /></td></tr>
 461
 462 </table>
 463
 464 <table>
 465
 466 <tr><td>Thor extension pain</td> <td><label><input type="checkbox" name="thor_extension_pain" value="yes" /></label></td></tr>
 467
 468 </table>
 469
 470 <table>
 471
 472 <tr><td>Thor extension response</td> <td><input type="text" name="thor_extension_response"  /></td></tr>
 473
 474 </table>
 475
 476 <table>
 477
 478 <tr><td>Thor lt lat flex rom</td> <td><input type="text" name="thor_lt_lat_flex_rom"  /></td></tr>
 479
 480 </table>
 481
 482 <table>
 483
 484 <tr><td>Thor lt lat flex pain</td> <td><label><input type="checkbox" name="thor_lt_lat_flex_pain" value="yes" /></label></td></tr>
 485
 486 </table>
 487
 488 <table>
 489
 490 <tr><td>Thor lt lat flex response</td> <td><input type="text" name="thor_lt_lat_flex_response"  /></td></tr>
 491
 492 </table>
 493
 494 <table>
 495
 496 <tr><td>Thor rt lat flex rom</td> <td><input type="text" name="thor_rt_lat_flex_rom"  /></td></tr>
 497
 498 </table>
 499
 500 <table>
 501
 502 <tr><td>Thor rt lat flex pain</td> <td><label><input type="checkbox" name="thor_rt_lat_flex_pain" value="yes" /></label></td></tr>
 503
 504 </table>
 505
 506 <table>
 507
 508 <tr><td>Thor rt lat flex response</td> <td><input type="text" name="thor_rt_lat_flex_response"  /></td></tr>
 509
 510 </table>
 511
 512 <table>
 513
 514 <tr><td>Thor lt rotation rom</td> <td><input type="text" name="thor_lt_rotation_rom"  /></td></tr>
 515
 516 </table>
 517
 518 <table>
 519
 520 <tr><td>Thor lt rotation pain</td> <td><label><input type="checkbox" name="thor_lt_rotation_pain" value="yes" /></label></td></tr>
 521
 522 </table>
 523
 524 <table>
 525
 526 <tr><td>Thor lt rotation response</td> <td><input type="text" name="thor_lt_rotation_response"  /></td></tr>
 527
 528 </table>
 529
 530 <table>
 531
 532 <tr><td>Thor rt rotation rom</td> <td><input type="text" name="thor_rt_rotation_rom"  /></td></tr>
 533
 534 </table>
 535
 536 <table>
 537
 538 <tr><td>Thor rt rotation pain</td> <td><label><input type="checkbox" name="thor_rt_rotation_pain" value="yes" /></label></td></tr>
 539
 540 </table>
 541
 542 <table>
 543
 544 <tr><td>Thor rt rotation response</td> <td><input type="text" name="thor_rt_rotation_response"  /></td></tr>
 545
 546 </table>
 547
 548 <table>
 549
 550 <tr><td>Lumb rom</td> <td><label><input type="checkbox" name="lumb_rom[]" value="Subject" />Subject</label> <label><input type="checkbox" name="lumb_rom[]" value="Object" />Object</label> <label><input type="checkbox" name="lumb_rom[]" value="WNL" />WNL</label></td></tr>
 551
 552 </table>
 553
 554 <table>
 555
 556 <tr><td>Lumb flexion rom</td> <td><input type="text" name="lumb_flexion_rom"  /></td></tr>
 557
 558 </table>
 559
 560 <table>
 561
 562 <tr><td>Lumb flexion pain</td> <td><label><input type="checkbox" name="lumb_flexion_pain" value="yes" /></label></td></tr>
 563
 564 </table>
 565
 566 <table>
 567
 568 <tr><td>Lumb flexion response</td> <td><input type="text" name="lumb_flexion_response"  /></td></tr>
 569
 570 </table>
 571
 572 <table>
 573
 574 <tr><td>Lumb extension rom</td> <td><input type="text" name="lumb_extension_rom"  /></td></tr>
 575
 576 </table>
 577
 578 <table>
 579
 580 <tr><td>Lumb extension pain</td> <td><label><input type="checkbox" name="lumb_extension_pain" value="yes" /></label></td></tr>
 581
 582 </table>
 583
 584 <table>
 585
 586 <tr><td>Lumb extension response</td> <td><input type="text" name="lumb_extension_response"  /></td></tr>
 587
 588 </table>
 589
 590 <table>
 591
 592 <tr><td>Lumb lt lat flex rom</td> <td><input type="text" name="lumb_lt_lat_flex_rom"  /></td></tr>
 593
 594 </table>
 595
 596 <table>
 597
 598 <tr><td>Lumb lt lat flex pain</td> <td><label><input type="checkbox" name="lumb_lt_lat_flex_pain" value="yes" /></label></td></tr>
 599
 600 </table>
 601
 602 <table>
 603
 604 <tr><td>Lumb lt lat flex response</td> <td><input type="text" name="lumb_lt_lat_flex_response"  /></td></tr>
 605
 606 </table>
 607
 608 <table>
 609
 610 <tr><td>Lumb rt lat flex rom</td> <td><input type="text" name="lumb_rt_lat_flex_rom"  /></td></tr>
 611
 612 </table>
 613
 614 <table>
 615
 616 <tr><td>Lumb rt lat flex pain</td> <td><label><input type="checkbox" name="lumb_rt_lat_flex_pain" value="yes" /></label></td></tr>
 617
 618 </table>
 619
 620 <table>
 621
 622 <tr><td>Lumb rt lat flex response</td> <td><input type="text" name="lumb_rt_lat_flex_response"  /></td></tr>
 623
 624 </table>
 625
 626 <table>
 627
 628 <tr><td>Lumb lt rotation rom</td> <td><input type="text" name="lumb_lt_rotation_rom"  /></td></tr>
 629
 630 </table>
 631
 632 <table>
 633
 634 <tr><td>Lumb lt rotation pain</td> <td><label><input type="checkbox" name="lumb_lt_rotation_pain" value="yes" /></label></td></tr>
 635
 636 </table>
 637
 638 <table>
 639
 640 <tr><td>Lumb lt rotation response</td> <td><input type="text" name="lumb_lt_rotation_response"  /></td></tr>
 641
 642 </table>
 643
 644 <table>
 645
 646 <tr><td>Lumb rt rotation rom</td> <td><input type="text" name="lumb_rt_rotation_rom"  /></td></tr>
 647
 648 </table>
 649
 650 <table>
 651
 652 <tr><td>Lumb rt rotation pain</td> <td><label><input type="checkbox" name="lumb_rt_rotation_pain" value="yes" /></label></td></tr>
 653
 654 </table>
 655
 656 <table>
 657
 658 <tr><td>Lumb rt rotation response</td> <td><input type="text" name="lumb_rt_rotation_response"  /></td></tr>
 659
 660 </table>
 661 <br>
 662 <h3>Orthopedic Neurological</h3>
 663
 664 <table>
 665
 666 <tr><td>Cervical test</td> <td><label><input type="checkbox" name="cervical_test" value="yes" /></label></td></tr>
 667
 668 </table>
 669
 670 <table>
 671
 672 <tr><td>Lt cervical comp</td> <td><label><input type="checkbox" name="lt_cervical_comp[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_cervical_comp[]" value="Positive" />Positive</label></td></tr>
 673
 674 </table>
 675
 676 <table>
 677
 678 <tr><td>Lt cervical comp response</td> <td><input type="text" name="lt_cervical_comp_response"  /></td></tr>
 679
 680 </table>
 681
 682 <table>
 683
 684 <tr><td>Rt cervical comp</td> <td><label><input type="checkbox" name="rt_cervical_comp[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_cervical_comp[]" value="Positive" />Positive</label></td></tr>
 685
 686 </table>
 687
 688 <table>
 689
 690 <tr><td>Rt cervical comp response</td> <td><input type="text" name="rt_cervical_comp_response"  /></td></tr>
