3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: chiro_history");
6 $obj = formFetch("form_chiro_history", $_GET["id"]); //#Use the formFetch function from api.inc to get values for existing form.
8 function chkdata_Txt(&$obj, $var) {
9 return htmlentities($obj{"$var"});
11 function chkdata_Date(&$obj, $var) {
12 return htmlentities($obj{"$var"});
14 function chkdata_CB(&$obj, $nam, $var) {
15 if (preg_match("/Negative.*$var/",$obj{$nam}))
21 if (preg_match("/Positive.*$var/",$obj{$nam}))
27 if(preg_match("/$var/",$obj{$nam}))
39 function chkdata_Radio(&$obj, $nam, $var) {
40 if (strpos($obj{$nam},$var) !== false) {return "checked";}
43 function chkdata_PopOrScroll(&$obj, $nam, $var) {
44 if (preg_match("/Negative.*$var/",$obj{$nam}))
50 if (preg_match("/Positive.*$var/",$obj{$nam}))
68 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
70 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
71 <style type
="text/css">@import
url(../../../library
/dynarch_calendar
.css
);</style
>
72 <script type
="text/javascript" src
="../../../library/dialog.js"></script
>
73 <script type
="text/javascript" src
="../../../library/textformat.js"></script
>
74 <script type
="text/javascript" src
="../../../library/dynarch_calendar.js"></script
>
75 <script type
="text/javascript" src
="../../../library/dynarch_calendar_en.js"></script
>
76 <script type
="text/javascript" src
="../../../library/dynarch_calendar_setup.js"></script
>
77 <script language
='JavaScript'> var mypcc
= '1'; </script
>
79 <form method
=post action
="<?php echo $rootdir;?>/forms/chiro_history/save.php?mode=update&id=<?php echo $_GET["id
"];?>" name
="my_form" onsubmit
="return top.restoreSession()">
81 <h1
> <?php
xl("Chiropractic History",'e') ?
> </h1
>
83 <a href
='<?php echo $GLOBALS['webroot
']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick
='top.restoreSession()'> <?php
xl("[do not save]",'e') ?
> </a
>
84 <input type
="submit" name
="submit form" value
="submit form" /><br
>
86 <h3
> <?php
xl("History",'e') ?
> </h3
>
89 <table id
="HIS" style
="width:80%;margin-right:auto;margin-left:20px;"><tbody
class="data" style
="padding:2px 0px 0px 2px;margin:0px;line-height:10px;">
92 <td
><table
><tbody
class="data">
94 <td
><?php
xl("Past","e") ?
><br
/></td
><td colspan
=2><?php
xl("Present","e") ?
><br
/><?php
xl("General","e") ?
></td
>
97 <td
><input type
="checkbox" name
="general_condit['allergy'][0]" value
= "allergy" /></td
>
98 <td
><input type
="checkbox" name
="general_condit['allergy'][1]" value
= "allergy" /></td
>
99 <td
><?php
xl("Allergy", "e") ?
></td
> </tr
>
101 <td
><input type
="checkbox" name
="general_condit['convulsion'][0]" value
= "convulsion" /></td
>
102 <td
><input type
="checkbox" name
="general_condit['convulsion'][1]" value
= "convulsion" /></td
>
103 <td
><?php
xl("Convulsion", "e") ?
></td
></tr
>
105 <td
><input type
="checkbox" name
="general_condit['dizziness'][0]" value
= "dizziness" /></td
>
106 <td
><input type
="checkbox" name
="general_condit['dizziness'][1]" value
= "dizziness" /></td
>
107 <td
><?php
xl("Dizziness", "e") ?
></td
></tr
>
109 <td
><input type
="checkbox" name
="general_condit['fainting'][0]" value
= "fainting" /></td
>
110 <td
><input type
="checkbox" name
="general_condit['fainting'][1]" value
= "fainting" /></td
>
111 <td
><?php
xl("Fainting", "e") ?
></td
></tr
>
113 <td
><input type
="checkbox" name
="general_condit['fatigue'][0]" value
= "fatigue" /></td
>
114 <td
><input type
="checkbox" name
="general_condit['fatigue'][1]" value
= "fatigue" /></td
>
115 <td
><?php
xl("Fatigue", "e") ?
></td
></tr
>
117 <td
><input type
="checkbox" name
="general_condit['depression'][0]" value
= "depression" /></td
>
118 <td
><input type
="checkbox" name
="general_condit['depression'][1]" value
= "depression" /></td
>
119 <td
><?php
xl("Depression", "e") ?
