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fixed, contribution by danly7
[openemr.git] / contrib / forms / ros2 / templates / general_new.html
blob08e7253ec22c8118ce5c280a3f9f1c7b58cea8d3
1 <html>
2 <head>
3 {php}html_header_show();{/php}
4 {literal}
5
6 <style type="text/css" title="mystyles" media="all">
7 <!--
8 td {
9 font-size:12pt;
10 font-family:helvetica;
11 }
12 li{
13 font-size:11pt;
14 font-family:helvetica;
15 margin-left: 15px;
16 }
17 a {
18 font-size:11pt;
19 font-family:helvetica;
20 }
21 .title {
22 font-family: sans-serif;
23 font-size: 12pt;
24 font-weight: bold;
25 text-decoration: none;
26 color: #000000;
27 }
28
29 .form_text{
30 font-family: sans-serif;
31 font-size: 9pt;
32 text-decoration: none;
33 color: #000000;
34 }
35
36 -->
37 </style>
38 {/literal}
39 </head>
40 <body bgcolor="{$STYLE.BGCOLOR2}">
41 <p><span class="title">Review of Systems &#150; Details</span></p>
42 <form name="ros2" method="post" action="{$FORM_ACTION}/interface/forms/ros2/save.php"
43 onsubmit="return top.restoreSession()">
44
45 <TABLE WIDTH=591 BORDER=1 BORDERCOLOR='#000000' CELLPADDING=7 CELLSPACING=0 STYLE='page-break-before: always'>
46 <TR>
47 <TD WIDTH=162px>
48 <P ALIGN=CENTER>GENERAL:
49 </P>
50 </TD>
51 <TD WIDTH=100px>
52 <table border=0 cellpadding=0 cellspacing=0>
53 <tr>
54 <td><INPUT TYPE=radio NAME='general_headache' VALUE='Yes' '{$data->get_general_headache_yes()}'></td><td>Yes</td>
55 <td><INPUT TYPE=radio NAME='general_headache' VALUE='No' '{$data->get_general_headache_no()}'></td><td>No</td>
56 </tr>
57 </table>
58 </TD>
59 <TD WIDTH=161px>
60 <P>headache</P>
61 </TD>
62 <TD WIDTH=162px VALIGN=TOP>
63 <P><textarea name='general_headache_text' cols='30' rows='2'>{$data->get_general_headache_text()}</textarea>
64 </P>
65 </TD>
66 </TR>
67
68 <TR>
69 <TD WIDTH=162px>
70 <P ALIGN=CENTER><BR/>
71 </P>
72 </TD>
73 <TD WIDTH=100px>
74 <table border=0 cellpadding=0 cellspacing=0>
75 <tr>
76 <td><INPUT TYPE=radio NAME='general_fever' VALUE='Yes' '{$data->get_general_fever_yes()}'></td><td>Yes</td>
77 <td><INPUT TYPE=radio NAME='general_fever' VALUE='No' '{$data->get_general_fever_no()}'></td><td>No</td>
78 </tr>
79 </table>
80 </TD>
81 <TD WIDTH=161px>
82 <P>fever</P>
83 </TD>
84 <TD WIDTH=162px VALIGN=TOP>
85 <P><textarea name='general_fever_text' cols='30' rows='2'>{$data->get_general_fever_text()}</textarea>
86 </P>
87 </TD>
88 </TR>
89
90 <TR>
91 <TD WIDTH=162px>
92 <P ALIGN=CENTER><BR/>
93 </P>
94 </TD>
95 <TD WIDTH=100px>
96 <table border=0 cellpadding=0 cellspacing=0>
97 <tr>
98 <td><INPUT TYPE=radio NAME='general_chills' VALUE='Yes' '{$data->get_general_chills_yes()}'></td><td>Yes</td>
99 <td><INPUT TYPE=radio NAME='general_chills' VALUE='No' '{$data->get_general_chills_no()}'></td><td>No</td>
100 </tr>
101 </table>
102 </TD>
103 <TD WIDTH=161px>
104 <P>chills</P>
105 </TD>
106 <TD WIDTH=162px VALIGN=TOP>
107 <P><textarea name='general_chills_text' cols='30' rows='2'>{$data->get_general_chills_text()}</textarea>
108 </P>
109 </TD>
110 </TR>
111
112 <TR>
113 <TD WIDTH=162px>
114 <P ALIGN=CENTER><BR/>
115 </P>
116 </TD>
117 <TD WIDTH=100px>
118 <table border=0 cellpadding=0 cellspacing=0>
119 <tr>
120 <td><INPUT TYPE=radio NAME='general_body_aches' VALUE='Yes' '{$data->get_general_body_aches_yes()}'></td><td>Yes</td>
121 <td><INPUT TYPE=radio NAME='general_body_aches' VALUE='No' '{$data->get_general_body_aches_no()}'></td><td>No</td>
122 </tr>
123 </table>
124 </TD>
125 <TD WIDTH=161px>
126 <P>body aches</P>
127 </TD>
128 <TD WIDTH=162px VALIGN=TOP>
129 <P><textarea name='general_body_aches_text' cols='30' rows='2'>{$data->get_general_body_aches_text()}</textarea>
130 </P>
131 </TD>
132 </TR>
133
134 <TR>
135 <TD WIDTH=162px>
136 <P ALIGN=CENTER><BR/>
137 </P>
138 </TD>
139 <TD WIDTH=100px>
140 <table border=0 cellpadding=0 cellspacing=0>
141 <tr>
142 <td><INPUT TYPE=radio NAME='general_fatigue' VALUE='Yes' '{$data->get_general_fatigue_yes()}'></td><td>Yes</td>
143 <td><INPUT TYPE=radio NAME='general_fatigue' VALUE='No' '{$data->get_general_fatigue_no()}'></td><td>No</td>
144 </tr>
145 </table>
146 </TD>
147 <TD WIDTH=161px>
148 <P>fatigue</P>
149 </TD>
150 <TD WIDTH=162px VALIGN=TOP>
151 <P><textarea name='general_fatigue_text' cols='30' rows='2'>{$data->get_general_fatigue_text()}</textarea>
152 </P>
153 </TD>
154 </TR>
155
156 <TR>
157 <TD WIDTH=162px>
158 <P ALIGN=CENTER><BR/>
159 </P>
160 </TD>
161 <TD WIDTH=100px>
162 <table border=0 cellpadding=0 cellspacing=0>
163 <tr>
164 <td><INPUT TYPE=radio NAME='general_loss_of_appetite' VALUE='Yes' '{$data->get_general_loss_of_appetite_yes()}'></td><td>Yes</td>
165 <td><INPUT TYPE=radio NAME='general_loss_of_appetite' VALUE='No' '{$data->get_general_loss_of_appetite_no()}'></td><td>No</td>
166 </tr>
167 </table>
168 </TD>
169 <TD WIDTH=161px>
170 <P>loss of appetite</P>
171 </TD>
172 <TD WIDTH=162px VALIGN=TOP>
173 <P><textarea name='general_loss_of_appetite_text' cols='30' rows='2'>{$data->get_general_loss_of_appetite_text()}</textarea>
174 </P>
175 </TD>
176 </TR>
177
178 <TR>
179 <TD WIDTH=162px>
180 <P ALIGN=CENTER><BR/>
181 </P>
182 </TD>
183 <TD WIDTH=100px>
184 <table border=0 cellpadding=0 cellspacing=0>
185 <tr>
186 <td><INPUT TYPE=radio NAME='general_weight_loss' VALUE='Yes' '{$data->get_general_weight_loss_yes()}'></td><td>Yes</td>
187 <td><INPUT TYPE=radio NAME='general_weight_loss' VALUE='No' '{$data->get_general_weight_loss_no()}'></td><td>No</td>
188 </tr>
189 </table>
190 </TD>
191 <TD WIDTH=161px>
192 <P>weight loss</P>
193 </TD>
194 <TD WIDTH=162px VALIGN=TOP>
195 <P><textarea name='general_weight_loss_text' cols='30' rows='2'>{$data->get_general_weight_loss_text()}</textarea>
196 </P>
197 </TD>
198 </TR>
199
200 <TR>
201 <TD WIDTH=162px>
202 <P ALIGN=CENTER><BR/>
203 </P>
204 </TD>
205 <TD WIDTH=100px>
206 <table border=0 cellpadding=0 cellspacing=0>
207 <tr>
208 <td><INPUT TYPE=radio NAME='general_daytime_drowsiness' VALUE='Yes' '{$data->get_general_daytime_drowsiness_yes()}'></td><td>Yes</td>
209 <td><INPUT TYPE=radio NAME='general_daytime_drowsiness' VALUE='No' '{$data->get_general_daytime_drowsiness_no()}'></td><td>No</td>
210 </tr>
211 </table>
212 </TD>
213 <TD WIDTH=161px>
214 <P>daytime drowsiness</P>
215 </TD>
216 <TD WIDTH=162px VALIGN=TOP>
217 <P><textarea name='general_daytime_drowsiness_text' cols='30' rows='2'>{$data->get_general_daytime_drowsiness_text()}</textarea>
218 </P>
219 </TD>
220 </TR>
221
222 <TR>
223 <TD WIDTH=162px>
224 <P ALIGN=CENTER><BR/>
225 </P>
226 </TD>
227 <TD WIDTH=100px>
228 <table border=0 cellpadding=0 cellspacing=0>
229 <tr>