 691
 692 </table>
 693
 694 <table>
 695
 696 <tr><td>Soto hall</td> <td><label><input type="checkbox" name="soto_hall[]" value="Negative" />Negative</label> <label><input type="checkbox" name="soto_hall[]" value="Positive" />Positive</label></td></tr>
 697
 698 </table>
 699
 700 <table>
 701
 702 <tr><td>Soto hall response</td> <td><input type="text" name="soto_hall_response"  /></td></tr>
 703
 704 </table>
 705
 706 <table>
 707
 708 <tr><td>Lt shoulder depression</td> <td><label><input type="checkbox" name="lt_shoulder_depression[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_shoulder_depression[]" value="Positive" />Positive</label></td></tr>
 709
 710 </table>
 711
 712 <table>
 713
 714 <tr><td>Lt shoulder depression response</td> <td><input type="text" name="lt_shoulder_depression_response"  /></td></tr>
 715
 716 </table>
 717
 718 <table>
 719
 720 <tr><td>Rt shoulder depression</td> <td><label><input type="checkbox" name="rt_shoulder_depression[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_shoulder_depression[]" value="Positive" />Positive</label></td></tr>
 721
 722 </table>
 723
 724 <table>
 725
 726 <tr><td>Rt shoulder depression response</td> <td><input type="text" name="rt_shoulder_depression_response"  /></td></tr>
 727
 728 </table>
 729
 730 <table>
 731
 732 <tr><td>Ditraction test</td> <td><label><input type="checkbox" name="ditraction_test[]" value="Negative" />Negative</label> <label><input type="checkbox" name="ditraction_test[]" value="Positive" />Positive</label></td></tr>
 733
 734 </table>
 735
 736 <table>
 737
 738 <tr><td>Ditraction test response</td> <td><input type="text" name="ditraction_test_response"  /></td></tr>
 739
 740 </table>
 741
 742 <table>
 743
 744 <tr><td>Extremity other</td> <td><label><input type="checkbox" name="extremity_other[]" value="Negative" />Negative</label> <label><input type="checkbox" name="extremity_other[]" value="Positive" />Positive</label></td></tr>
 745
 746 </table>
 747
 748 <table>
 749
 750 <tr><td>Extremity other response</td> <td><input type="text" name="extremity_other_response"  /></td></tr>
 751
 752 </table>
 753
 754 <table>
 755
 756 <tr><td>Lumbar test</td> <td><label><input type="checkbox" name="lumbar_test" value="yes" /></label></td></tr>
 757
 758 </table>
 759
 760 <table>
 761
 762 <tr><td>Left slr</td> <td><label><input type="checkbox" name="left_slr[]" value="Negative" />Negative</label> <label><input type="checkbox" name="left_slr[]" value="Positive" />Positive</label></td></tr>
 763
 764 </table>
 765
 766 <table>
 767
 768 <tr><td>Left slr response</td> <td><input type="text" name="left_slr_response"  /></td></tr>
 769
 770 </table>
 771
 772 <table>
 773
 774 <tr><td>Right slr</td> <td><label><input type="checkbox" name="right_slr[]" value="Negative" />Negative</label> <label><input type="checkbox" name="right_slr[]" value="Positive" />Positive</label></td></tr>
 775
 776 </table>
 777
 778 <table>
 779
 780 <tr><td>Right slr response</td> <td><input type="text" name="right_slr_response"  /></td></tr>
 781
 782 </table>
 783
 784 <table>
 785
 786 <tr><td>Lt braggards</td> <td><label><input type="checkbox" name="lt_braggards[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_braggards[]" value="Positive" />Positive</label></td></tr>
 787
 788 </table>
 789
 790 <table>
 791
 792 <tr><td>Lt braggards response</td> <td><input type="text" name="lt_braggards_response"  /></td></tr>
 793
 794 </table>
 795
 796 <table>
 797
 798 <tr><td>Rt braggards</td> <td><label><input type="checkbox" name="rt_braggards[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_braggards[]" value="Positive" />Positive</label></td></tr>
 799
 800 </table>
 801
 802 <table>
 803
 804 <tr><td>Rt braggards response</td> <td><input type="text" name="rt_braggards_response"  /></td></tr>
 805
 806 </table>
 807
 808 <table>
 809
 810 <tr><td>Lt patricks faber</td> <td><label><input type="checkbox" name="lt_patricks_faber[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_patricks_faber[]" value="Positive" />Positive</label></td></tr>
 811
 812 </table>
 813
 814 <table>
 815
 816 <tr><td>Lt patricks faber response</td> <td><input type="text" name="lt_patricks_faber_response"  /></td></tr>
 817
 818 </table>
 819
 820 <table>
 821
 822 <tr><td>Rt patricks faber</td> <td><label><input type="checkbox" name="rt_patricks_faber[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_patricks_faber[]" value="Positive" />Positive</label></td></tr>
 823
 824 </table>
 825
 826 <table>
 827
 828 <tr><td>Rt patricks faber response</td> <td><input type="text" name="rt_patricks_faber_response"  /></td></tr>
 829
 830 </table>
 831
 832 <table>
 833
 834 <tr><td>Lt elys</td> <td><label><input type="checkbox" name="lt_elys[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_elys[]" value="Positive" />Positive</label></td></tr>
 835
 836 </table>
 837
 838 <table>
 839
 840 <tr><td>Lt elys response</td> <td><input type="text" name="lt_elys_response"  /></td></tr>
 841
 842 </table>
 843
 844 <table>
 845
 846 <tr><td>Rt elys</td> <td><label><input type="checkbox" name="rt_elys[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_elys[]" value="Positive" />Positive</label></td></tr>
 847
 848 </table>
 849
 850 <table>
 851
 852 <tr><td>Rt elys response</td> <td><input type="text" name="rt_elys_response"  /></td></tr>
 853
 854 </table>
 855
 856 <table>
 857
 858 <tr><td>Milgrams</td> <td><label><input type="checkbox" name="milgrams[]" value="Negative" />Negative</label> <label><input type="checkbox" name="milgrams[]" value="Positive" />Positive</label></td></tr>
 859
 860 </table>
 861
 862 <table>
 863
 864 <tr><td>Milgrams response</td> <td><input type="text" name="milgrams_response"  /></td></tr>
 865
 866 </table>
 867
 868 <table>
 869
 870 <tr><td>Lt yeomans</td> <td><label><input type="checkbox" name="lt_yeomans[]" value="Negative" />Negative</label> <label><input type="checkbox" name="lt_yeomans[]" value="Positive" />Positive</label></td></tr>
 871
 872 </table>
 873
 874 <table>
 875
 876 <tr><td>Lt yeomans response</td> <td><input type="text" name="lt_yeomans_response"  /></td></tr>
 877
 878 </table>
 879
 880 <table>
 881
 882 <tr><td>Rt yeomans</td> <td><label><input type="checkbox" name="rt_yeomans[]" value="Negative" />Negative</label> <label><input type="checkbox" name="rt_yeomans[]" value="Positive" />Positive</label></td></tr>