></td
></tr
>
121 <td
><input type
="checkbox" name
="general_condit['headache'][0]" value
= "headache" /></td
>
122 <td
><input type
="checkbox" name
="general_condit['headache'][1]" value
= "headache" /></td
>
123 <td
><?php
xl("Headache", "e") ?
> </td
></tr
>
124 </tbody
></table
></td
>
126 <td
><table
><tbody
class="data">
128 <td
><?php
xl("Past","e") ?
><br
/></td
><td colspan
=2><?php
xl("Present","e") ?
><br
/><?php
xl("Gastro-Intestinal","e") ?
></td
>
131 <td
><input type
="checkbox" name
="gastrointest['constipation'][0]" value
= "constipation" /></td
>
132 <td
><input type
="checkbox" name
="gastrointest['constipation'][1]" value
= "constipation" /></td
>
133 <td
><?php
xl("Constipation", "e") ?
></td
> </tr
>
135 <td
><input type
="checkbox" name
="gastrointest['diarrhea'][0]" value
= "diarrhea" /></td
>
136 <td
><input type
="checkbox" name
="gastrointest['diarrhea'][1]" value
= "diarrhea" /></td
>
137 <td
><?php
xl("Diarrhea", "e") ?
></td
></tr
>
139 <td
><input type
="checkbox" name
="gastrointest['digestion_trouble'][0]" value
= "digestion_trouble" /></td
>
140 <td
><input type
="checkbox" name
="gastrointest['digestion_trouble'][1]" value
= "digestion_trouble" /></td
>
141 <td
><?php
xl("Difficult/Painful Digestion", "e") ?
></td
></tr
>
143 <td
><input type
="checkbox" name
="gastrointest['post_meal_short_breath'][0]" value
= "post_meal_short_breath" /></td
>
144 <td
><input type
="checkbox" name
="gastrointest['post_meal_short_breath'][1]" value
= "post_meal_short_breath" /></td
>
145 <td
><?php
xl("Shortness of Breathing after Meals", "e") ?
></td
></tr
>
147 <td
><input type
="checkbox" name
="gastrointest['ulcers'][0]" value
= "ulcers" /></td
>
148 <td
><input type
="checkbox" name
="gastrointest['ulcers'][1]" value
= "ulcers" /></td
>
149 <td
><?php
xl("Ulcers", "e") ?
></td
></tr
>
151 <td
><input type
="checkbox" name
="gastrointest['intestinal_gas'][0]" value
= "intestinal_gas" /></td
>
152 <td
><input type
="checkbox" name
="gastrointest['intestinal_gas'][1]" value
= "intestinal_gas" /></td
>
153 <td
><?php
xl("Intestinal Gas", "e") ?
></td
></tr
>
155 <td
><input type
="checkbox" name
="gastrointest['hemorrhoids'][0]" value
= "hemorrhoids" /></td
>
156 <td
><input type
="checkbox" name
="gastrointest['hemorrhoids'][1]" value
= "hemorrhoids" /></td
>
157 <td
><?php
xl("Hemorrhoids", "e") ?
> </td
></tr
>
159 <td
><input type
="checkbox" name
="gastrointest['heartburn'][0]" value
= "heartburn" /></td
>
160 <td
><input type
="checkbox" name
="gastrointest['heartburn'][1]" value
= "heartburn" /></td
>
161 <td
><?php
xl("Heartburn", "e") ?
></td
></tr
>
163 <td
><input type
="checkbox" name
="gastrointest['histal_hernia'][0]" value
= "histal_hernia" /></td
>
164 <td
><input type
="checkbox" name
="gastrointest['histal_hernia'][1]" value
= "histal_hernia" /></td
>
165 <td
><?php
xl("Histal Hernia", "e") ?
> </td
></tr
>
166 </tbody
></table
></td
>
168 <td
><table
><tbody
class="data">
170 <td
><?php
xl("Past","e") ?
><br
/></td
><td colspan
=2><?php
xl("Present","e") ?
><br
/><?php
xl("Eyes,Ears,Nose&Throat","e") ?
></td
>
173 <td
><input type
="checkbox" name
="head_neck['eye_pain'][0]" value
= "eye_pain" /></td
>
174 <td
><input type
="checkbox" name
="head_neck['eye_pain'][1]" value
= "eye_pain" /></td
>
175 <td
><?php
xl("Eye Pain", "e") ?
></td
> </tr
>
177 <td
><input type
="checkbox" name
="head_neck['nearorfar_sighted'][0]" value
= "nearorfar_sighted" /></td
>
178 <td
><input type
="checkbox" name
="head_neck['nearorfar_sighted'][1]" value
= "nearorfar_sighted" /></td
>
179 <td
><?php
xl("Near or Far Sighted", "e") ?