230 <td><INPUT TYPE=radio NAME='general_excessive_snoring' VALUE='Yes' '{$data->get_general_excessive_snoring_yes()}'></td><td>Yes</td>
231 <td><INPUT TYPE=radio NAME='general_excessive_snoring' VALUE='No' '{$data->get_general_excessive_snoring_no()}'></td><td>No</td>
232 </tr>
233 </table>
234 </TD>
235 <TD WIDTH=161px>
236 <P>excessive snoring</P>
237 </TD>
238 <TD WIDTH=162px VALIGN=TOP>
239 <P><textarea name='general_excessive_snoring_text' cols='30' rows='2'>{$data->get_general_excessive_snoring_text()}</textarea>
240 </P>
241 </TD>
242 </TR>
243
244 <TR>
245 <TD WIDTH=162px>
246 <P ALIGN=CENTER>NEURO:
247 </P>
248 </TD>
249 <TD WIDTH=100px>
250 <table border=0 cellpadding=0 cellspacing=0>
251 <tr>
252 <td><INPUT TYPE=radio NAME='neuro_disorientation' VALUE='Yes' '{$data->get_neuro_disorientation_yes()}'></td><td>Yes</td>
253 <td><INPUT TYPE=radio NAME='neuro_disorientation' VALUE='No' '{$data->get_neuro_disorientation_no()}'></td><td>No</td>
254 </tr>
255 </table>
256 </TD>
257 <TD WIDTH=161px>
258 <P>disorientation</P>
259 </TD>
260 <TD WIDTH=162px VALIGN=TOP>
261 <P><textarea name='neuro_disorientation_text' cols='30' rows='2'>{$data->get_neuro_disorientation_text()}</textarea>
262 </P>
263 </TD>
264 </TR>
265
266 <TR>
267 <TD WIDTH=162px>
268 <P ALIGN=CENTER><BR/>
269 </P>
270 </TD>
271 <TD WIDTH=100px>
272 <table border=0 cellpadding=0 cellspacing=0>
273 <tr>
274 <td><INPUT TYPE=radio NAME='neuro_loss_of_consciousness' VALUE='Yes' '{$data->get_neuro_loss_of_consciousness_yes()}'></td><td>Yes</td>
275 <td><INPUT TYPE=radio NAME='neuro_loss_of_consciousness' VALUE='No' '{$data->get_neuro_loss_of_consciousness_no()}'></td><td>No</td>
276 </tr>
277 </table>
278 </TD>
279 <TD WIDTH=161px>
280 <P>loss of consciousness</P>
281 </TD>
282 <TD WIDTH=162px VALIGN=TOP>
283 <P><textarea name='neuro_loss_of_consciousness_text' cols='30' rows='2'>{$data->get_neuro_loss_of_consciousness_text()}</textarea>
284 </P>
285 </TD>
286 </TR>
287
288 <TR>
289 <TD WIDTH=162px>
290 <P ALIGN=CENTER><BR/>
291 </P>
292 </TD>
293 <TD WIDTH=100px>
294 <table border=0 cellpadding=0 cellspacing=0>
295 <tr>
296 <td><INPUT TYPE=radio NAME='neuro_numbness' VALUE='Yes' '{$data->get_neuro_numbness_yes()}'></td><td>Yes</td>
297 <td><INPUT TYPE=radio NAME='neuro_numbness' VALUE='No' '{$data->get_neuro_numbness_no()}'></td><td>No</td>
298 </tr>
299 </table>
300 </TD>
301 <TD WIDTH=161px>
302 <P>numbness</P>
303 </TD>
304 <TD WIDTH=162px VALIGN=TOP>
305 <P><textarea name='neuro_numbness_text' cols='30' rows='2'>{$data->get_neuro_numbness_text()}</textarea>
306 </P>
307 </TD>
308 </TR>
309
310 <TR>
311 <TD WIDTH=162px>
312 <P ALIGN=CENTER><BR/>
313 </P>
314 </TD>
315 <TD WIDTH=100px>
316 <table border=0 cellpadding=0 cellspacing=0>
317 <tr>
318 <td><INPUT TYPE=radio NAME='neuro_tingling' VALUE='Yes' '{$data->get_neuro_tingling_yes()}'></td><td>Yes</td>
319 <td><INPUT TYPE=radio NAME='neuro_tingling' VALUE='No' '{$data->get_neuro_tingling_no()}'></td><td>No</td>
320 </tr>
321 </table>
322 </TD>
323 <TD WIDTH=161px>
324 <P>tingling</P>
325 </TD>
326 <TD WIDTH=162px VALIGN=TOP>
327 <P><textarea name='neuro_tingling_text' cols='30' rows='2'>{$data->get_neuro_tingling_text()}</textarea>
328 </P>
329 </TD>
330 </TR>
331
332 <TR>
333 <TD WIDTH=162px>
334 <P ALIGN=CENTER><BR/>
335 </P>
336 </TD>
337 <TD WIDTH=100px>
338 <table border=0 cellpadding=0 cellspacing=0>
339 <tr>
340 <td><INPUT TYPE=radio NAME='neuro_restlessness' VALUE='Yes' '{$data->get_neuro_restlessness_yes()}'></td><td>Yes</td>
341 <td><INPUT TYPE=radio NAME='neuro_restlessness' VALUE='No' '{$data->get_neuro_restlessness_no()}'></td><td>No</td>
342 </tr>
343 </table>
344 </TD>
345 <TD WIDTH=161px>
346 <P>restlessness</P>
347 </TD>
348 <TD WIDTH=162px VALIGN=TOP>
349 <P><textarea name='neuro_restlessness_text' cols='30' rows='2'>{$data->get_neuro_restlessness_text()}</textarea>
350 </P>
351 </TD>
352 </TR>
353
354 <TR>
355 <TD WIDTH=162px>
356 <P ALIGN=CENTER><BR/>
357 </P>
358 </TD>
359 <TD WIDTH=100px>
360 <table border=0 cellpadding=0 cellspacing=0>
361 <tr>
362 <td><INPUT TYPE=radio NAME='neuro_dizziness' VALUE='Yes' '{$data->get_neuro_dizziness_yes()}'></td><td>Yes</td>
363 <td><INPUT TYPE=radio NAME='neuro_dizziness' VALUE='No' '{$data->get_neuro_dizziness_no()}'></td><td>No</td>
364 </tr>
365 </table>
366 </TD>
367 <TD WIDTH=161px>
368 <P>dizziness</P>
369 </TD>
370 <TD WIDTH=162px VALIGN=TOP>
371 <P><textarea name='neuro_dizziness_text' cols='30' rows='2'>{$data->get_neuro_dizziness_text()}</textarea>
372 </P>
373 </TD>
374 </TR>
375
376 <TR>
377 <TD WIDTH=162px>
378 <P ALIGN=CENTER><BR/>
379 </P>
380 </TD>
381 <TD WIDTH=100px>
382 <table border=0 cellpadding=0 cellspacing=0>
383 <tr>
384 <td><INPUT TYPE=radio NAME='neuro_vertigo' VALUE='Yes' '{$data->get_neuro_vertigo_yes()}'></td><td>Yes</td>
385 <td><INPUT TYPE=radio NAME='neuro_vertigo' VALUE='No' '{$data->get_neuro_vertigo_no()}'></td><td>No</td>
386 </tr>
387 </table>
388 </TD>
389 <TD WIDTH=161px>
390 <P>vertigo</P>
391 </TD>
392 <TD WIDTH=162px VALIGN=TOP>
393 <P><textarea name='neuro_vertigo_text' cols='30' rows='2'>{$data->get_neuro_vertigo_text()}</textarea>
394 </P>
395 </TD>
396 </TR>
397
398 <TR>
399 <TD WIDTH=162px>
400 <P ALIGN=CENTER><BR/>
401 </P>
402 </TD>
403 <TD WIDTH=100px>
404 <table border=0 cellpadding=0 cellspacing=0>
405 <tr>
406 <td><INPUT TYPE=radio NAME='neuro_amaurosis_fugax' VALUE='Yes' '{$data->get_neuro_amaurosis_fugax_yes()}'></td><td>Yes</td>
407 <td><INPUT TYPE=radio NAME='neuro_amaurosis_fugax' VALUE='No' '{$data->get_neuro_amaurosis_fugax_no()}'></td><td>No</td>
408 </tr>
409 </table>
410 </TD>
411 <TD WIDTH=161px>
412 <P>Amaurosis Fugax</P>
413 </TD>
414 <TD WIDTH=162px VALIGN=TOP>
415 <P><textarea name='neuro_amaurosis_fugax_text' cols='30' rows='2'>{$data->get_neuro_amaurosis_fugax_text()}</textarea>
416 </P>
417 </TD>
418 </TR>
419
420 <TR>
421 <TD WIDTH=162px>
422 <P ALIGN=CENTER><BR/>
423 </P>
424 </TD>
425 <TD WIDTH=100px>
426 <table border=0 cellpadding=0 cellspacing=0>
427 <tr>
428 <td><INPUT TYPE=radio NAME='neuro_stroke' VALUE='Yes' '{$data->get_neuro_stroke_yes()}'></td><td>Yes</td>
429 <td><INPUT TYPE=radio NAME='neuro_stroke' VALUE='No' '{$data->get_neuro_stroke_no()}'></td><td>No</td>
430 </tr>
431 </table>
432 </TD>
433 <TD WIDTH=161px>
434 <P>Stroke</P>
435 </TD>
436 <TD WIDTH=162px VALIGN=TOP>
437 <P><textarea name='neuro_stroke_text' cols='30' rows='2'>{$data->get_neuro_stroke_text()}</textarea>
438 </P>
439 </TD>
440 </TR>
441
442 <TR>
443 <TD WIDTH=162px>
444 <P ALIGN=CENTER><BR/>
445 </P>
446 </TD>
447 <TD WIDTH=100px>
448 <table border=0 cellpadding=0 cellspacing=0>
449 <tr>
450 <td><INPUT TYPE=radio NAME='neuro_gait_abnormality' VALUE='Yes' '{$data->get_neuro_gait_abnormality_yes()}'></td><td>Yes</td>