 883
 884 </table>
 885
 886 <table>
 887
 888 <tr><td>Rt yeomans response</td> <td><input type="text" name="rt_yeomans_response"  /></td></tr>
 889
 890 </table>
 891 <br>
 892 <h3>Palpatory Tenderness</h3>
 893
 894 <table>
 895
 896 <tr><td>Oc c1</td> <td><label><input type="checkbox" name="oc_c1[]" value="Left" />Left</label> <label><input type="checkbox" name="oc_c1[]" value="Right" />Right</label></td></tr>
 897
 898 </table>
 899
 900 <table>
 901
 902 <tr><td>C1 c2</td> <td><label><input type="checkbox" name="c1_c2[]" value="Left" />Left</label> <label><input type="checkbox" name="c1_c2[]" value="Right" />Right</label></td></tr>
 903
 904 </table>
 905
 906 <table>
 907
 908 <tr><td>C2 c3</td> <td><label><input type="checkbox" name="c2_c3[]" value="Left" />Left</label> <label><input type="checkbox" name="c2_c3[]" value="Right" />Right</label></td></tr>
 909
 910 </table>
 911
 912 <table>
 913
 914 <tr><td>C3 c4</td> <td><label><input type="checkbox" name="c3_c4[]" value="Left" />Left</label> <label><input type="checkbox" name="c3_c4[]" value="Right" />Right</label></td></tr>
 915
 916 </table>
 917
 918 <table>
 919
 920 <tr><td>C4 c5</td> <td><label><input type="checkbox" name="c4_c5[]" value="Left" />Left</label> <label><input type="checkbox" name="c4_c5[]" value="Right" />Right</label></td></tr>
 921
 922 </table>
 923
 924 <table>
 925
 926 <tr><td>C5 c6</td> <td><label><input type="checkbox" name="c5_c6[]" value="Left" />Left</label> <label><input type="checkbox" name="c5_c6[]" value="Right" />Right</label></td></tr>
 927
 928 </table>
 929
 930 <table>
 931
 932 <tr><td>C6 c7</td> <td><label><input type="checkbox" name="c6_c7[]" value="Left" />Left</label> <label><input type="checkbox" name="c6_c7[]" value="Right" />Right</label></td></tr>
 933
 934 </table>
 935
 936 <table>
 937
 938 <tr><td>C7 t1</td> <td><label><input type="checkbox" name="c7_t1[]" value="Left" />Left</label> <label><input type="checkbox" name="c7_t1[]" value="Right" />Right</label></td></tr>
 939
 940 </table>
 941
 942 <table>
 943
 944 <tr><td>T1 t2</td> <td><label><input type="checkbox" name="t1_t2[]" value="Left" />Left</label> <label><input type="checkbox" name="t1_t2[]" value="Right" />Right</label></td></tr>
 945
 946 </table>
 947
 948 <table>
 949
 950 <tr><td>T2 t3</td> <td><label><input type="checkbox" name="t2_t3[]" value="Left" />Left</label> <label><input type="checkbox" name="t2_t3[]" value="Right" />Right</label></td></tr>
 951
 952 </table>
 953
 954 <table>
 955
 956 <tr><td>T3 t4</td> <td><label><input type="checkbox" name="t3_t4[]" value="Left" />Left</label> <label><input type="checkbox" name="t3_t4[]" value="Right" />Right</label></td></tr>
 957
 958 </table>
 959
 960 <table>
 961
 962 <tr><td>T4 t5</td> <td><label><input type="checkbox" name="t4_t5[]" value="Left" />Left</label> <label><input type="checkbox" name="t4_t5[]" value="Right" />Right</label></td></tr>
 963
 964 </table>
 965
 966 <table>
 967
 968 <tr><td>T5 t6</td> <td><label><input type="checkbox" name="t5_t6[]" value="Left" />Left</label> <label><input type="checkbox" name="t5_t6[]" value="Right" />Right</label></td></tr>
 969
 970 </table>
 971
 972 <table>
 973
 974 <tr><td>T6 t7</td> <td><label><input type="checkbox" name="t6_t7[]" value="Left" />Left</label> <label><input type="checkbox" name="t6_t7[]" value="Right" />Right</label></td></tr>
 975
 976 </table>
 977
 978 <table>
 979
 980 <tr><td>T7 t8</td> <td><label><input type="checkbox" name="t7_t8[]" value="Left" />Left</label> <label><input type="checkbox" name="t7_t8[]" value="Right" />Right</label></td></tr>
 981
 982 </table>
 983
 984 <table>
 985
 986 <tr><td>T8 t9</td> <td><label><input type="checkbox" name="t8_t9[]" value="Left" />Left</label> <label><input type="checkbox" name="t8_t9[]" value="Right" />Right</label></td></tr>
 987
 988 </table>
 989
 990 <table>
 991
 992 <tr><td>T9 t10</td> <td><label><input type="checkbox" name="t9_t10[]" value="Left" />Left</label> <label><input type="checkbox" name="t9_t10[]" value="Right" />Right</label></td></tr>
 993
 994 </table>
 995
 996 <table>
 997
 998 <tr><td>T10 t11</td> <td><label><input type="checkbox" name="t10_t11[]" value="Left" />Left</label> <label><input type="checkbox" name="t10_t11[]" value="Right" />Right</label></td></tr>
 999
1000 </table>
1001
1002 <table>
1003
1004 <tr><td>T11 t12</td> <td><label><input type="checkbox" name="t11_t12[]" value="Left" />Left</label> <label><input type="checkbox" name="t11_t12[]" value="Right" />Right</label></td></tr>
1005
1006 </table>
1007
1008 <table>
1009
1010 <tr><td>T12 l1</td> <td><label><input type="checkbox" name="t12_l1[]" value="Left" />Left</label> <label><input type="checkbox" name="t12_l1[]" value="Right" />Right</label></td></tr>
1011
1012 </table>
1013
1014 <table>
1015
1016 <tr><td>L1 l2</td> <td><label><input type="checkbox" name="l1_l2[]" value="Left" />Left</label> <label><input type="checkbox" name="l1_l2[]" value="Right" />Right</label></td></tr>
1017
1018 </table>
1019
1020 <table>
1021
1022 <tr><td>L2 l3</td> <td><label><input type="checkbox" name="l2_l3[]" value="Left" />Left</label> <label><input type="checkbox" name="l2_l3[]" value="Right" />Right</label></td></tr>
1023
1024 </table>
1025
1026 <table>
1027
1028 <tr><td>L3 l4</td> <td><label><input type="checkbox" name="l3_l4[]" value="Left" />Left</label> <label><input type="checkbox" name="l3_l4[]" value="Right" />Right</label></td></tr>
1029
1030 </table>
1031
1032 <table>
1033
1034 <tr><td>L4 l5</td> <td><label><input type="checkbox" name="l4_l5[]" value="Left" />Left</label> <label><input type="checkbox" name="l4_l5[]" value="Right" />Right</label></td></tr>
1035
1036 </table>
1037
1038 <table>
1039
1040 <tr><td>L5 si</td> <td><label><input type="checkbox" name="l5_si[]" value="Left" />Left</label> <label><input type="checkbox" name="l5_si[]" value="Right" />Right</label></td></tr>
1041
1042 </table>
1043
1044 <table>
1045
1046 <tr><td>Si</td> <td><label><input type="checkbox" name="si[]" value="Left" />Left</label> <label><input type="checkbox" name="si[]" value="Right" />Right</label></td></tr>
1047
1048 </table>
1049
1050 <table>
1051
1052 <tr><td>Reflexes</td> <td><label><input type="checkbox" name="reflexes" value="yes" /></label></td></tr>
1053
1054 </table>
1055
1056 <table>
1057
1058 <tr><td>Bicep left</td> <td><select name="bicep_left" >
1059 <option value=""></option>
1060 <option value="Increase">Increase</option>