></td
></tr
>
181 <td
><input type
="checkbox" name
="head_neck['light_sensitivity'][0]" value
= "light_sensitivity" /></td
>
182 <td
><input type
="checkbox" name
="head_neck['light_sensitivity'][1]" value
= "light_sensitivity" /></td
>
183 <td
><?php
xl("Light Bothers Eyes", "e") ?
></td
></tr
>
185 <td
><input type
="checkbox" name
="head_neck['deafness'][0]" value
= "deafness" /></td
>
186 <td
><input type
="checkbox" name
="head_neck['deafness'][1]" value
= "deafness" /></td
>
187 <td
><?php
xl("Deafness", "e") ?
></td
></tr
>
189 <td
><input type
="checkbox" name
="head_neck['earaches'][0]" value
= "earaches" /></td
>
190 <td
><input type
="checkbox" name
="head_neck['earaches'][1]" value
= "earaches" /></td
>
191 <td
><?php
xl("Earaches", "e") ?
></td
></tr
>
193 <td
><input type
="checkbox" name
="head_neck['ear_noises'][0]" value
= "ear_noises" /></td
>
194 <td
><input type
="checkbox" name
="head_neck['ear_noises'][1]" value
= "ear_noises" /></td
>
195 <td
><?php
xl("Ear Noises", "e") ?
></td
></tr
>
197 <td
><input type
="checkbox" name
="head_neck['sinus'][0]" value
= "sinus" /></td
>
198 <td
><input type
="checkbox" name
="head_neck['sinus'][1]" value
= "sinus" /></td
>
199 <td
><?php
xl("Sinus", "e") ?
> </td
></tr
>
200 </tbody
></table
></td
>
205 <td
><table
><tbody
class="data">
207 <td
/><td colspan
=2><?php
xl("Muscle & Joints","e") ?
></td
>
210 <td
><input type
="checkbox" name
="muscle_joint['jaw_problems'][0]" value
= "jaw_problems" /></td
>
211 <td
><input type
="checkbox" name
="muscle_joint['jaw_problems'][1]" value
= "jaw_problems" /></td
>
212 <td
><?php
xl("Jaw Problems", "e") ?
></td
> </tr
>
214 <td
><input type
="checkbox" name
="muscle_joint['grindclench_teeth'][0]" value
= "grindclench_teeth" /></td
>
215 <td
><input type
="checkbox" name
="muscle_joint['grindclench_teeth'][1]" value
= "grindclench_teeth" /></td
>
216 <td
><?php
xl("Grinding or Clenching Teeth", "e") ?
></td
></tr
>
218 <td
><input type
="checkbox" name
="muscle_joint['lowback_pain'][0]" value
= "lowback_pain" /></td
>
219 <td
><input type
="checkbox" name
="muscle_joint['lowback_pain'][1]" value
= "lowback_pain" /></td
>
220 <td
><?php
xl("Lower Back Pain", "e") ?
></td
></tr
>
222 <td
><input type
="checkbox" name
="muscle_joint['betweenshoulder_pain'][0]" value
= "betweenshoulder_pain" /></td
>
223 <td
><input type
="checkbox" name
="muscle_joint['betweenshoulder_pain'][1]" value
= "betweenshoulder_pain" /></td
>
224 <td
><?php
xl("Pain Between Shoulders", "e") ?
></td
></tr
>
225 </tbody
></table
></td
>
227 <td
><table
><tbody
class="data">
229 <td
/><td colspan
=2><?php
xl("Genito-Urinary","e") ?
></td
>
232 <td
><input type
="checkbox" name
="genitouro['bed_wetting'][0]" value
= "bed_wetting" /></td
>
233 <td
><input type
="checkbox" name
="genitouro['bed_wetting'][1]" value
= "bed_wetting" /></td
>
234 <td
><?php
xl("Bed Wetting", "e") ?
></td
> </tr
>
236 <td
><input type
="checkbox" name
="genitouro['blood_urine'][0]" value
= "blood_urine" /></td
>
237 <td
><input type
="checkbox" name
="genitouro['blood_urine'][1]" value
= "blood_urine" /></td
>
238 <td
><?php
xl("Blood in Urine", "e") ?
></td
></tr
>
240 <td
><input type
="checkbox" name
="genitouro['frequent_urine'][0]" value
= "frequent_urine" /></td
>
241 <td
><input type
="checkbox" name
="genitouro['frequent_urine'][1]" value
= "frequent_urine" /></td
>
242 <td
><?php
xl("Frequent Urination", "e") ?