451 <td><INPUT TYPE=radio NAME='neuro_gait_abnormality' VALUE='No' '{$data->get_neuro_gait_abnormality_no()}'></td><td>No</td>
452 </tr>
453 </table>
454 </TD>
455 <TD WIDTH=161px>
456 <P>Gait Abnormality</P>
457 </TD>
458 <TD WIDTH=162px VALIGN=TOP>
459 <P><textarea name='neuro_gait_abnormality_text' cols='30' rows='2'>{$data->get_neuro_gait_abnormality_text()}</textarea>
460 </P>
461 </TD>
462 </TR>
463
464 <TR>
465 <TD WIDTH=162px>
466 <P ALIGN=CENTER><BR/>
467 </P>
468 </TD>
469 <TD WIDTH=100px>
470 <table border=0 cellpadding=0 cellspacing=0>
471 <tr>
472 <td><INPUT TYPE=radio NAME='neuro_frequent_headaches' VALUE='Yes' '{$data->get_neuro_frequent_headaches_yes()}'></td><td>Yes</td>
473 <td><INPUT TYPE=radio NAME='neuro_frequent_headaches' VALUE='No' '{$data->get_neuro_frequent_headaches_no()}'></td><td>No</td>
474 </tr>
475 </table>
476 </TD>
477 <TD WIDTH=161px>
478 <P>Frequent headaches</P>
479 </TD>
480 <TD WIDTH=162px VALIGN=TOP>
481 <P><textarea name='neuro_frequent_headaches_text' cols='30' rows='2'>{$data->get_neuro_frequent_headaches_text()}</textarea>
482 </P>
483 </TD>
484 </TR>
485
486 <TR>
487 <TD WIDTH=162px>
488 <P ALIGN=CENTER><BR/>
489 </P>
490 </TD>
491 <TD WIDTH=100px>
492 <table border=0 cellpadding=0 cellspacing=0>
493 <tr>
494 <td><INPUT TYPE=radio NAME='neuro_parathesias' VALUE='Yes' '{$data->get_neuro_parathesias_yes()}'></td><td>Yes</td>
495 <td><INPUT TYPE=radio NAME='neuro_parathesias' VALUE='No' '{$data->get_neuro_parathesias_no()}'></td><td>No</td>
496 </tr>
497 </table>
498 </TD>
499 <TD WIDTH=161px>
500 <P>Parathesias</P>
501 </TD>
502 <TD WIDTH=162px VALIGN=TOP>
503 <P><textarea name='neuro_parathesias_text' cols='30' rows='2'>{$data->get_neuro_parathesias_text()}</textarea>
504 </P>
505 </TD>
506 </TR>
507
508 <TR>
509 <TD WIDTH=162px>
510 <P ALIGN=CENTER><BR/>
511 </P>
512 </TD>
513 <TD WIDTH=100px>
514 <table border=0 cellpadding=0 cellspacing=0>
515 <tr>
516 <td><INPUT TYPE=radio NAME='neuro_seizures' VALUE='Yes' '{$data->get_neuro_seizures_yes()}'></td><td>Yes</td>
517 <td><INPUT TYPE=radio NAME='neuro_seizures' VALUE='No' '{$data->get_neuro_seizures_no()}'></td><td>No</td>
518 </tr>
519 </table>
520 </TD>
521 <TD WIDTH=161px>
522 <P>Seizures</P>
523 </TD>
524 <TD WIDTH=162px VALIGN=TOP>
525 <P><textarea name='neuro_seizures_text' cols='30' rows='2'>{$data->get_neuro_seizures_text()}</textarea>
526 </P>
527 </TD>
528 </TR>
529
530 <TR>
531 <TD WIDTH=162px>
532 <P ALIGN=CENTER><BR/>
533 </P>
534 </TD>
535 <TD WIDTH=100px>
536 <table border=0 cellpadding=0 cellspacing=0>
537 <tr>
538 <td><INPUT TYPE=radio NAME='neuro_trans_ischemic_attacks' VALUE='Yes' '{$data->get_neuro_trans_ischemic_attacks_yes()}'></td><td>Yes</td>
539 <td><INPUT TYPE=radio NAME='neuro_trans_ischemic_attacks' VALUE='No' '{$data->get_neuro_trans_ischemic_attacks_no()}'></td><td>No</td>
540 </tr>
541 </table>
542 </TD>
543 <TD WIDTH=161px>
544 <P>Trans Ischemic Attacks</P>
545 </TD>
546 <TD WIDTH=162px VALIGN=TOP>
547 <P><textarea name='neuro_trans_ischemic_attacks_text' cols='30' rows='2'>{$data->get_neuro_trans_ischemic_attacks_text()}</textarea>
548 </P>
549 </TD>
550 </TR>
551
552 <TR>
553 <TD WIDTH=162px>
554 <P ALIGN=CENTER><BR/>
555 </P>
556 </TD>
557 <TD WIDTH=100px>
558 <table border=0 cellpadding=0 cellspacing=0>
559 <tr>
560 <td><INPUT TYPE=radio NAME='neuro_significant_tremors' VALUE='Yes' '{$data->get_neuro_significant_tremors_yes()}'></td><td>Yes</td>
561 <td><INPUT TYPE=radio NAME='neuro_significant_tremors' VALUE='No' '{$data->get_neuro_significant_tremors_no()}'></td><td>No</td>
562 </tr>
563 </table>
564 </TD>
565 <TD WIDTH=161px>
566 <P>Significant Tremors</P>
567 </TD>
568 <TD WIDTH=162px VALIGN=TOP>
569 <P><textarea name='neuro_significant_tremors_text' cols='30' rows='2'>{$data->get_neuro_significant_tremors_text()}</textarea>
570 </P>
571 </TD>
572 </TR>
573
574 <TR>
575 <TD WIDTH=162px>
576 <P ALIGN=CENTER>NECK:
577 </P>
578 </TD>
579 <TD WIDTH=100px>
580 <table border=0 cellpadding=0 cellspacing=0>
581 <tr>
582 <td><INPUT TYPE=radio NAME='neck_neck_stiffness' VALUE='Yes' '{$data->get_neck_neck_stiffness_yes()}'></td><td>Yes</td>
583 <td><INPUT TYPE=radio NAME='neck_neck_stiffness' VALUE='No' '{$data->get_neck_neck_stiffness_no()}'></td><td>No</td>
584 </tr>
585 </table>
586 </TD>
587 <TD WIDTH=161px>
588 <P>neck stiffness</P>
589 </TD>
590 <TD WIDTH=162px VALIGN=TOP>
591 <P><textarea name='neck_neck_stiffness_text' cols='30' rows='2'>{$data->get_neck_neck_stiffness_text()}</textarea>
592 </P>
593 </TD>
594 </TR>
595
596 <TR>
597 <TD WIDTH=162px>
598 <P ALIGN=CENTER><BR/>
599 </P>
600 </TD>
601 <TD WIDTH=100px>
602 <table border=0 cellpadding=0 cellspacing=0>
603 <tr>
604 <td><INPUT TYPE=radio NAME='neck_neck_pain' VALUE='Yes' '{$data->get_neck_neck_pain_yes()}'></td><td>Yes</td>
605 <td><INPUT TYPE=radio NAME='neck_neck_pain' VALUE='No' '{$data->get_neck_neck_pain_no()}'></td><td>No</td>
606 </tr>
607 </table>
608 </TD>
609 <TD WIDTH=161px>
610 <P>neck pain</P>
611 </TD>
612 <TD WIDTH=162px VALIGN=TOP>
613 <P><textarea name='neck_neck_pain_text' cols='30' rows='2'>{$data->get_neck_neck_pain_text()}</textarea>
614 </P>
615 </TD>
616 </TR>
617
618 <TR>
619 <TD WIDTH=162px>
620 <P ALIGN=CENTER><BR/>
621 </P>
622 </TD>
623 <TD WIDTH=100px>
624 <table border=0 cellpadding=0 cellspacing=0>
625 <tr>
626 <td><INPUT TYPE=radio NAME='neck_neck_masses' VALUE='Yes' '{$data->get_neck_neck_masses_yes()}'></td><td>Yes</td>
627 <td><INPUT TYPE=radio NAME='neck_neck_masses' VALUE='No' '{$data->get_neck_neck_masses_no()}'></td><td>No</td>
628 </tr>
629 </table>
630 </TD>
631 <TD WIDTH=161px>
632 <P>Neck Masses</P>
633 </TD>
634 <TD WIDTH=162px VALIGN=TOP>
635 <P><textarea name='neck_neck_masses_text' cols='30' rows='2'>{$data->get_neck_neck_masses_text()}</textarea>
636 </P>
637 </TD>
638 </TR>
639
640 <TR>
641 <TD WIDTH=162px>
642 <P ALIGN=CENTER><BR/>
643 </P>
644 </TD>
645 <TD WIDTH=100px>
646 <table border=0 cellpadding=0 cellspacing=0>
647 <tr>
648 <td><INPUT TYPE=radio NAME='neck_neck_tenderness' VALUE='Yes' '{$data->get_neck_neck_tenderness_yes()}'></td><td>Yes</td>
649 <td><INPUT TYPE=radio NAME='neck_neck_tenderness' VALUE='No' '{$data->get_neck_neck_tenderness_no()}'></td><td>No</td>
650 </tr>
651 </table>
652 </TD>
653 <TD WIDTH=161px>
654 <P>Neck Tenderness</P>
655 </TD>
656 <TD WIDTH=162px VALIGN=TOP>
657 <P><textarea name='neck_neck_tenderness_text' cols='30' rows='2'>{$data->get_neck_neck_tenderness_text()}</textarea>
658 </P>
659 </TD>
660 </TR>
661
662 <TR>
663 <TD WIDTH=162px>
664 <P ALIGN=CENTER>HEENT:
665 </P>
666 </TD>