1061 <option value="Decrease">Decrease</option>
1062 <option value="Within Normal">Within Normal</option>
1063 </select></td></tr>
1064
1065 </table>
1066
1067 <table>
1068
1069 <tr><td>Bicep right</td> <td><select name="bicep_right" >
1070 <option value=""></option>
1071 <option value="Increase">Increase</option>
1072 <option value="Decrease">Decrease</option>
1073 <option value="Within Normal">Within Normal</option>
1074 </select></td></tr>
1075
1076 </table>
1077
1078 <table>
1079
1080 <tr><td>Brachio left</td> <td><select name="brachio_left" >
1081 <option value=""></option>
1082 <option value="Increase">Increase</option>
1083 <option value="Decrease">Decrease</option>
1084 <option value="Within Normal">Within Normal</option>
1085 </select></td></tr>
1086
1087 </table>
1088
1089 <table>
1090
1091 <tr><td>Brachio right</td> <td><select name="brachio_right" >
1092 <option value=""></option>
1093 <option value="Increase">Increase</option>
1094 <option value="Decrease">Decrease</option>
1095 <option value="Within Normal">Within Normal</option>
1096 </select></td></tr>
1097
1098 </table>
1099
1100 <table>
1101
1102 <tr><td>Tricep left</td> <td><select name="tricep_left" >
1103 <option value=""></option>
1104 <option value="Increase">Increase</option>
1105 <option value="Decrease">Decrease</option>
1106 <option value="Within Normal">Within Normal</option>
1107 </select></td></tr>
1108
1109 </table>
1110
1111 <table>
1112
1113 <tr><td>Tricep right</td> <td><select name="tricep_right" >
1114 <option value=""></option>
1115 <option value="Increase">Increase</option>
1116 <option value="Decrease">Decrease</option>
1117 <option value="Within Normal">Within Normal</option>
1118 </select></td></tr>
1119
1120 </table>
1121
1122 <table>
1123
1124 <tr><td>Patellar left</td> <td><select name="patellar_left" >
1125 <option value=""></option>
1126 <option value="Increase">Increase</option>
1127 <option value="Decrease">Decrease</option>
1128 <option value="Within Normal">Within Normal</option>
1129 </select></td></tr>
1130
1131 </table>
1132
1133 <table>
1134
1135 <tr><td>Patellar right</td> <td><select name="patellar_right" >
1136 <option value=""></option>
1137 <option value="Increase">Increase</option>
1138 <option value="Decrease">Decrease</option>
1139 <option value="Within Normal">Within Normal</option>
1140 </select></td></tr>
1141
1142 </table>
1143
1144 <table>
1145
1146 <tr><td>Achilles left</td> <td><select name="achilles_left" >
1147 <option value=""></option>
1148 <option value="Increase">Increase</option>
1149 <option value="Decrease">Decrease</option>
1150 <option value="Within Normal">Within Normal</option>
1151 </select></td></tr>
1152
1153 </table>
1154
1155 <table>
1156
1157 <tr><td>Achilles right</td> <td><select name="achilles_right" >
1158 <option value=""></option>
1159 <option value="Increase">Increase</option>
1160 <option value="Decrease">Decrease</option>
1161 <option value="Within Normal">Within Normal</option>
1162 </select></td></tr>
1163
1164 </table>
1165
1166 <table>
1167
1168 <tr><td>Vbi</td> <td><label><input type="checkbox" name="vbi[]" value="Negative" />Negative</label> <label><input type="checkbox" name="vbi[]" value="Positive" />Positive</label></td></tr>
1169
1170 </table>
1171
1172 <table>
1173
1174 <tr><td>Neurology</td> <td><label><input type="checkbox" name="neurology" value="yes" /></label></td></tr>
1175
1176 </table>
1177
1178 <table>
1179
1180 <tr><td>C5 motor</td> <td><select name="c5_motor" >
1181 <option value=""></option>
1182 <option value="Increase">Increase</option>
1183 <option value="Decrease">Decrease</option>
1184 <option value="Within Normal">Within Normal</option>
1185 </select></td></tr>
1186
1187 </table>
1188
1189 <table>
1190
1191 <tr><td>C5 sensation</td> <td><select name="c5_sensation" >
1192 <option value=""></option>
1193 <option value="Increase">Increase</option>
1194 <option value="Decrease">Decrease</option>
1195 <option value="Within Normal">Within Normal</option>
1196 </select></td></tr>
1197
1198 </table>
1199
1200 <table>
1201
1202 <tr><td>C6 motor</td> <td><select name="c6_motor" >
1203 <option value=""></option>
1204 <option value="Increase">Increase</option>
1205 <option value="Decrease">Decrease</option>
1206 <option value="Within Normal">Within Normal</option>
1207 </select></td></tr>
1208
1209 </table>
1210
1211 <table>
1212
1213 <tr><td>C6 sensation</td> <td><select name="c6_sensation" >
1214 <option value=""></option>
1215 <option value="Increase">Increase</option>
1216 <option value="Decrease">Decrease</option>
1217 <option value="Within Normal">Within Normal</option>
1218 </select></td></tr>
1219
1220 </table>
1221
1222 <table>
1223
1224 <tr><td>C7 motor</td> <td><select name="c7_motor" >
1225 <option value=""></option>
1226 <option value="Increase">Increase</option>
1227 <option value="Decrease">Decrease</option>
1228 <option value="Within Normal">Within Normal</option>
1229 </select></td></tr>
1230
1231 </table>
1232
1233 <table>
1234
1235 <tr><td>C7 sensation</td> <td><select name="c7_sensation" >
1236 <option value=""></option>
1237 <option value="Increase">Increase</option>
1238 <option value="Decrease">Decrease</option>
1239 <option value="Within Normal">Within Normal</option>
1240 </select></td></tr>
1241
1242 </table>
1243
1244 <table>
1245
1246 <tr><td>C8 motor</td> <td><select name="c8_motor" >
1247 <option value=""></option>
1248 <option value="Increase">Increase</option>
1249 <option value="Decrease">Decrease</option>
1250 <option value="Within Normal">Within Normal</option>
1251 </select></td></tr>
1252
1253 </table>
1254
1255 <table>
1256
1257 <tr><td>C8 sensation</td> <td><select name="c8_sensation" >
1258 <option value=""></option>
1259 <option value="Increase">Increase</option>
1260 <option value="Decrease">Decrease</option>
1261 <option value="Within Normal">Within Normal</option>
1262 </select></td></tr>
1263
1264 </table>
1265
1266 <table>
1267
1268 <tr><td>T1 motor</td> <td><select name="t1_motor" >
1269 <option value=""></option>
1270 <option value="Increase">Increase</option>
1271 <option value="Decrease">Decrease</option>
1272 <option value="Within Normal">Within Normal</option>
1273 </select></td></tr>
1274
1275 </table>
1276
1277 <table>
1278
1279 <tr><td>T1 sensation</td> <td><select name="t1_sensation" >
1280 <option value=""></option>
1281 <option value="Increase">Increase</option>