></td
></tr
>
244 <td
><input type
="checkbox" name
="genitouro['no_kidney_control'][0]" value
= "no_kidney_control" /></td
>
245 <td
><input type
="checkbox" name
="genitouro['no_kidney_control'][1]" value
= "no_kidney_control" /></td
>
246 <td
><?php
xl("Inability to Control Kidneys", "e") ?
></td
></tr
>
248 <td
><input type
="checkbox" name
="genitouro['kidney_infectionorstones'][0]" value
= "kidney_infectionorstones" /></td
>
249 <td
><input type
="checkbox" name
="genitouro['kidney_infectionorstones'][1]" value
= "kidney_infectionorstones" /></td
>
250 <td
><?php
xl("Kidney Infection or Stones", "e") ?
></td
></tr
>
252 <td
><input type
="checkbox" name
="genitouro['painful_urination'][0]" value
= "painful_urination" /></td
>
253 <td
><input type
="checkbox" name
="genitouro['painful_urination'][1]" value
= "painful_urination" /></td
>
254 <td
><?php
xl("Painful Urination", "e") ?
></td
></tr
>
256 <td
><input type
="checkbox" name
="genitouro['prostate_trouble'][0]" value
= "prostate_trouble" /></td
>
257 <td
><input type
="checkbox" name
="genitouro['prostate_trouble'][1]" value
= "prostate_trouble" /></td
>
258 <td
><?php
xl("Prostate Trouble", "e") ?
> </td
></tr
>
260 <td
><input type
="checkbox" name
="genitouro['urine_pus'][0]" value
= "urine_pus" /></td
>
261 <td
><input type
="checkbox" name
="genitouro['urine_pus'][1]" value
= "urine_pus" /></td
>
262 <td
><?php
xl("Pus in Urine", "e") ?
></td
></tr
>
264 <td
><input type
="checkbox" name
="genitouro['bladder_infection'][0]" value
= "bladder_infection" /></td
>
265 <td
><input type
="checkbox" name
="genitouro['bladder_infection'][1]" value
= "bladder_infection" /></td
>
266 <td
><?php
xl("Bladder Infection", "e") ?
> </td
></tr
>
267 </tbody
></table
></td
>
269 <td
><table
><tbody
class="data">
271 <td
/><td colspan
=2><?php
xl("Cardiovascular","e") ?
></td
>
274 <td
><input type
="checkbox" name
="cardiovascular['high_bpressure'][0]" value
= "high_bpressure" /></td
>
275 <td
><input type
="checkbox" name
="cardiovascular['high_bpressure'][1]" value
= "high_bpressure" /></td
>
276 <td
><?php
xl("High Blood Pressure", "e") ?
></td
> </tr
>
278 <td
><input type
="checkbox" name
="cardiovascular['low_bpressure'][0]" value
= "low_bpressure" /></td
>
279 <td
><input type
="checkbox" name
="cardiovascular['low_bpressure'][1]" value
= "low_bpressure" /></td
>
280 <td
><?php
xl("Low Blood Pressure", "e") ?
></td
></tr
>
282 <td
><input type
="checkbox" name
="cardiovascular['poor_circulation'][0]" value
= "poor_circulation" /></td
>
283 <td
><input type
="checkbox" name
="cardiovascular['poor_circulation'][1]" value
= "poor_circulation" /></td
>
284 <td
><?php
xl("Poor Circulation", "e") ?
></td
></tr
>
286 <td
><input type
="checkbox" name
="cardiovascular['rapid_heartbeat'][0]" value
= "rapid_heartbeat" /></td
>
287 <td
><input type
="checkbox" name
="cardiovascular['rapid_heartbeat'][1]" value
= "rapid_heartbeat" /></td
>
288 <td
><?php
xl("Rapid Heartbeat", "e") ?
></td
></tr
>
290 <td
><input type
="checkbox" name
="cardiovascular['slow_heartbeat'][0]" value
= "slow_heartbeat" /></td
>
291 <td
><input type
="checkbox" name
="cardiovascular['slow_heartbeat'][1]" value
= "slow_heartbeat" /></td
>
292 <td
><?php
xl("Slow Heartbeat", "e") ?
></td
></tr
>
293 </tbody
></table
></td
>
298 <td
><table
><tbody
class="data">
300 <td
/><td colspan
=2><?php
xl("Pain or Numbness In:","e") ?
></td
>
303 <td
><input type
="checkbox" name
="pain_numb_locat['neck'][0]" value
= "neck" /></td
>
304 <td
><input type
="checkbox" name
="pain_numb_locat['neck'][1]" value
= "neck" /></td
>
305 <td
><?php
xl("Neck", "e") ?