667 <TD WIDTH=100px>
668 <table border=0 cellpadding=0 cellspacing=0>
669 <tr>
670 <td><INPUT TYPE=radio NAME='heent_oral_ulcers' VALUE='Yes' '{$data->get_heent_oral_ulcers_yes()}'></td><td>Yes</td>
671 <td><INPUT TYPE=radio NAME='heent_oral_ulcers' VALUE='No' '{$data->get_heent_oral_ulcers_no()}'></td><td>No</td>
672 </tr>
673 </table>
674 </TD>
675 <TD WIDTH=161px>
676 <P>oral ulcers</P>
677 </TD>
678 <TD WIDTH=162px VALIGN=TOP>
679 <P><textarea name='heent_oral_ulcers_text' cols='30' rows='2'>{$data->get_heent_oral_ulcers_text()}</textarea>
680 </P>
681 </TD>
682 </TR>
683
684 <TR>
685 <TD WIDTH=162px>
686 <P ALIGN=CENTER><BR/>
687 </P>
688 </TD>
689 <TD WIDTH=100px>
690 <table border=0 cellpadding=0 cellspacing=0>
691 <tr>
692 <td><INPUT TYPE=radio NAME='heent_excessive_cavities' VALUE='Yes' '{$data->get_heent_excessive_cavities_yes()}'></td><td>Yes</td>
693 <td><INPUT TYPE=radio NAME='heent_excessive_cavities' VALUE='No' '{$data->get_heent_excessive_cavities_no()}'></td><td>No</td>
694 </tr>
695 </table>
696 </TD>
697 <TD WIDTH=161px>
698 <P>Excessive Cavities</P>
699 </TD>
700 <TD WIDTH=162px VALIGN=TOP>
701 <P><textarea name='heent_excessive_cavities_text' cols='30' rows='2'>{$data->get_heent_excessive_cavities_text()}</textarea>
702 </P>
703 </TD>
704 </TR>
705
706 <TR>
707 <TD WIDTH=162px>
708 <P ALIGN=CENTER><BR/>
709 </P>
710 </TD>
711 <TD WIDTH=100px>
712 <table border=0 cellpadding=0 cellspacing=0>
713 <tr>
714 <td><INPUT TYPE=radio NAME='heent_gingival_disease' VALUE='Yes' '{$data->get_heent_gingival_disease_yes()}'></td><td>Yes</td>
715 <td><INPUT TYPE=radio NAME='heent_gingival_disease' VALUE='No' '{$data->get_heent_gingival_disease_no()}'></td><td>No</td>
716 </tr>
717 </table>
718 </TD>
719 <TD WIDTH=161px>
720 <P>Gingival Disease</P>
721 </TD>
722 <TD WIDTH=162px VALIGN=TOP>
723 <P><textarea name='heent_gingival_disease_text' cols='30' rows='2'>{$data->get_heent_gingival_disease_text()}</textarea>
724 </P>
725 </TD>
726 </TR>
727
728 <TR>
729 <TD WIDTH=162px>
730 <P ALIGN=CENTER><BR/>
731 </P>
732 </TD>
733 <TD WIDTH=100px>
734 <table border=0 cellpadding=0 cellspacing=0>
735 <tr>
736 <td><INPUT TYPE=radio NAME='heent_persistent_hoarseness' VALUE='Yes' '{$data->get_heent_persistent_hoarseness_yes()}'></td><td>Yes</td>
737 <td><INPUT TYPE=radio NAME='heent_persistent_hoarseness' VALUE='No' '{$data->get_heent_persistent_hoarseness_no()}'></td><td>No</td>
738 </tr>
739 </table>
740 </TD>
741 <TD WIDTH=161px>
742 <P>Persistent hoarseness</P>
743 </TD>
744 <TD WIDTH=162px VALIGN=TOP>
745 <P><textarea name='heent_persistent_hoarseness_text' cols='30' rows='2'>{$data->get_heent_persistent_hoarseness_text()}</textarea>
746 </P>
747 </TD>
748 </TR>
749
750 <TR>
751 <TD WIDTH=162px>
752 <P ALIGN=CENTER><BR/>
753 </P>
754 </TD>
755 <TD WIDTH=100px>
756 <table border=0 cellpadding=0 cellspacing=0>
757 <tr>
758 <td><INPUT TYPE=radio NAME='heent_mouth_lesions' VALUE='Yes' '{$data->get_heent_mouth_lesions_yes()}'></td><td>Yes</td>
759 <td><INPUT TYPE=radio NAME='heent_mouth_lesions' VALUE='No' '{$data->get_heent_mouth_lesions_no()}'></td><td>No</td>
760 </tr>
761 </table>
762 </TD>
763 <TD WIDTH=161px>
764 <P>Mouth Lesions</P>
765 </TD>
766 <TD WIDTH=162px VALIGN=TOP>
767 <P><textarea name='heent_mouth_lesions_text' cols='30' rows='2'>{$data->get_heent_mouth_lesions_text()}</textarea>
768 </P>
769 </TD>
770 </TR>
771
772 <TR>
773 <TD WIDTH=162px>
774 <P ALIGN=CENTER><BR/>
775 </P>
776 </TD>
777 <TD WIDTH=100px>
778 <table border=0 cellpadding=0 cellspacing=0>
779 <tr>
780 <td><INPUT TYPE=radio NAME='heent_dysphagia' VALUE='Yes' '{$data->get_heent_dysphagia_yes()}'></td><td>Yes</td>
781 <td><INPUT TYPE=radio NAME='heent_dysphagia' VALUE='No' '{$data->get_heent_dysphagia_no()}'></td><td>No</td>
782 </tr>
783 </table>
784 </TD>
785 <TD WIDTH=161px>
786 <P>Dysphagia</P>
787 </TD>
788 <TD WIDTH=162px VALIGN=TOP>
789 <P><textarea name='heent_dysphagia_text' cols='30' rows='2'>{$data->get_heent_dysphagia_text()}</textarea>
790 </P>
791 </TD>
792 </TR>
793
794 <TR>
795 <TD WIDTH=162px>
796 <P ALIGN=CENTER><BR/>
797 </P>
798 </TD>
799 <TD WIDTH=100px>
800 <table border=0 cellpadding=0 cellspacing=0>
801 <tr>
802 <td><INPUT TYPE=radio NAME='heent_odynophagia' VALUE='Yes' '{$data->get_heent_odynophagia_yes()}'></td><td>Yes</td>
803 <td><INPUT TYPE=radio NAME='heent_odynophagia' VALUE='No' '{$data->get_heent_odynophagia_no()}'></td><td>No</td>
804 </tr>
805 </table>
806 </TD>
807 <TD WIDTH=161px>
808 <P>Odynophagia</P>
809 </TD>
810 <TD WIDTH=162px VALIGN=TOP>
811 <P><textarea name='heent_odynophagia_text' cols='30' rows='2'>{$data->get_heent_odynophagia_text()}</textarea>
812 </P>
813 </TD>
814 </TR>
815
816 <TR>
817 <TD WIDTH=162px>
818 <P ALIGN=CENTER><BR/>
819 </P>
820 </TD>
821 <TD WIDTH=100px>
822 <table border=0 cellpadding=0 cellspacing=0>
823 <tr>
824 <td><INPUT TYPE=radio NAME='heent_dental_pain' VALUE='Yes' '{$data->get_heent_dental_pain_yes()}'></td><td>Yes</td>
825 <td><INPUT TYPE=radio NAME='heent_dental_pain' VALUE='No' '{$data->get_heent_dental_pain_no()}'></td><td>No</td>
826 </tr>
827 </table>
828 </TD>
829 <TD WIDTH=161px>
830 <P>dental pain</P>
831 </TD>
832 <TD WIDTH=162px VALIGN=TOP>
833 <P><textarea name='heent_dental_pain_text' cols='30' rows='2'>{$data->get_heent_dental_pain_text()}</textarea>
834 </P>
835 </TD>
836 </TR>
837
838 <TR>
839 <TD WIDTH=162px>
840 <P ALIGN=CENTER><BR/>
841 </P>
842 </TD>
843 <TD WIDTH=100px>
844 <table border=0 cellpadding=0 cellspacing=0>
845 <tr>
846 <td><INPUT TYPE=radio NAME='heent_sore_throat' VALUE='Yes' '{$data->get_heent_sore_throat_yes()}'></td><td>Yes</td>
847 <td><INPUT TYPE=radio NAME='heent_sore_throat' VALUE='No' '{$data->get_heent_sore_throat_no()}'></td><td>No</td>
848 </tr>
849 </table>
850 </TD>
851 <TD WIDTH=161px>
852 <P>sore throat</P>
853 </TD>
854 <TD WIDTH=162px VALIGN=TOP>
855 <P><textarea name='heent_sore_throat_text' cols='30' rows='2'>{$data->get_heent_sore_throat_text()}</textarea>
856 </P>
857 </TD>
858 </TR>
859
860 <TR>
861 <TD WIDTH=162px>
862 <P ALIGN=CENTER><BR/>
863 </P>
864 </TD>
865 <TD WIDTH=100px>
866 <table border=0 cellpadding=0 cellspacing=0>
867 <tr>
868 <td><INPUT TYPE=radio NAME='heent_ear_pain' VALUE='Yes' '{$data->get_heent_ear_pain_yes()}'></td><td>Yes</td>
869 <td><INPUT TYPE=radio NAME='heent_ear_pain' VALUE='No' '{$data->get_heent_ear_pain_no()}'></td><td>No</td>
870 </tr>
871 </table>
872 </TD>
873 <TD WIDTH=161px>
874 <P>ear pain</P>
875 </TD>
876 <TD WIDTH=162px VALIGN=TOP>
877 <P><textarea name='heent_ear_pain_text' cols='30' rows='2'>{$data->get_heent_ear_pain_text()}</textarea>
878 </P>
879 </TD>
880 </TR>
881
882 <TR>