1282 <option value="Decrease">Decrease</option>
1283 <option value="Within Normal">Within Normal</option>
1284 </select></td></tr>
1285
1286 </table>
1287
1288 <table>
1289
1290 <tr><td>L4 motor</td> <td><select name="l4_motor" >
1291 <option value=""></option>
1292 <option value="Increase">Increase</option>
1293 <option value="Decrease">Decrease</option>
1294 <option value="Within Normal">Within Normal</option>
1295 </select></td></tr>
1296
1297 </table>
1298
1299 <table>
1300
1301 <tr><td>L4 sensation</td> <td><select name="l4_sensation" >
1302 <option value=""></option>
1303 <option value="Increase">Increase</option>
1304 <option value="Decrease">Decrease</option>
1305 <option value="Within Normal">Within Normal</option>
1306 </select></td></tr>
1307
1308 </table>
1309
1310 <table>
1311
1312 <tr><td>L5 motor</td> <td><select name="l5_motor" >
1313 <option value=""></option>
1314 <option value="Increase">Increase</option>
1315 <option value="Decrease">Decrease</option>
1316 <option value="Within Normal">Within Normal</option>
1317 </select></td></tr>
1318
1319 </table>
1320
1321 <table>
1322
1323 <tr><td>L5 sensation</td> <td><select name="l5_sensation" >
1324 <option value=""></option>
1325 <option value="Increase">Increase</option>
1326 <option value="Decrease">Decrease</option>
1327 <option value="Within Normal">Within Normal</option>
1328 </select></td></tr>
1329
1330 </table>
1331
1332 <table>
1333
1334 <tr><td>S1 motor</td> <td><select name="s1_motor" >
1335 <option value=""></option>
1336 <option value="Increase">Increase</option>
1337 <option value="Decrease">Decrease</option>
1338 <option value="Within Normal">Within Normal</option>
1339 </select></td></tr>
1340
1341 </table>
1342
1343 <table>
1344
1345 <tr><td>S1 sensation</td> <td><select name="s1_sensation" >
1346 <option value=""></option>
1347 <option value="Increase">Increase</option>
1348 <option value="Decrease">Decrease</option>
1349 <option value="Within Normal">Within Normal</option>
1350 </select></td></tr>
1351
1352 </table>
1353
1354 <table>
1355
1356 <tr><td>Coordination sensation</td> <td><select name="coordination_sensation" >
1357 <option value=""></option>
1358 <option value="Increase">Increase</option>
1359 <option value="Decrease">Decrease</option>
1360 <option value="Within Normal">Within Normal</option>
1361 </select></td></tr>
1362
1363 </table>
1364
1365 <table>
1366
1367 <tr><td>Muscle testing</td> <td><label><input type="checkbox" name="muscle_testing" value="yes" /></label></td></tr>
1368
1369 </table>
1370
1371 <table>
1372
1373 <tr><td>Cerv flex strgth</td> <td><select name="cerv_flex_strgth" >
1374 <option value=""></option>
1375 <option value="0">0</option>
1376 <option value="1">1</option>
1377 <option value="2">2</option>
1378 <option value="3">3</option>
1379 <option value="4">4</option>
1380 <option value="5">5</option>
1381 </select></td></tr>
1382
1383 </table>
1384
1385 <table>
1386
1387 <tr><td>Cerv flex tone</td> <td><select name="cerv_flex_tone" >
1388 <option value=""></option>
1389 <option value="Increase">Increase</option>
1390 <option value="Decrease">Decrease</option>
1391 <option value="Within Normal">Within Normal</option>
1392 </select></td></tr>
1393
1394 </table>
1395
1396 <table>
1397
1398 <tr><td>Cerv flex spasm</td> <td><label><input type="checkbox" name="cerv_flex_spasm" value="yes" /></label></td></tr>
1399
1400 </table>
1401
1402 <table>
1403
1404 <tr><td>Cerv flex pain</td> <td><select name="cerv_flex_pain" >
1405 <option value=""></option>
1406 <option value="Increase">Increase</option>
1407 <option value="Decrease">Decrease</option>
1408 <option value="Within Normal">Within Normal</option>
1409 </select></td></tr>
1410
1411 </table>
1412
1413 <table>
1414
1415 <tr><td>Scm strgth</td> <td><select name="scm_strgth" >
1416 <option value=""></option>
1417 <option value="0">0</option>
1418 <option value="1">1</option>
1419 <option value="2">2</option>
1420 <option value="3">3</option>
1421 <option value="4">4</option>
1422 <option value="5">5</option>
1423 </select></td></tr>
1424
1425 </table>
1426
1427 <table>
1428
1429 <tr><td>Scm tone</td> <td><select name="scm_tone" >
1430 <option value=""></option>
1431 <option value="Increase">Increase</option>
1432 <option value="Decrease">Decrease</option>
1433 <option value="Within Normal">Within Normal</option>
1434 </select></td></tr>
1435
1436 </table>
1437
1438 <table>
1439
1440 <tr><td>Scm spasm</td> <td><label><input type="checkbox" name="scm_spasm" value="yes" /></label></td></tr>
1441
1442 </table>
1443
1444 <table>
1445
1446 <tr><td>Scm pain</td> <td><select name="scm_pain" >
1447 <option value=""></option>
1448 <option value="Increase">Increase</option>
1449 <option value="Decrease">Decrease</option>
1450 <option value="Within Normal">Within Normal</option>
1451 </select></td></tr>
1452
1453 </table>
1454
1455 <table>
1456
1457 <tr><td>Upper trap strgth</td> <td><select name="upper_trap_strgth" >
1458 <option value=""></option>
1459 <option value="0">0</option>
1460 <option value="1">1</option>
1461 <option value="2">2</option>
1462 <option value="3">3</option>
1463 <option value="4">4</option>
1464 <option value="5">5</option>
1465 </select></td></tr>
1466
1467 </table>
1468
1469 <table>
1470
1471 <tr><td>Upper trap tone</td> <td><select name="upper_trap_tone" >
1472 <option value=""></option>
1473 <option value="Increase">Increase</option>
1474 <option value="Decrease">Decrease</option>
1475 <option value="Within Normal">Within Normal</option>
1476 </select></td></tr>
1477
1478 </table>
1479
1480 <table>
1481
1482 <tr><td>Upper trap spasm</td> <td><label><input type="checkbox" name="upper_trap_spasm" value="yes" /></label></td></tr>
1483
1484 </table>
1485
1486 <table>
1487
1488 <tr><td>Upper trap pain</td> <td><select name="upper_trap_pain" >
1489 <option value=""></option>
1490 <option value="Increase">Increase</option>
1491 <option value="Decrease">Decrease</option>
1492 <option value="Within Normal">Within Normal</option>
1493 </select></td></tr>
1494
1495 </table>
1496
1497 <table>
1498
1499 <tr><td>Mid trap strgth</td> <td><select name="mid_trap_strgth" >
1500 <option value=""></option>
1501 <option value="0">0</option>
1502 <option value="1">1</option>
1503 <option value="2">2</option>
1504 <option value="3">3</option>
1505 <option value="4">4</option>
1506 <option value="5">5</option>
1507 </select></td></tr>
1508
1509 </table>
1510
1511 <table>
1512