></td
> </tr
>
307 <td
><input type
="checkbox" name
="pain_numb_locat['shoulder'][0]" value
= "shoulder" /></td
>
308 <td
><input type
="checkbox" name
="pain_numb_locat['shoulder'][1]" value
= "shoulder" /></td
>
309 <td
><?php
xl("Shoulder", "e") ?
></td
></tr
>
311 <td
><input type
="checkbox" name
="pain_numb_locat['arm'][0]" value
= "arm" /></td
>
312 <td
><input type
="checkbox" name
="pain_numb_locat['arm'][1]" value
= "arm" /></td
>
313 <td
><?php
xl("Arm", "e") ?
></td
></tr
>
315 <td
><input type
="checkbox" name
="pain_numb_locat['elbow'][0]" value
= "elbow" /></td
>
316 <td
><input type
="checkbox" name
="pain_numb_locat['elbow'][1]" value
= "elbow" /></td
>
317 <td
><?php
xl("Elbow", "e") ?
></td
></tr
>
319 <td
><input type
="checkbox" name
="pain_numb_locat['hands'][0]" value
= "hands" /></td
>
320 <td
><input type
="checkbox" name
="pain_numb_locat['hands'][1]" value
= "hands" /></td
>
321 <td
><?php
xl("Hands", "e") ?
></td
> </tr
>
323 <td
><input type
="checkbox" name
="pain_numb_locat['hip'][0]" value
= "hip" /></td
>
324 <td
><input type
="checkbox" name
="pain_numb_locat['hip'][1]" value
= "hip" /></td
>
325 <td
><?php
xl("Hip", "e") ?
></td
></tr
>
327 <td
><input type
="checkbox" name
="pain_numb_locat['legs'][0]" value
= "legs" /></td
>
328 <td
><input type
="checkbox" name
="pain_numb_locat['legs'][1]" value
= "legs" /></td
>
329 <td
><?php
xl("Legs", "e") ?
></td
></tr
>
331 <td
><input type
="checkbox" name
="pain_numb_locat['knees'][0]" value
= "knees" /></td
>
332 <td
><input type
="checkbox" name
="pain_numb_locat['knees'][1]" value
= "knees" /></td
>
333 <td
><?php
xl("Knees", "e") ?
></td
></tr
>
335 <td
><input type
="checkbox" name
="pain_numb_locat['feet'][0]" value
= "feet" /></td
>
336 <td
><input type
="checkbox" name
="pain_numb_locat['feet'][1]" value
= "feet" /></td
>
337 <td
><?php
xl("Feet", "e") ?
></td
></tr
>
338 </tbody
></table
></td
>
340 <td
><table
><tbody
class="data">
342 <td
/><td colspan
=2><?php
xl("Respiratory","e") ?
></td
>
345 <td
><input type
="checkbox" name
="respiratory['chronic_cough'][0]" value
= "chronic_cough" /></td
>
346 <td
><input type
="checkbox" name
="respiratory['chronic_cough'][1]" value
= "chronic_cough" /></td
>
347 <td
><?php
xl("Chronic Cough", "e") ?
></td
> </tr
>
349 <td
><input type
="checkbox" name
="respiratory['chest_pain'][0]" value
= "chest_pain" /></td
>
350 <td
><input type
="checkbox" name
="respiratory['chest_pain'][1]" value
= "chest_pain" /></td
>
351 <td
><?php
xl("Chest Pain", "e") ?
></td
></tr
>
353 <td
><input type
="checkbox" name
="respiratory['difficulty_breathing'][0]" value
= "difficulty_breathing" /></td
>
354 <td
><input type
="checkbox" name
="respiratory['difficulty_breathing'][1]" value
= "difficulty_breathing" /></td
>
355 <td
><?php
xl("Difficulty Breathing", "e") ?
></td
></tr
>
357 <td
><input type
="checkbox" name
="respiratory['blood_spitting'][0]" value
= "blood_spitting" /></td
>
358 <td
><input type
="checkbox" name
="respiratory['blood_spitting'][1]" value
= "blood_spitting" /></td
>
359 <td
><?php
xl("Spitting up Blood", "e") ?
></td
></tr
>
361 <td
><input type
="checkbox" name
="respiratory['wheezing'][0]" value
= "wheezing" /></td
>
362 <td
><input type
="checkbox" name
="respiratory['wheezing'][1]" value
= "wheezing" /></td
>
363 <td
><?php
xl("Wheezing", "e") ?