883 <TD WIDTH=162px>
884 <P ALIGN=CENTER><BR/>
885 </P>
886 </TD>
887 <TD WIDTH=100px>
888 <table border=0 cellpadding=0 cellspacing=0>
889 <tr>
890 <td><INPUT TYPE=radio NAME='heent_ear_discharge' VALUE='Yes' '{$data->get_heent_ear_discharge_yes()}'></td><td>Yes</td>
891 <td><INPUT TYPE=radio NAME='heent_ear_discharge' VALUE='No' '{$data->get_heent_ear_discharge_no()}'></td><td>No</td>
892 </tr>
893 </table>
894 </TD>
895 <TD WIDTH=161px>
896 <P>ear discharge</P>
897 </TD>
898 <TD WIDTH=162px VALIGN=TOP>
899 <P><textarea name='heent_ear_discharge_text' cols='30' rows='2'>{$data->get_heent_ear_discharge_text()}</textarea>
900 </P>
901 </TD>
902 </TR>
903
904 <TR>
905 <TD WIDTH=162px>
906 <P ALIGN=CENTER><BR/>
907 </P>
908 </TD>
909 <TD WIDTH=100px>
910 <table border=0 cellpadding=0 cellspacing=0>
911 <tr>
912 <td><INPUT TYPE=radio NAME='heent_tinnitus' VALUE='Yes' '{$data->get_heent_tinnitus_yes()}'></td><td>Yes</td>
913 <td><INPUT TYPE=radio NAME='heent_tinnitus' VALUE='No' '{$data->get_heent_tinnitus_no()}'></td><td>No</td>
914 </tr>
915 </table>
916 </TD>
917 <TD WIDTH=161px>
918 <P>tinnitus</P>
919 </TD>
920 <TD WIDTH=162px VALIGN=TOP>
921 <P><textarea name='heent_tinnitus_text' cols='30' rows='2'>{$data->get_heent_tinnitus_text()}</textarea>
922 </P>
923 </TD>
924 </TR>
925
926 <TR>
927 <TD WIDTH=162px>
928 <P ALIGN=CENTER><BR/>
929 </P>
930 </TD>
931 <TD WIDTH=100px>
932 <table border=0 cellpadding=0 cellspacing=0>
933 <tr>
934 <td><INPUT TYPE=radio NAME='heent_hearing_loss' VALUE='Yes' '{$data->get_heent_hearing_loss_yes()}'></td><td>Yes</td>
935 <td><INPUT TYPE=radio NAME='heent_hearing_loss' VALUE='No' '{$data->get_heent_hearing_loss_no()}'></td><td>No</td>
936 </tr>
937 </table>
938 </TD>
939 <TD WIDTH=161px>
940 <P>hearing loss</P>
941 </TD>
942 <TD WIDTH=162px VALIGN=TOP>
943 <P><textarea name='heent_hearing_loss_text' cols='30' rows='2'>{$data->get_heent_hearing_loss_text()}</textarea>
944 </P>
945 </TD>
946 </TR>
947
948 <TR>
949 <TD WIDTH=162px>
950 <P ALIGN=CENTER><BR/>
951 </P>
952 </TD>
953 <TD WIDTH=100px>
954 <table border=0 cellpadding=0 cellspacing=0>
955 <tr>
956 <td><INPUT TYPE=radio NAME='heent_allergic_rhinitis' VALUE='Yes' '{$data->get_heent_allergic_rhinitis_yes()}'></td><td>Yes</td>
957 <td><INPUT TYPE=radio NAME='heent_allergic_rhinitis' VALUE='No' '{$data->get_heent_allergic_rhinitis_no()}'></td><td>No</td>
958 </tr>
959 </table>
960 </TD>
961 <TD WIDTH=161px>
962 <P>Allergic Rhinitis</P>
963 </TD>
964 <TD WIDTH=162px VALIGN=TOP>
965 <P><textarea name='heent_allergic_rhinitis_text' cols='30' rows='2'>{$data->get_heent_allergic_rhinitis_text()}</textarea>
966 </P>
967 </TD>
968 </TR>
969
970 <TR>
971 <TD WIDTH=162px>
972 <P ALIGN=CENTER><BR/>
973 </P>
974 </TD>
975 <TD WIDTH=100px>
976 <table border=0 cellpadding=0 cellspacing=0>
977 <tr>
978 <td><INPUT TYPE=radio NAME='heent_nasal_congestion' VALUE='Yes' '{$data->get_heent_nasal_congestion_yes()}'></td><td>Yes</td>
979 <td><INPUT TYPE=radio NAME='heent_nasal_congestion' VALUE='No' '{$data->get_heent_nasal_congestion_no()}'></td><td>No</td>
980 </tr>
981 </table>
982 </TD>
983 <TD WIDTH=161px>
984 <P>Nasal Congestion</P>
985 </TD>
986 <TD WIDTH=162px VALIGN=TOP>
987 <P><textarea name='heent_nasal_congestion_text' cols='30' rows='2'>{$data->get_heent_nasal_congestion_text()}</textarea>
988 </P>
989 </TD>
990 </TR>
991
992 <TR>
993 <TD WIDTH=162px>
994 <P ALIGN=CENTER><BR/>
995 </P>
996 </TD>
997 <TD WIDTH=100px>
998 <table border=0 cellpadding=0 cellspacing=0>
999 <tr>
1000 <td><INPUT TYPE=radio NAME='heent_nasal_discharge' VALUE='Yes' '{$data->get_heent_nasal_discharge_yes()}'></td><td>Yes</td>
1001 <td><INPUT TYPE=radio NAME='heent_nasal_discharge' VALUE='No' '{$data->get_heent_nasal_discharge_no()}'></td><td>No</td>
1002 </tr>
1003 </table>
1004 </TD>
1005 <TD WIDTH=161px>
1006 <P>Nasal Discharge</P>
1007 </TD>
1008 <TD WIDTH=162px VALIGN=TOP>
1009 <P><textarea name='heent_nasal_discharge_text' cols='30' rows='2'>{$data->get_heent_nasal_discharge_text()}</textarea>
1010 </P>
1011 </TD>
1012 </TR>
1013
1014 <TR>
1015 <TD WIDTH=162px>
1016 <P ALIGN=CENTER><BR/>
1017 </P>
1018 </TD>
1019 <TD WIDTH=100px>
1020 <table border=0 cellpadding=0 cellspacing=0>
1021 <tr>
1022 <td><INPUT TYPE=radio NAME='heent_nasal_injury' VALUE='Yes' '{$data->get_heent_nasal_injury_yes()}'></td><td>Yes</td>
1023 <td><INPUT TYPE=radio NAME='heent_nasal_injury' VALUE='No' '{$data->get_heent_nasal_injury_no()}'></td><td>No</td>
1024 </tr>
1025 </table>
1026 </TD>
1027 <TD WIDTH=161px>
1028 <P>Nasal Injury</P>
1029 </TD>
1030 <TD WIDTH=162px VALIGN=TOP>
1031 <P><textarea name='heent_nasal_injury_text' cols='30' rows='2'>{$data->get_heent_nasal_injury_text()}</textarea>
1032 </P>
1033 </TD>
1034 </TR>
1035
1036 <TR>
1037 <TD WIDTH=162px>
1038 <P ALIGN=CENTER><BR/>
1039 </P>
1040 </TD>
1041 <TD WIDTH=100px>
1042 <table border=0 cellpadding=0 cellspacing=0>
1043 <tr>
1044 <td><INPUT TYPE=radio NAME='heent_nasal_surgery' VALUE='Yes' '{$data->get_heent_nasal_surgery_yes()}'></td><td>Yes</td>
1045 <td><INPUT TYPE=radio NAME='heent_nasal_surgery' VALUE='No' '{$data->get_heent_nasal_surgery_no()}'></td><td>No</td>
1046 </tr>
1047 </table>
1048 </TD>
1049 <TD WIDTH=161px>
1050 <P>Nasal Surgery</P>
1051 </TD>
1052 <TD WIDTH=162px VALIGN=TOP>
1053 <P><textarea name='heent_nasal_surgery_text' cols='30' rows='2'>{$data->get_heent_nasal_surgery_text()}</textarea>
1054 </P>
1055 </TD>
1056 </TR>
1057
1058 <TR>
1059 <TD WIDTH=162px>
1060 <P ALIGN=CENTER><BR/>
1061 </P>
1062 </TD>
1063 <TD WIDTH=100px>
1064 <table border=0 cellpadding=0 cellspacing=0>
1065 <tr>
1066 <td><INPUT TYPE=radio NAME='heent_nose_bleeds' VALUE='Yes' '{$data->get_heent_nose_bleeds_yes()}'></td><td>Yes</td>
1067 <td><INPUT TYPE=radio NAME='heent_nose_bleeds' VALUE='No' '{$data->get_heent_nose_bleeds_no()}'></td><td>No</td>
1068 </tr>
1069 </table>
1070 </TD>
1071 <TD WIDTH=161px>
1072 <P>Nose Bleeds</P>
1073 </TD>
1074 <TD WIDTH=162px VALIGN=TOP>
1075 <P><textarea name='heent_nose_bleeds_text' cols='30' rows='2'>{$data->get_heent_nose_bleeds_text()}</textarea>
1076 </P>
1077 </TD>
1078 </TR>
1079
1080 <TR>
1081 <TD WIDTH=162px>
1082 <P ALIGN=CENTER><BR/>
1083 </P>
1084 </TD>
1085 <TD WIDTH=100px>
1086 <table border=0 cellpadding=0 cellspacing=0>
1087 <tr>
1088 <td><INPUT TYPE=radio NAME='heent_post_nasal_drip' VALUE='Yes' '{$data->get_heent_post_nasal_drip_yes()}'></td><td>Yes</td>
1089 <td><INPUT TYPE=radio NAME='heent_post_nasal_drip' VALUE='No' '{$data->get_heent_post_nasal_drip_no()}'></td><td>No</td>
1090 </tr>
1091 </table>
1092 </TD>
1093 <TD WIDTH=161px>
1094 <P>post nasal drip</P>
1095 </TD>
1096 <TD WIDTH=162px VALIGN=TOP>