1513 <tr><td>Mid trap tone</td> <td><select name="mid_trap_tone" >
1514 <option value=""></option>
1515 <option value="Increase">Increase</option>
1516 <option value="Decrease">Decrease</option>
1517 <option value="Within Normal">Within Normal</option>
1518 </select></td></tr>
1519
1520 </table>
1521
1522 <table>
1523
1524 <tr><td>Mid trap spasm</td> <td><label><input type="checkbox" name="mid_trap_spasm" value="yes" /></label></td></tr>
1525
1526 </table>
1527
1528 <table>
1529
1530 <tr><td>Mid trap pain</td> <td><select name="mid_trap_pain" >
1531 <option value=""></option>
1532 <option value="Increase">Increase</option>
1533 <option value="Decrease">Decrease</option>
1534 <option value="Within Normal">Within Normal</option>
1535 </select></td></tr>
1536
1537 </table>
1538
1539 <table>
1540
1541 <tr><td>Lower trap strgth</td> <td><select name="lower_trap_strgth" >
1542 <option value=""></option>
1543 <option value="0">0</option>
1544 <option value="1">1</option>
1545 <option value="2">2</option>
1546 <option value="3">3</option>
1547 <option value="4">4</option>
1548 <option value="5">5</option>
1549 </select></td></tr>
1550
1551 </table>
1552
1553 <table>
1554
1555 <tr><td>Lower trap tone</td> <td><select name="lower_trap_tone" >
1556 <option value=""></option>
1557 <option value="Increase">Increase</option>
1558 <option value="Decrease">Decrease</option>
1559 <option value="Within Normal">Within Normal</option>
1560 </select></td></tr>
1561
1562 </table>
1563
1564 <table>
1565
1566 <tr><td>Lower trap spasm</td> <td><label><input type="checkbox" name="lower_trap_spasm" value="yes" /></label></td></tr>
1567
1568 </table>
1569
1570 <table>
1571
1572 <tr><td>Lower trap pain</td> <td><select name="lower_trap_pain" >
1573 <option value=""></option>
1574 <option value="Increase">Increase</option>
1575 <option value="Decrease">Decrease</option>
1576 <option value="Within Normal">Within Normal</option>
1577 </select></td></tr>
1578
1579 </table>
1580
1581 <table>
1582
1583 <tr><td>Scalenes strgth</td> <td><select name="scalenes_strgth" >
1584 <option value=""></option>
1585 <option value="0">0</option>
1586 <option value="1">1</option>
1587 <option value="2">2</option>
1588 <option value="3">3</option>
1589 <option value="4">4</option>
1590 <option value="5">5</option>
1591 </select></td></tr>
1592
1593 </table>
1594
1595 <table>
1596
1597 <tr><td>Scalenes tone</td> <td><select name="scalenes_tone" >
1598 <option value=""></option>
1599 <option value="Increase">Increase</option>
1600 <option value="Decrease">Decrease</option>
1601 <option value="Within Normal">Within Normal</option>
1602 </select></td></tr>
1603
1604 </table>
1605
1606 <table>
1607
1608 <tr><td>Scalenes spasm</td> <td><label><input type="checkbox" name="scalenes_spasm" value="yes" /></label></td></tr>
1609
1610 </table>
1611
1612 <table>
1613
1614 <tr><td>Scalenes pain</td> <td><select name="scalenes_pain" >
1615 <option value=""></option>
1616 <option value="Increase">Increase</option>
1617 <option value="Decrease">Decrease</option>
1618 <option value="Within Normal">Within Normal</option>
1619 </select></td></tr>
1620
1621 </table>
1622
1623 <table>
1624
1625 <tr><td>Subscap strgth</td> <td><select name="subscap_strgth" >
1626 <option value=""></option>
1627 <option value="0">0</option>
1628 <option value="1">1</option>
1629 <option value="2">2</option>
1630 <option value="3">3</option>
1631 <option value="4">4</option>
1632 <option value="5">5</option>
1633 </select></td></tr>
1634
1635 </table>
1636
1637 <table>
1638
1639 <tr><td>Subscap tone</td> <td><select name="subscap_tone" >
1640 <option value=""></option>
1641 <option value="Increase">Increase</option>
1642 <option value="Decrease">Decrease</option>
1643 <option value="Within Normal">Within Normal</option>
1644 </select></td></tr>
1645
1646 </table>
1647
1648 <table>
1649
1650 <tr><td>Subscap spasm</td> <td><label><input type="checkbox" name="subscap_spasm" value="yes" /></label></td></tr>
1651
1652 </table>
1653
1654 <table>
1655
1656 <tr><td>Subscap pain</td> <td><select name="subscap_pain" >
1657 <option value=""></option>
1658 <option value="Increase">Increase</option>
1659 <option value="Decrease">Decrease</option>
1660 <option value="Within Normal">Within Normal</option>
1661 </select></td></tr>
1662
1663 </table>
1664
1665 <table>
1666
1667 <tr><td>Supraspin strgth</td> <td><select name="supraspin_strgth" >
1668 <option value=""></option>
1669 <option value="0">0</option>
1670 <option value="1">1</option>
1671 <option value="2">2</option>
1672 <option value="3">3</option>
1673 <option value="4">4</option>
1674 <option value="5">5</option>
1675 </select></td></tr>
1676
1677 </table>
1678
1679 <table>
1680
1681 <tr><td>Supraspin tone</td> <td><select name="supraspin_tone" >
1682 <option value=""></option>
1683 <option value="Increase">Increase</option>
1684 <option value="Decrease">Decrease</option>
1685 <option value="Within Normal">Within Normal</option>
1686 </select></td></tr>
1687
1688 </table>
1689
1690 <table>
1691
1692 <tr><td>Supraspin spasm</td> <td><label><input type="checkbox" name="supraspin_spasm" value="yes" /></label></td></tr>
1693
1694 </table>
1695
1696 <table>
1697
1698 <tr><td>Supraspin pain</td> <td><select name="supraspin_pain" >
1699 <option value=""></option>
1700 <option value="Increase">Increase</option>
1701 <option value="Decrease">Decrease</option>
1702 <option value="Within Normal">Within Normal</option>
1703 </select></td></tr>
1704
1705 </table>
1706
1707 <table>
1708
1709 <tr><td>Teres strgth</td> <td><select name="teres_strgth" >
1710 <option value=""></option>
1711 <option value="0">0</option>
1712 <option value="1">1</option>
1713 <option value="2">2</option>
1714 <option value="3">3</option>
1715 <option value="4">4</option>
1716 <option value="5">5</option>
1717 </select></td></tr>
1718
1719 </table>
1720
1721 <table>
1722
1723 <tr><td>Teres tone</td> <td><select name="teres_tone" >
1724 <option value=""></option>
1725 <option value="Increase">Increase</option>
1726 <option value="Decrease">Decrease</option>
1727 <option value="Within Normal">Within Normal</option>
1728 </select></td></tr>
1729
1730 </table>
1731
1732 <table>
1733
1734 <tr><td>Teres spasm</td> <td><label><input type="checkbox" name="teres_spasm" value="yes" /></label></td></tr>
1735
1736 </table>
1737
1738 <table>
1739
1740 <tr><td>Teres pain</td> <td><select name="teres_pain" >