></td
></tr
>
365 <td
><input type
="checkbox" name
="respiratory['asthma'][0]" value
= "asthma" /></td
>
366 <td
><input type
="checkbox" name
="respiratory['asthma'][1]" value
= "asthma" /></td
>
367 <td
><?php
xl("Asthma", "e") ?
></td
></tr
>
368 </tbody
></table
></td
>
370 <td
><table
><tbody
class="data">
372 <td
/><td colspan
=2><?php
xl("Women Only","e") ?
></td
>
375 <td
><input type
="checkbox" name
="women_health['congested_breasts'][0]" value
= "congested_breasts" /></td
>
376 <td
><input type
="checkbox" name
="women_health['congested_breasts'][1]" value
= "congested_breasts" /></td
>
377 <td
><?php
xl("Congested Breasts", "e") ?
></td
> </tr
>
379 <td
><input type
="checkbox" name
="women_health['cramps_backache'][0]" value
= "cramps_backache" /></td
>
380 <td
><input type
="checkbox" name
="women_health['cramps_backache'][1]" value
= "cramps_backache" /></td
>
381 <td
><?php
xl("Cramps or Backache", "e") ?
></td
></tr
>
383 <td
><input type
="checkbox" name
="women_health['excessive_menses'][0]" value
= "excessive_menses" /></td
>
384 <td
><input type
="checkbox" name
="women_health['excessive_menses'][1]" value
= "excessive_menses" /></td
>
385 <td
><?php
xl("Excessive Menstruation", "e") ?
></td
></tr
>
387 <td
><input type
="checkbox" name
="women_health['menopausal_signs'][0]" value
= "menopausal_signs" /></td
>
388 <td
><input type
="checkbox" name
="women_health['menopausal_signs'][1]" value
= "menopausal_signs" /></td
>
389 <td
><?php
xl("Menopausal Symptoms", "e") ?
></td
></tr
>
391 <td
><input type
="checkbox" name
="women_health['irregular_cycle'][0]" value
= "irregular_cycle" /></td
>
392 <td
><input type
="checkbox" name
="women_health['irregular_cycle'][1]" value
= "irregular_cycle" /></td
>
393 <td
><?php
xl("Irregular Cycle", "e") ?
></td
></tr
>
395 <td
><input type
="checkbox" name
="women_health['lumps'][0]" value
= "lumps" /></td
>
396 <td
><input type
="checkbox" name
="women_health['lumps'][1]" value
= "lumps" /></td
>
397 <td
><?php
xl("Lumps in Breasts", "e") ?
></td
> </tr
>
399 <td
><input type
="checkbox" name
="women_health['painful_menses'][0]" value
= "painful_menses" /></td
>
400 <td
><input type
="checkbox" name
="women_health['painful_menses'][1]" value
= "painful_menses" /></td
>
401 <td
><?php
xl("Painful Menstruation", "e") ?
></td
></tr
>
403 <td
><input type
="checkbox" name
="women_health['vaginal_discharge'][0]" value
= "vaginal_discharge" /></td
>
404 <td
><input type
="checkbox" name
="women_health['vaginal_discharge'][1]" value
= "vaginal_discharge" /></td
>
405 <td
><?php
xl("Vaginal Discharge", "e") ?
></td
></tr
>
407 <td
><input type
="checkbox" name
="women_health['endometriosis'][0]" value
= "endometriosis" /></td
>
408 <td
><input type
="checkbox" name
="women_health['endometriosis'][1]" value
= "endometriosis" /></td
>
409 <td
><?php
xl("Endometriosis", "e") ?
></td
></tr
>
411 <td
><input type
="checkbox" name
="women_health['premenstrual_syndrome'][0]" value
= "premenstrual_syndrome" /></td
>
412 <td
><input type
="checkbox" name
="women_health['premenstrual_syndrome'][1]" value
= "premenstrual_syndrome" /></td
>
413 <td
><?php
xl("Premenstrual Syndrome", "e") ?
></td
></tr
>
414 </tbody
></table
></td
>
418 <td colspan
=3><hr
/><table style
="width:100%;"><tbody
class="data"><tr
>
419 <td
><input type
="checkbox" name
="alcoholism" value
= "alcoholism" /> <?php
xl("Alcoholism", "e") ?
><br
/>
420 <input type
="checkbox" name
="anemia" value
= "anemia" /> <?php
xl("Anemia", "e") ?
><br
/>
421 <input type
="checkbox" name
="arthritis" value
= "arthritis" /> <?php
xl("Arthritis", "e") ?