1097 <P><textarea name='heent_post_nasal_drip_text' cols='30' rows='2'>{$data->get_heent_post_nasal_drip_text()}</textarea>
1098 </P>
1099 </TD>
1100 </TR>
1101
1102 <TR>
1103 <TD WIDTH=162px>
1104 <P ALIGN=CENTER><BR/>
1105 </P>
1106 </TD>
1107 <TD WIDTH=100px>
1108 <table border=0 cellpadding=0 cellspacing=0>
1109 <tr>
1110 <td><INPUT TYPE=radio NAME='heent_sinus_pressure' VALUE='Yes' '{$data->get_heent_sinus_pressure_yes()}'></td><td>Yes</td>
1111 <td><INPUT TYPE=radio NAME='heent_sinus_pressure' VALUE='No' '{$data->get_heent_sinus_pressure_no()}'></td><td>No</td>
1112 </tr>
1113 </table>
1114 </TD>
1115 <TD WIDTH=161px>
1116 <P>sinus pressure</P>
1117 </TD>
1118 <TD WIDTH=162px VALIGN=TOP>
1119 <P><textarea name='heent_sinus_pressure_text' cols='30' rows='2'>{$data->get_heent_sinus_pressure_text()}</textarea>
1120 </P>
1121 </TD>
1122 </TR>
1123
1124 <TR>
1125 <TD WIDTH=162px>
1126 <P ALIGN=CENTER><BR/>
1127 </P>
1128 </TD>
1129 <TD WIDTH=100px>
1130 <table border=0 cellpadding=0 cellspacing=0>
1131 <tr>
1132 <td><INPUT TYPE=radio NAME='heent_sinus_pain' VALUE='Yes' '{$data->get_heent_sinus_pain_yes()}'></td><td>Yes</td>
1133 <td><INPUT TYPE=radio NAME='heent_sinus_pain' VALUE='No' '{$data->get_heent_sinus_pain_no()}'></td><td>No</td>
1134 </tr>
1135 </table>
1136 </TD>
1137 <TD WIDTH=161px>
1138 <P>sinus pain</P>
1139 </TD>
1140 <TD WIDTH=162px VALIGN=TOP>
1141 <P><textarea name='heent_sinus_pain_text' cols='30' rows='2'>{$data->get_heent_sinus_pain_text()}</textarea>
1142 </P>
1143 </TD>
1144 </TR>
1145
1146 <TR>
1147 <TD WIDTH=162px>
1148 <P ALIGN=CENTER><BR/>
1149 </P>
1150 </TD>
1151 <TD WIDTH=100px>
1152 <table border=0 cellpadding=0 cellspacing=0>
1153 <tr>
1154 <td><INPUT TYPE=radio NAME='heent_headache' VALUE='Yes' '{$data->get_heent_headache_yes()}'></td><td>Yes</td>
1155 <td><INPUT TYPE=radio NAME='heent_headache' VALUE='No' '{$data->get_heent_headache_no()}'></td><td>No</td>
1156 </tr>
1157 </table>
1158 </TD>
1159 <TD WIDTH=161px>
1160 <P>headache</P>
1161 </TD>
1162 <TD WIDTH=162px VALIGN=TOP>
1163 <P><textarea name='heent_headache_text' cols='30' rows='2'>{$data->get_heent_headache_text()}</textarea>
1164 </P>
1165 </TD>
1166 </TR>
1167
1168 <TR>
1169 <TD WIDTH=162px>
1170 <P ALIGN=CENTER><BR/>
1171 </P>
1172 </TD>
1173 <TD WIDTH=100px>
1174 <table border=0 cellpadding=0 cellspacing=0>
1175 <tr>
1176 <td><INPUT TYPE=radio NAME='heent_eye_pain' VALUE='Yes' '{$data->get_heent_eye_pain_yes()}'></td><td>Yes</td>
1177 <td><INPUT TYPE=radio NAME='heent_eye_pain' VALUE='No' '{$data->get_heent_eye_pain_no()}'></td><td>No</td>
1178 </tr>
1179 </table>
1180 </TD>
1181 <TD WIDTH=161px>
1182 <P>eye pain</P>
1183 </TD>
1184 <TD WIDTH=162px VALIGN=TOP>
1185 <P><textarea name='heent_eye_pain_text' cols='30' rows='2'>{$data->get_heent_eye_pain_text()}</textarea>
1186 </P>
1187 </TD>
1188 </TR>
1189
1190 <TR>
1191 <TD WIDTH=162px>
1192 <P ALIGN=CENTER><BR/>
1193 </P>
1194 </TD>
1195 <TD WIDTH=100px>
1196 <table border=0 cellpadding=0 cellspacing=0>
1197 <tr>
1198 <td><INPUT TYPE=radio NAME='heent_eye_redness' VALUE='Yes' '{$data->get_heent_eye_redness_yes()}'></td><td>Yes</td>
1199 <td><INPUT TYPE=radio NAME='heent_eye_redness' VALUE='No' '{$data->get_heent_eye_redness_no()}'></td><td>No</td>
1200 </tr>
1201 </table>
1202 </TD>
1203 <TD WIDTH=161px>
1204 <P>eye redness</P>
1205 </TD>
1206 <TD WIDTH=162px VALIGN=TOP>
1207 <P><textarea name='heent_eye_redness_text' cols='30' rows='2'>{$data->get_heent_eye_redness_text()}</textarea>
1208 </P>
1209 </TD>
1210 </TR>
1211
1212 <TR>
1213 <TD WIDTH=162px>
1214 <P ALIGN=CENTER><BR/>
1215 </P>
1216 </TD>
1217 <TD WIDTH=100px>
1218 <table border=0 cellpadding=0 cellspacing=0>
1219 <tr>
1220 <td><INPUT TYPE=radio NAME='heent_visual_changes' VALUE='Yes' '{$data->get_heent_visual_changes_yes()}'></td><td>Yes</td>
1221 <td><INPUT TYPE=radio NAME='heent_visual_changes' VALUE='No' '{$data->get_heent_visual_changes_no()}'></td><td>No</td>
1222 </tr>
1223 </table>
1224 </TD>
1225 <TD WIDTH=161px>
1226 <P>visual changes</P>
1227 </TD>
1228 <TD WIDTH=162px VALIGN=TOP>
1229 <P><textarea name='heent_visual_changes_text' cols='30' rows='2'>{$data->get_heent_visual_changes_text()}</textarea>
1230 </P>
1231 </TD>
1232 </TR>
1233
1234 <TR>
1235 <TD WIDTH=162px>
1236 <P ALIGN=CENTER><BR/>
1237 </P>
1238 </TD>
1239 <TD WIDTH=100px>
1240 <table border=0 cellpadding=0 cellspacing=0>
1241 <tr>
1242 <td><INPUT TYPE=radio NAME='heent_blurry_vision' VALUE='Yes' '{$data->get_heent_blurry_vision_yes()}'></td><td>Yes</td>
1243 <td><INPUT TYPE=radio NAME='heent_blurry_vision' VALUE='No' '{$data->get_heent_blurry_vision_no()}'></td><td>No</td>
1244 </tr>
1245 </table>
1246 </TD>
1247 <TD WIDTH=161px>
1248 <P>blurry vision</P>
1249 </TD>
1250 <TD WIDTH=162px VALIGN=TOP>
1251 <P><textarea name='heent_blurry_vision_text' cols='30' rows='2'>{$data->get_heent_blurry_vision_text()}</textarea>
1252 </P>
1253 </TD>
1254 </TR>
1255
1256 <TR>
1257 <TD WIDTH=162px>
1258 <P ALIGN=CENTER><BR/>
1259 </P>
1260 </TD>
1261 <TD WIDTH=100px>
1262 <table border=0 cellpadding=0 cellspacing=0>
1263 <tr>
1264 <td><INPUT TYPE=radio NAME='heent_eye_discharge' VALUE='Yes' '{$data->get_heent_eye_discharge_yes()}'></td><td>Yes</td>
1265 <td><INPUT TYPE=radio NAME='heent_eye_discharge' VALUE='No' '{$data->get_heent_eye_discharge_no()}'></td><td>No</td>
1266 </tr>
1267 </table>
1268 </TD>
1269 <TD WIDTH=161px>
1270 <P>Eye Discharge</P>
1271 </TD>
1272 <TD WIDTH=162px VALIGN=TOP>
1273 <P><textarea name='heent_eye_discharge_text' cols='30' rows='2'>{$data->get_heent_eye_discharge_text()}</textarea>
1274 </P>
1275 </TD>
1276 </TR>
1277
1278 <TR>
1279 <TD WIDTH=162px>
1280 <P ALIGN=CENTER><BR/>
1281 </P>
1282 </TD>
1283 <TD WIDTH=100px>
1284 <table border=0 cellpadding=0 cellspacing=0>
1285 <tr>
1286 <td><INPUT TYPE=radio NAME='heent_eye_glasses_contacts' VALUE='Yes' '{$data->get_heent_eye_glasses_contacts_yes()}'></td><td>Yes</td>
1287 <td><INPUT TYPE=radio NAME='heent_eye_glasses_contacts' VALUE='No' '{$data->get_heent_eye_glasses_contacts_no()}'></td><td>No</td>
1288 </tr>
1289 </table>
1290 </TD>
1291 <TD WIDTH=161px>
1292 <P>Eye Glasses/ Contacts</P>
1293 </TD>
1294 <TD WIDTH=162px VALIGN=TOP>
1295 <P><textarea name='heent_eye_glasses_contacts_text' cols='30' rows='2'>{$data->get_heent_eye_glasses_contacts_text()}</textarea>
1296 </P>
1297 </TD>
1298 </TR>
1299
1300 <TR>
1301 <TD WIDTH=162px>
1302 <P ALIGN=CENTER><BR/>
1303 </P>
1304 </TD>
1305 <TD WIDTH=100px>
1306 <table border=0 cellpadding=0 cellspacing=0>
1307 <tr>
1308 <td><INPUT TYPE=radio NAME='heent_excess_tearing' VALUE='Yes' '{$data->get_heent_excess_tearing_yes()}'></td><td>Yes</td>