1741 <option value=""></option>
1742 <option value="Increase">Increase</option>
1743 <option value="Decrease">Decrease</option>
1744 <option value="Within Normal">Within Normal</option>
1745 </select></td></tr>
1746
1747 </table>
1748
1749 <table>
1750
1751 <tr><td>Quadriceps strgth</td> <td><select name="quadriceps_strgth" >
1752 <option value=""></option>
1753 <option value="0">0</option>
1754 <option value="1">1</option>
1755 <option value="2">2</option>
1756 <option value="3">3</option>
1757 <option value="4">4</option>
1758 <option value="5">5</option>
1759 </select></td></tr>
1760
1761 </table>
1762
1763 <table>
1764
1765 <tr><td>Quadriceps tone</td> <td><select name="quadriceps_tone" >
1766 <option value=""></option>
1767 <option value="Increase">Increase</option>
1768 <option value="Decrease">Decrease</option>
1769 <option value="Within Normal">Within Normal</option>
1770 </select></td></tr>
1771
1772 </table>
1773
1774 <table>
1775
1776 <tr><td>Quadriceps spasm</td> <td><label><input type="checkbox" name="quadriceps_spasm" value="yes" /></label></td></tr>
1777
1778 </table>
1779
1780 <table>
1781
1782 <tr><td>Quadriceps pain</td> <td><select name="quadriceps_pain" >
1783 <option value=""></option>
1784 <option value="Increase">Increase</option>
1785 <option value="Decrease">Decrease</option>
1786 <option value="Within Normal">Within Normal</option>
1787 </select></td></tr>
1788
1789 </table>
1790
1791 <table>
1792
1793 <tr><td>Psoas strgth</td> <td><select name="psoas_strgth" >
1794 <option value=""></option>
1795 <option value="0">0</option>
1796 <option value="1">1</option>
1797 <option value="2">2</option>
1798 <option value="3">3</option>
1799 <option value="4">4</option>
1800 <option value="5">5</option>
1801 </select></td></tr>
1802
1803 </table>
1804
1805 <table>
1806
1807 <tr><td>Psoas tone</td> <td><select name="psoas_tone" >
1808 <option value=""></option>
1809 <option value="Increase">Increase</option>
1810 <option value="Decrease">Decrease</option>
1811 <option value="Within Normal">Within Normal</option>
1812 </select></td></tr>
1813
1814 </table>
1815
1816 <table>
1817
1818 <tr><td>Psoas spasm</td> <td><label><input type="checkbox" name="psoas_spasm" value="yes" /></label></td></tr>
1819
1820 </table>
1821
1822 <table>
1823
1824 <tr><td>Psoas pain</td> <td><select name="psoas_pain" >
1825 <option value=""></option>
1826 <option value="Increase">Increase</option>
1827 <option value="Decrease">Decrease</option>
1828 <option value="Within Normal">Within Normal</option>
1829 </select></td></tr>
1830
1831 </table>
1832
1833 <table>
1834
1835 <tr><td>Tfl strgth</td> <td><select name="tfl_strgth" >
1836 <option value=""></option>
1837 <option value="0">0</option>
1838 <option value="1">1</option>
1839 <option value="2">2</option>
1840 <option value="3">3</option>
1841 <option value="4">4</option>
1842 <option value="5">5</option>
1843 </select></td></tr>
1844
1845 </table>
1846
1847 <table>
1848
1849 <tr><td>Tfl tone</td> <td><select name="tfl_tone" >
1850 <option value=""></option>
1851 <option value="Increase">Increase</option>
1852 <option value="Decrease">Decrease</option>
1853 <option value="Within Normal">Within Normal</option>
1854 </select></td></tr>
1855
1856 </table>
1857
1858 <table>
1859
1860 <tr><td>Tfl spasm</td> <td><label><input type="checkbox" name="tfl_spasm" value="yes" /></label></td></tr>
1861
1862 </table>
1863
1864 <table>
1865
1866 <tr><td>Tfl pain</td> <td><select name="tfl_pain" >
1867 <option value=""></option>
1868 <option value="Increase">Increase</option>
1869 <option value="Decrease">Decrease</option>
1870 <option value="Within Normal">Within Normal</option>
1871 </select></td></tr>
1872
1873 </table>
1874
1875 <table>
1876
1877 <tr><td>Piriformis strgth</td> <td><select name="piriformis_strgth" >
1878 <option value=""></option>
1879 <option value="0">0</option>
1880 <option value="1">1</option>
1881 <option value="2">2</option>
1882 <option value="3">3</option>
1883 <option value="4">4</option>
1884 <option value="5">5</option>
1885 </select></td></tr>
1886
1887 </table>
1888
1889 <table>
1890
1891 <tr><td>Piriformis tone</td> <td><select name="piriformis_tone" >
1892 <option value=""></option>
1893 <option value="Increase">Increase</option>
1894 <option value="Decrease">Decrease</option>
1895 <option value="Within Normal">Within Normal</option>
1896 </select></td></tr>
1897
1898 </table>
1899
1900 <table>
1901
1902 <tr><td>Piriformis spasm</td> <td><label><input type="checkbox" name="piriformis_spasm" value="yes" /></label></td></tr>
1903
1904 </table>
1905
1906 <table>
1907
1908 <tr><td>Piriformis pain</td> <td><select name="piriformis_pain" >
1909 <option value=""></option>
1910 <option value="Increase">Increase</option>
1911 <option value="Decrease">Decrease</option>
1912 <option value="Within Normal">Within Normal</option>
1913 </select></td></tr>
1914
1915 </table>
1916
1917 <table>
1918
1919 <tr><td>Gluteus strgth</td> <td><select name="gluteus_strgth" >
1920 <option value=""></option>
1921 <option value="0">0</option>
1922 <option value="1">1</option>
1923 <option value="2">2</option>
1924 <option value="3">3</option>
1925 <option value="4">4</option>
1926 <option value="5">5</option>
1927 </select></td></tr>
1928
1929 </table>
1930
1931 <table>
1932
1933 <tr><td>Gluteus tone</td> <td><select name="gluteus_tone" >
1934 <option value=""></option>
1935 <option value="Increase">Increase</option>
1936 <option value="Decrease">Decrease</option>
1937 <option value="Within Normal">Within Normal</option>
1938 </select></td></tr>
1939
1940 </table>
1941
1942 <table>
1943
1944 <tr><td>Gluteus spasm</td> <td><label><input type="checkbox" name="gluteus_spasm" value="yes" /></label></td></tr>
1945
1946 </table>
1947
1948 <table>
1949
1950 <tr><td>Gluteus pain</td> <td><select name="gluteus_pain" >
1951 <option value=""></option>
1952 <option value="Increase">Increase</option>
1953 <option value="Decrease">Decrease</option>
1954 <option value="Within Normal">Within Normal</option>
1955 </select></td></tr>
1956
1957 </table>
1958
1959 <table>
1960
1961 <tr><td>Hamstring strgth</td> <td><select name="hamstring_strgth" >
1962 <option value=""></option>
1963 <option value="0">0</option>
1964 <option value="1">1</option>
1965 <option value="2">2</option>
1966 <option value="3">3</option>
1967 <option value="4">4</option>
1968 <option value="5">5</option>
1969 </select></td></tr>
1970
1971 </table>