><br
/>
422 <input type
="checkbox" name
="cancer" value
= "cancer" /> <?php
xl("Cancer", "e") ?
><br
/>
423 <input type
="checkbox" name
="herpes" value
= "herpes" /> <?php
xl("Herpes", "e") ?
><br
/>
424 <input type
="checkbox" name
="hypoglycemia" value
= "hypoglycemia" /> <?php
xl("Hypoglycemia", "e") ?
><br
/>
426 <td
><input type
="checkbox" name
="diabetes" value
= "diabetes" /> <?php
xl("Diabetes", "e") ?
><br
/>
427 <input type
="checkbox" name
="eczema" value
= "eczema" /> <?php
xl("Eczema", "e") ?
><br
/>
428 <input type
="checkbox" name
="emphysema" value
= "emphysema" /> <?php
xl("Emphysema", "e") ?
><br
/>
429 <input type
="checkbox" name
="goiter" value
= "goiter" /> <?php
xl("Goiter", "e") ?
><br
/>
430 <input type
="checkbox" name
="ulcers" value
= "ulcers" /> <?php
xl("Ulcers", "e") ?
><br
/>
432 <td
><input type
="checkbox" name
="gout" value
= "gout" /> <?php
xl("Gout", "e") ?
><br
/>
433 <input type
="checkbox" name
="heart_disease" value
= "heart_disease" /> <?php
xl("Heart Disease/Attack", "e") ?
><br
/>
434 <input type
="checkbox" name
="rheumetic_fever" value
= "rheumetic_fever" /> <?php
xl("Rheumatic Fever", "e") ?
><br
/>
435 <input type
="checkbox" name
="miscarriage" value
= "miscarriage" /> <?php
xl("Miscarriage", "e") ?
><br
/>
436 <input type
="checkbox" name
="polio" value
= "polio" /> <?php
xl("Polio", "e") ?
><br
/>
438 <td
><input type
="checkbox" name
="pneumonia" value
= "pneumonia" /> <?php
xl("Pneumonia", "e") ?
><br
/>
439 <input type
="checkbox" name
="atherosclerosis" value
= "atherosclerosis" /> <?php
xl("Atherosclerosis", "e") ?
><br
/>
440 <input type
="checkbox" name
="multiple_sclerosis" value
= "multiple_sclerosis" /> <?php
xl("Multiple Sclerosis", "e") ?
><br
/>
441 <input type
="checkbox" name
="stroke" value
= "stroke" /> <?php
xl("Stroke", "e") ?
><br
/>
442 <input type
="checkbox" name
="tuberculosis" value
= "tuberculosis" /> <?php
xl("Tuberculosis", "e") ?
><br
/>
444 <td
><input type
="checkbox" name
="epilepsy" value
= "epilepsy" /> <?php
xl("Epilepsy", "e") ?
><br
/>
445 <input type
="checkbox" name
="measles" value
= "measles" /> <?php
xl("Measles", "e") ?
><br
/>
446 <input type
="checkbox" name
="mumps" value
= "mumps" /> <?php
xl("Mumps", "e") ?
><br
/>
447 <input type
="checkbox" name
="chicken_pox" value
= "chicken_pox" /> <?php
xl("Chicken Pox", "e") ?
><br
/>
448 <input type
="checkbox" name
="venereal_disease" value
= "venereal_disease" /> <?php
xl("Venereal Disease", "e") ?
><br
/>
450 </tr
></tbody
></table
><hr
/></td
>
454 <td colspan
=3><table
><tbody
class="data">
456 <td colspan
=2><?php
xl("Please Indicate If You Have/Had Trouble With Any Glands/Organs", "e")?
><br
/>
458 <td colspan
=2><?php
xl("Family History: Have Your Mother or Father Had Any of These Disorders?", "e")?
><br
/>
463 <td
><label
><input type
="checkbox" name
="organ_gland[]" value
="pituitary" /><?php
xl("Pituitary", "e") ?
></lable
><br
/>
464 <label
><input type
="checkbox" name
="organ_gland[]" value
="thyroid" /><?php
xl("Thyroid", "e") ?
></lable
><br
/>
465 <label
><input type
="checkbox" name
="organ_gland[]" value
="pancreas" /><?php
xl("Pancreas", "e") ?
></lable
><br
/>
466 <label
><input type
="checkbox" name
="organ_gland[]" value
="adrenal" /><?php
xl("Adrenal", "e") ?
></lable
><br
/>
467 <label
><input type
="checkbox" name
="organ_gland[]" value
="ovary_teste" /><?php
xl("Ovary/Teste", "e") ?