1309 <td><INPUT TYPE=radio NAME='heent_excess_tearing' VALUE='No' '{$data->get_heent_excess_tearing_no()}'></td><td>No</td>
1310 </tr>
1311 </table>
1312 </TD>
1313 <TD WIDTH=161px>
1314 <P>Excess Tearing</P>
1315 </TD>
1316 <TD WIDTH=162px VALIGN=TOP>
1317 <P><textarea name='heent_excess_tearing_text' cols='30' rows='2'>{$data->get_heent_excess_tearing_text()}</textarea>
1318 </P>
1319 </TD>
1320 </TR>
1321
1322 <TR>
1323 <TD WIDTH=162px>
1324 <P ALIGN=CENTER><BR/>
1325 </P>
1326 </TD>
1327 <TD WIDTH=100px>
1328 <table border=0 cellpadding=0 cellspacing=0>
1329 <tr>
1330 <td><INPUT TYPE=radio NAME='heent_photophobia' VALUE='Yes' '{$data->get_heent_photophobia_yes()}'></td><td>Yes</td>
1331 <td><INPUT TYPE=radio NAME='heent_photophobia' VALUE='No' '{$data->get_heent_photophobia_no()}'></td><td>No</td>
1332 </tr>
1333 </table>
1334 </TD>
1335 <TD WIDTH=161px>
1336 <P>Photophobia</P>
1337 </TD>
1338 <TD WIDTH=162px VALIGN=TOP>
1339 <P><textarea name='heent_photophobia_text' cols='30' rows='2'>{$data->get_heent_photophobia_text()}</textarea>
1340 </P>
1341 </TD>
1342 </TR>
1343
1344 <TR>
1345 <TD WIDTH=162px>
1346 <P ALIGN=CENTER><BR/>
1347 </P>
1348 </TD>
1349 <TD WIDTH=100px>
1350 <table border=0 cellpadding=0 cellspacing=0>
1351 <tr>
1352 <td><INPUT TYPE=radio NAME='heent_scotomata' VALUE='Yes' '{$data->get_heent_scotomata_yes()}'></td><td>Yes</td>
1353 <td><INPUT TYPE=radio NAME='heent_scotomata' VALUE='No' '{$data->get_heent_scotomata_no()}'></td><td>No</td>
1354 </tr>
1355 </table>
1356 </TD>
1357 <TD WIDTH=161px>
1358 <P>Scotomata</P>
1359 </TD>
1360 <TD WIDTH=162px VALIGN=TOP>
1361 <P><textarea name='heent_scotomata_text' cols='30' rows='2'>{$data->get_heent_scotomata_text()}</textarea>
1362 </P>
1363 </TD>
1364 </TR>
1365
1366 <TR>
1367 <TD WIDTH=162px>
1368 <P ALIGN=CENTER><BR/>
1369 </P>
1370 </TD>
1371 <TD WIDTH=100px>
1372 <table border=0 cellpadding=0 cellspacing=0>
1373 <tr>
1374 <td><INPUT TYPE=radio NAME='heent_tunnel_vision' VALUE='Yes' '{$data->get_heent_tunnel_vision_yes()}'></td><td>Yes</td>
1375 <td><INPUT TYPE=radio NAME='heent_tunnel_vision' VALUE='No' '{$data->get_heent_tunnel_vision_no()}'></td><td>No</td>
1376 </tr>
1377 </table>
1378 </TD>
1379 <TD WIDTH=161px>
1380 <P>Tunnel vision</P>
1381 </TD>
1382 <TD WIDTH=162px VALIGN=TOP>
1383 <P><textarea name='heent_tunnel_vision_text' cols='30' rows='2'>{$data->get_heent_tunnel_vision_text()}</textarea>
1384 </P>
1385 </TD>
1386 </TR>
1387
1388 <TR>
1389 <TD WIDTH=162px>
1390 <P ALIGN=CENTER><BR/>
1391 </P>
1392 </TD>
1393 <TD WIDTH=100px>
1394 <table border=0 cellpadding=0 cellspacing=0>
1395 <tr>
1396 <td><INPUT TYPE=radio NAME='heent_glaucoma' VALUE='Yes' '{$data->get_heent_glaucoma_yes()}'></td><td>Yes</td>
1397 <td><INPUT TYPE=radio NAME='heent_glaucoma' VALUE='No' '{$data->get_heent_glaucoma_no()}'></td><td>No</td>
1398 </tr>
1399 </table>
1400 </TD>
1401 <TD WIDTH=161px>
1402 <P>Glaucoma</P>
1403 </TD>
1404 <TD WIDTH=162px VALIGN=TOP>
1405 <P><textarea name='heent_glaucoma_text' cols='30' rows='2'>{$data->get_heent_glaucoma_text()}</textarea>
1406 </P>
1407 </TD>
1408 </TR>
1409
1410 <TR>
1411 <TD WIDTH=162px>
1412 <P ALIGN=CENTER>CARDIOVASCULAR:
1413 </P>
1414 </TD>
1415 <TD WIDTH=100px>
1416 <table border=0 cellpadding=0 cellspacing=0>
1417 <tr>
1418 <td><INPUT TYPE=radio NAME='cardiovascular_sub_sternal_or_left_chest_pain' VALUE='Yes' '{$data->get_cardiovascular_sub_sternal_or_left_chest_pain_yes()}'></td><td>Yes</td>
1419 <td><INPUT TYPE=radio NAME='cardiovascular_sub_sternal_or_left_chest_pain' VALUE='No' '{$data->get_cardiovascular_sub_sternal_or_left_chest_pain_no()}'></td><td>No</td>
1420 </tr>
1421 </table>
1422 </TD>
1423 <TD WIDTH=161px>
1424 <P>sub sternal or left chest pain</P>
1425 </TD>
1426 <TD WIDTH=162px VALIGN=TOP>
1427 <P><textarea name='cardiovascular_sub_sternal_or_left_chest_pain_text' cols='30' rows='2'>{$data->get_cardiovascular_sub_sternal_or_left_chest_pain_text()}</textarea>
1428 </P>
1429 </TD>
1430 </TR>
1431
1432 <TR>
1433 <TD WIDTH=162px>
1434 <P ALIGN=CENTER><BR/>
1435 </P>
1436 </TD>
1437 <TD WIDTH=100px>
1438 <table border=0 cellpadding=0 cellspacing=0>
1439 <tr>
1440 <td><INPUT TYPE=radio NAME='cardiovascular_other_chest_pain' VALUE='Yes' '{$data->get_cardiovascular_other_chest_pain_yes()}'></td><td>Yes</td>
1441 <td><INPUT TYPE=radio NAME='cardiovascular_other_chest_pain' VALUE='No' '{$data->get_cardiovascular_other_chest_pain_no()}'></td><td>No</td>
1442 </tr>
1443 </table>
1444 </TD>
1445 <TD WIDTH=161px>
1446 <P>other chest pain</P>
1447 </TD>
1448 <TD WIDTH=162px VALIGN=TOP>
1449 <P><textarea name='cardiovascular_other_chest_pain_text' cols='30' rows='2'>{$data->get_cardiovascular_other_chest_pain_text()}</textarea>
1450 </P>
1451 </TD>
1452 </TR>
1453
1454 <TR>
1455 <TD WIDTH=162px>
1456 <P ALIGN=CENTER><BR/>
1457 </P>
1458 </TD>
1459 <TD WIDTH=100px>
1460 <table border=0 cellpadding=0 cellspacing=0>
1461 <tr>
1462 <td><INPUT TYPE=radio NAME='cardiovascular_palpitations' VALUE='Yes' '{$data->get_cardiovascular_palpitations_yes()}'></td><td>Yes</td>
1463 <td><INPUT TYPE=radio NAME='cardiovascular_palpitations' VALUE='No' '{$data->get_cardiovascular_palpitations_no()}'></td><td>No</td>
1464 </tr>
1465 </table>
1466 </TD>
1467 <TD WIDTH=161px>
1468 <P>palpitations</P>
1469 </TD>
1470 <TD WIDTH=162px VALIGN=TOP>
1471 <P><textarea name='cardiovascular_palpitations_text' cols='30' rows='2'>{$data->get_cardiovascular_palpitations_text()}</textarea>
1472 </P>
1473 </TD>
1474 </TR>
1475
1476 <TR>
1477 <TD WIDTH=162px>
1478 <P ALIGN=CENTER><BR/>
1479 </P>
1480 </TD>
1481 <TD WIDTH=100px>
1482 <table border=0 cellpadding=0 cellspacing=0>
1483 <tr>
1484 <td><INPUT TYPE=radio NAME='cardiovascular_irregular_rhythm' VALUE='Yes' '{$data->get_cardiovascular_irregular_rhythm_yes()}'></td><td>Yes</td>
1485 <td><INPUT TYPE=radio NAME='cardiovascular_irregular_rhythm' VALUE='No' '{$data->get_cardiovascular_irregular_rhythm_no()}'></td><td>No</td>
1486 </tr>
1487 </table>
1488 </TD>
1489 <TD WIDTH=161px>
1490 <P>irregular rhythm</P>
1491 </TD>
1492 <TD WIDTH=162px VALIGN=TOP>
1493 <P><textarea name='cardiovascular_irregular_rhythm_text' cols='30' rows='2'>{$data->get_cardiovascular_irregular_rhythm_text()}</textarea>
1494 </P>
1495 </TD>
1496 </TR>
1497
1498 <TR>
1499 <TD WIDTH=162px>
1500 <P ALIGN=CENTER><BR/>
1501 </P>
1502 </TD>
1503 <TD WIDTH=100px>
1504 <table border=0 cellpadding=0 cellspacing=0>
1505 <tr>
1506 <td><INPUT TYPE=radio NAME='cardiovascular_jugular_vein_distention' VALUE='Yes' '{$data->get_cardiovascular_jugular_vein_distention_yes()}'></td><td>Yes</td>