1972
1973 <table>
1974
1975 <tr><td>Hamstring tone</td> <td><select name="hamstring_tone" >
1976 <option value=""></option>
1977 <option value="Increase">Increase</option>
1978 <option value="Decrease">Decrease</option>
1979 <option value="Within Normal">Within Normal</option>
1980 </select></td></tr>
1981
1982 </table>
1983
1984 <table>
1985
1986 <tr><td>Hamstring spasm</td> <td><label><input type="checkbox" name="hamstring_spasm" value="yes" /></label></td></tr>
1987
1988 </table>
1989
1990 <table>
1991
1992 <tr><td>Hamstring pain</td> <td><select name="hamstring_pain" >
1993 <option value=""></option>
1994 <option value="Increase">Increase</option>
1995 <option value="Decrease">Decrease</option>
1996 <option value="Within Normal">Within Normal</option>
1997 </select></td></tr>
1998
1999 </table>
2000
2001 <table>
2002
2003 <tr><td>Quad lum strgth</td> <td><select name="quad_lum_strgth" >
2004 <option value=""></option>
2005 <option value="0">0</option>
2006 <option value="1">1</option>
2007 <option value="2">2</option>
2008 <option value="3">3</option>
2009 <option value="4">4</option>
2010 <option value="5">5</option>
2011 </select></td></tr>
2012
2013 </table>
2014
2015 <table>
2016
2017 <tr><td>Quad lum tone</td> <td><select name="quad_lum_tone" >
2018 <option value=""></option>
2019 <option value="Increase">Increase</option>
2020 <option value="Decrease">Decrease</option>
2021 <option value="Within Normal">Within Normal</option>
2022 </select></td></tr>
2023
2024 </table>
2025
2026 <table>
2027
2028 <tr><td>Quad lum spasm</td> <td><label><input type="checkbox" name="quad_lum_spasm" value="yes" /></label></td></tr>
2029
2030 </table>
2031
2032 <table>
2033
2034 <tr><td>Quad lum pain</td> <td><select name="quad_lum_pain" >
2035 <option value=""></option>
2036 <option value="Increase">Increase</option>
2037 <option value="Decrease">Decrease</option>
2038 <option value="Within Normal">Within Normal</option>
2039 </select></td></tr>
2040
2041 </table>
2042
2043 <table>
2044
2045 <tr><td>Lat dorsi strgth</td> <td><select name="lat_dorsi_strgth" >
2046 <option value=""></option>
2047 <option value="0">0</option>
2048 <option value="1">1</option>
2049 <option value="2">2</option>
2050 <option value="3">3</option>
2051 <option value="4">4</option>
2052 <option value="5">5</option>
2053 </select></td></tr>
2054
2055 </table>
2056
2057 <table>
2058
2059 <tr><td>Lat dorsi tone</td> <td><select name="lat_dorsi_tone" >
2060 <option value=""></option>
2061 <option value="Increase">Increase</option>
2062 <option value="Decrease">Decrease</option>
2063 <option value="Within Normal">Within Normal</option>
2064 </select></td></tr>
2065
2066 </table>
2067
2068 <table>
2069
2070 <tr><td>Lat dorsi spasm</td> <td><label><input type="checkbox" name="lat_dorsi_spasm" value="yes" /></label></td></tr>
2071
2072 </table>
2073
2074 <table>
2075
2076 <tr><td>Lat dorsi pain</td> <td><select name="lat_dorsi_pain" >
2077 <option value=""></option>
2078 <option value="Increase">Increase</option>
2079 <option value="Decrease">Decrease</option>
2080 <option value="Within Normal">Within Normal</option>
2081 </select></td></tr>
2082
2083 </table>
2084
2085 <table>
2086
2087 <tr><td>Infrspinatus strgth</td> <td><select name="infrspinatus_strgth" >
2088 <option value=""></option>
2089 <option value="0">0</option>
2090 <option value="1">1</option>
2091 <option value="2">2</option>
2092 <option value="3">3</option>
2093 <option value="4">4</option>
2094 <option value="5">5</option>
2095 </select></td></tr>
2096
2097 </table>
2098
2099 <table>
2100
2101 <tr><td>Infrspinatus tone</td> <td><select name="infrspinatus_tone" >
2102 <option value=""></option>
2103 <option value="Increase">Increase</option>
2104 <option value="Decrease">Decrease</option>
2105 <option value="Within Normal">Within Normal</option>
2106 </select></td></tr>
2107
2108 </table>
2109
2110 <table>
2111
2112 <tr><td>Infrspinatus spasm</td> <td><label><input type="checkbox" name="infrspinatus_spasm" value="yes" /></label></td></tr>
2113
2114 </table>
2115
2116 <table>
2117
2118 <tr><td>Infrspinatus pain</td> <td><select name="infrspinatus_pain" >
2119 <option value=""></option>
2120 <option value="Increase">Increase</option>
2121 <option value="Decrease">Decrease</option>
2122 <option value="Within Normal">Within Normal</option>
2123 </select></td></tr>
2124
2125 </table>
2126
2127 <table>
2128
2129 <tr><td>Diagnosis</td> <td><label><input type="checkbox" name="diagnosis[]" value="Cervical" />Cervical</label> <label><input type="checkbox" name="diagnosis[]" value="Thoracic" />Thoracic</label> <label><input type="checkbox" name="diagnosis[]" value="Lumbar" />Lumbar</label> <label><input type="checkbox" name="diagnosis[]" value="SI" />SI</label> <label><input type="checkbox" name="diagnosis[]" value="Dysfunction" />Dysfunction</label> <label><input type="checkbox" name="diagnosis[]" value="Strain Ligamentous Injury" />Strain Ligamentous Injury</label> <label><input type="checkbox" name="diagnosis[]" value="Muscle Spasms" />Muscle Spasms</label></td></tr>
2130
2131 </table>
2132
2133 <table>
2134
2135 <tr><td>Diagnosis other</td> <td><input type="text" name="diagnosis_other"  /></td></tr>
2136
2137 </table>
2138
2139 <table>
2140
2141 <tr><td>Treatment plan</td> <td><label><input type="checkbox" name="treatment_plan[]" value="Manual Manipulation" />Manual Manipulation</label> <label><input type="checkbox" name="treatment_plan[]" value="Manual Therapy Massage" />Manual Therapy Massage</label> <label><input type="checkbox" name="treatment_plan[]" value="Exercise Prescription" />Exercise Prescription</label></td></tr>
2142
2143 </table>
2144
2145 <table>
2146
2147 <tr><td>Treatment plan other</td> <td><input type="text" name="treatment_plan_other"  /></td></tr>
2148
2149 </table>
2150
2151 <table>
2152
2153 <tr><td>Frequency</td> <td><label><input type="checkbox" name="frequency[]" value="4-8 Tx" />4-8 Tx</label> <label><input type="checkbox" name="frequency[]" value="12-15 Tx Then Re-Exam" />12-15 Tx Then Re-Exam</label> <label><input type="checkbox" name="frequency[]" value="PRN Flare-Up" />PRN Flare-Up</label></td></tr>
2154
2155 </table>
2156
2157 <table>
2158
2159 <tr><td>Frequency other</td> <td><input type="text" name="frequency_other"  /></td></tr>
2160
2161 </table>
2162 <table></table><input type="submit" name="submit form" value="submit form" />
2163 </form>
2164 </body>
2165 </html>