></lable
><br
/>
468 <label
><input type
="checkbox" name
="organ_gland[]" value
="liver" /><?php
xl("Liver", "e") ?
></lable
><br
/>
469 <label
><input type
="checkbox" name
="organ_gland[]" value
="gall_bladder" /><?php
xl("Gall Bladder", "e") ?
></label
></td
>
471 <td
><label
><input type
="checkbox" name
="organ_gland[]" value
="stomach" /><?php
xl("Stomach", "e") ?
></lable
><br
/>
472 <label
><input type
="checkbox" name
="organ_gland[]" value
="small_intestine" /><?php
xl("Small Intestine", "e") ?
></lable
><br
/>
473 <label
><input type
="checkbox" name
="organ_gland[]" value
="large_intestine" /><?php
xl("Large Intestine", "e") ?
></lable
><br
/>
474 <label
><input type
="checkbox" name
="organ_gland[]" value
="bladder" /><?php
xl("Bladder", "e") ?
></lable
><br
/>
475 <label
><input type
="checkbox" name
="organ_gland[]" value
="lungs" /><?php
xl("Lungs", "e") ?
></lable
><br
/>
476 <label
><input type
="checkbox" name
="organ_gland[]" value
="prostate_uterus" /><?php
xl("Prostate/Uterus", "e") ?
></label
></td
>
478 <td
><label
><input type
="checkbox" name
="family_history[]" value
="arthritis" /><?php
xl("Arthritis", "e") ?
></lable
><br
/>
479 <label
><input type
="checkbox" name
="family_history[]" value
="atherosclerosis" /><?php
xl("Atherosclerosis", "e") ?
></lable
><br
/>
480 <label
><input type
="checkbox" name
="family_history[]" value
="osteoprosis" /><?php
xl("Osteoporosis", "e") ?
></lable
><br
/>
481 <label
><input type
="checkbox" name
="family_history[]" value
="allergies" /><?php
xl("Allergies", "e") ?
></lable
><br
/>
482 <label
><input type
="checkbox" name
="family_history[]" value
="cancer" /><?php
xl("Cancer", "e") ?
></lable
><br
/>
483 <label
><input type
="checkbox" name
="family_history[]" value
="obesity" /><?php
xl("Obesity", "e") ?
></lable
><br
/>
484 <label
><input type
="checkbox" name
="family_history[]" value
="hemorrhoids" /><?php
xl("Hemorrhoids", "e") ?
></label
></td
>
486 <td
><label
><input type
="checkbox" name
="family_history[]" value
="stroke" /><?php
xl("Stroke", "e") ?
></lable
><br
/>
487 <label
><input type
="checkbox" name
="family_history[]" value
="alcoholism" /><?php
xl("Alcoholism", "e") ?
></lable
><br
/>
488 <label
><input type
="checkbox" name
="family_history[]" value
="high_bpressure" /><?php
xl("High Blood Pressure", "e") ?
></lable
><br
/>
489 <label
><input type
="checkbox" name
="family_history[]" value
="heart_disease" /><?php
xl("Heart Trouble", "e") ?
></lable
><br
/>
490 <label
><input type
="checkbox" name
="family_history[]" value
="kidney_disease" /><?php
xl("Kidney Disorders", "e") ?
></lable
><br
/>
491 <label
><input type
="checkbox" name
="family_history[]" value
="nervous_disorder" /><?php
xl("Other Nervous Systems", "e") ?
></lable
><br
/>
492 <label
><input type
="checkbox" name
="family_history[]" value
="spinal_disorder" /><?php
xl("Spinal Problems", "e") ?
></label
></td
>
495 </tbody
></table
></td
>
498 <tr
><td colspan
=3><hr
/>
499 <?php
xl("Check Which Meals That You Eat Regularly: ", "e")?
>
500 <input type
="checkbox" name
="regular_meals" value
="breakfast" /><?php
xl(" Breakfast", "e")?
>
501 <input type
="checkbox" name
="regular_meals" value
="lunch" /><?php
xl(" Lunch", "e")?
>
502 <input type
="checkbox" name
="regular_meals" value
="dinner" /><?php
xl(" Dinner", "e")?
>
503 <input type
="checkbox" name
="regular_meals" value
="between_meals" /><?php
xl(" Between Meals", "e")?
>
504 <input type
="checkbox" name
="regular_meals" value
="before_bed" /><?php
xl(" Before Bed", "e")?
>
508 <input type
="submit" name
="submit form" value
="submit form" />
510 <a href
='<?php echo $GLOBALS['webroot
']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick
='top.restoreSession()'> <?php
xl("[do not save]",'e') ?
> </a
>