1507 <td><INPUT TYPE=radio NAME='cardiovascular_jugular_vein_distention' VALUE='No' '{$data->get_cardiovascular_jugular_vein_distention_no()}'></td><td>No</td>
1508 </tr>
1509 </table>
1510 </TD>
1511 <TD WIDTH=161px>
1512 <P>jugular vein distention</P>
1513 </TD>
1514 <TD WIDTH=162px VALIGN=TOP>
1515 <P><textarea name='cardiovascular_jugular_vein_distention_text' cols='30' rows='2'>{$data->get_cardiovascular_jugular_vein_distention_text()}</textarea>
1516 </P>
1517 </TD>
1518 </TR>
1519
1520 <TR>
1521 <TD WIDTH=162px>
1522 <P ALIGN=CENTER><BR/>
1523 </P>
1524 </TD>
1525 <TD WIDTH=100px>
1526 <table border=0 cellpadding=0 cellspacing=0>
1527 <tr>
1528 <td><INPUT TYPE=radio NAME='cardiovascular_claudication' VALUE='Yes' '{$data->get_cardiovascular_claudication_yes()}'></td><td>Yes</td>
1529 <td><INPUT TYPE=radio NAME='cardiovascular_claudication' VALUE='No' '{$data->get_cardiovascular_claudication_no()}'></td><td>No</td>
1530 </tr>
1531 </table>
1532 </TD>
1533 <TD WIDTH=161px>
1534 <P>Claudication</P>
1535 </TD>
1536 <TD WIDTH=162px VALIGN=TOP>
1537 <P><textarea name='cardiovascular_claudication_text' cols='30' rows='2'>{$data->get_cardiovascular_claudication_text()}</textarea>
1538 </P>
1539 </TD>
1540 </TR>
1541
1542 <TR>
1543 <TD WIDTH=162px>
1544 <P ALIGN=CENTER><BR/>
1545 </P>
1546 </TD>
1547 <TD WIDTH=100px>
1548 <table border=0 cellpadding=0 cellspacing=0>
1549 <tr>
1550 <td><INPUT TYPE=radio NAME='cardiovascular_dizziness' VALUE='Yes' '{$data->get_cardiovascular_dizziness_yes()}'></td><td>Yes</td>
1551 <td><INPUT TYPE=radio NAME='cardiovascular_dizziness' VALUE='No' '{$data->get_cardiovascular_dizziness_no()}'></td><td>No</td>
1552 </tr>
1553 </table>
1554 </TD>
1555 <TD WIDTH=161px>
1556 <P>Dizziness</P>
1557 </TD>
1558 <TD WIDTH=162px VALIGN=TOP>
1559 <P><textarea name='cardiovascular_dizziness_text' cols='30' rows='2'>{$data->get_cardiovascular_dizziness_text()}</textarea>
1560 </P>
1561 </TD>
1562 </TR>
1563
1564 <TR>
1565 <TD WIDTH=162px>
1566 <P ALIGN=CENTER><BR/>
1567 </P>
1568 </TD>
1569 <TD WIDTH=100px>
1570 <table border=0 cellpadding=0 cellspacing=0>
1571 <tr>
1572 <td><INPUT TYPE=radio NAME='cardiovascular_dyspnea_on_exertion' VALUE='Yes' '{$data->get_cardiovascular_dyspnea_on_exertion_yes()}'></td><td>Yes</td>
1573 <td><INPUT TYPE=radio NAME='cardiovascular_dyspnea_on_exertion' VALUE='No' '{$data->get_cardiovascular_dyspnea_on_exertion_no()}'></td><td>No</td>
1574 </tr>
1575 </table>
1576 </TD>
1577 <TD WIDTH=161px>
1578 <P>Dyspnea on Exertion</P>
1579 </TD>
1580 <TD WIDTH=162px VALIGN=TOP>
1581 <P><textarea name='cardiovascular_dyspnea_on_exertion_text' cols='30' rows='2'>{$data->get_cardiovascular_dyspnea_on_exertion_text()}</textarea>
1582 </P>
1583 </TD>
1584 </TR>
1585
1586 <TR>
1587 <TD WIDTH=162px>
1588 <P ALIGN=CENTER><BR/>
1589 </P>
1590 </TD>
1591 <TD WIDTH=100px>
1592 <table border=0 cellpadding=0 cellspacing=0>
1593 <tr>
1594 <td><INPUT TYPE=radio NAME='cardiovascular_orthopnea' VALUE='Yes' '{$data->get_cardiovascular_orthopnea_yes()}'></td><td>Yes</td>
1595 <td><INPUT TYPE=radio NAME='cardiovascular_orthopnea' VALUE='No' '{$data->get_cardiovascular_orthopnea_no()}'></td><td>No</td>
1596 </tr>
1597 </table>
1598 </TD>
1599 <TD WIDTH=161px>
1600 <P>Orthopnea</P>
1601 </TD>
1602 <TD WIDTH=162px VALIGN=TOP>
1603 <P><textarea name='cardiovascular_orthopnea_text' cols='30' rows='2'>{$data->get_cardiovascular_orthopnea_text()}</textarea>
1604 </P>
1605 </TD>
1606 </TR>
1607
1608 <TR>
1609 <TD WIDTH=162px>
1610 <P ALIGN=CENTER><BR/>
1611 </P>
1612 </TD>
1613 <TD WIDTH=100px>
1614 <table border=0 cellpadding=0 cellspacing=0>
1615 <tr>
1616 <td><INPUT TYPE=radio NAME='cardiovascular_noctural_dyspnea' VALUE='Yes' '{$data->get_cardiovascular_noctural_dyspnea_yes()}'></td><td>Yes</td>
1617 <td><INPUT TYPE=radio NAME='cardiovascular_noctural_dyspnea' VALUE='No' '{$data->get_cardiovascular_noctural_dyspnea_no()}'></td><td>No</td>
1618 </tr>
1619 </table>
1620 </TD>
1621 <TD WIDTH=161px>
1622 <P>Noctural Dyspnea</P>
1623 </TD>
1624 <TD WIDTH=162px VALIGN=TOP>
1625 <P><textarea name='cardiovascular_noctural_dyspnea_text' cols='30' rows='2'>{$data->get_cardiovascular_noctural_dyspnea_text()}</textarea>
1626 </P>
1627 </TD>
1628 </TR>
1629
1630 <TR>
1631 <TD WIDTH=162px>
1632 <P ALIGN=CENTER><BR/>
1633 </P>
1634 </TD>
1635 <TD WIDTH=100px>
1636 <table border=0 cellpadding=0 cellspacing=0>
1637 <tr>
1638 <td><INPUT TYPE=radio NAME='cardiovascular_edema' VALUE='Yes' '{$data->get_cardiovascular_edema_yes()}'></td><td>Yes</td>
1639 <td><INPUT TYPE=radio NAME='cardiovascular_edema' VALUE='No' '{$data->get_cardiovascular_edema_no()}'></td><td>No</td>
1640 </tr>
1641 </table>
1642 </TD>
1643 <TD WIDTH=161px>
1644 <P>Edema</P>
1645 </TD>
1646 <TD WIDTH=162px VALIGN=TOP>
1647 <P><textarea name='cardiovascular_edema_text' cols='30' rows='2'>{$data->get_cardiovascular_edema_text()}</textarea>
1648 </P>
1649 </TD>
1650 </TR>
1651
1652 <TR>
1653 <TD WIDTH=162px>
1654 <P ALIGN=CENTER><BR/>
1655 </P>
1656 </TD>
1657 <TD WIDTH=100px>
1658 <table border=0 cellpadding=0 cellspacing=0>
1659 <tr>
1660 <td><INPUT TYPE=radio NAME='cardiovascular_presyncope' VALUE='Yes' '{$data->get_cardiovascular_presyncope_yes()}'></td><td>Yes</td>
1661 <td><INPUT TYPE=radio NAME='cardiovascular_presyncope' VALUE='No' '{$data->get_cardiovascular_presyncope_no()}'></td><td>No</td>
1662 </tr>
1663 </table>
1664 </TD>
1665 <TD WIDTH=161px>
1666 <P>Presyncope</P>
1667 </TD>
1668 <TD WIDTH=162px VALIGN=TOP>
1669 <P><textarea name='cardiovascular_presyncope_text' cols='30' rows='2'>{$data->get_cardiovascular_presyncope_text()}</textarea>
1670 </P>
1671 </TD>
1672 </TR>
1673
1674 <TR>
1675 <TD WIDTH=162px>
1676 <P ALIGN=CENTER><BR/>
1677 </P>
1678 </TD>
1679 <TD WIDTH=100px>
1680 <table border=0 cellpadding=0 cellspacing=0>
1681 <tr>
1682 <td><INPUT TYPE=radio NAME='cardiovascular_syncope' VALUE='Yes' '{$data->get_cardiovascular_syncope_yes()}'></td><td>Yes</td>
1683 <td><INPUT TYPE=radio NAME='cardiovascular_syncope' VALUE='No' '{$data->get_cardiovascular_syncope_no()}'></td><td>No</td>
1684 </tr>
1685 </table>
1686 </TD>
1687 <TD WIDTH=161px>
1688 <P>Syncope</P>
1689 </TD>
1690 <TD WIDTH=162px VALIGN=TOP>
1691 <P><textarea name='cardiovascular_syncope_text' cols='30' rows='2'>{$data->get_cardiovascular_syncope_text()}</textarea>
1692 </P>
1693 </TD>
1694 </TR>
1695
1696 <TR>
1697 <TD WIDTH=162px>
1698 <P ALIGN=CENTER><BR/>
1699 </P>
1700 </TD>
1701 <TD WIDTH=100px>
1702 <table border=0 cellpadding=0 cellspacing=0>
1703 <tr>
1704 <td><INPUT TYPE=radio NAME='cardiovascular_heart_murmur' VALUE='Yes' '{$data->get_cardiovascular_heart_murmur_yes()}'></td><td>Yes</td>
1705 <td><INPUT TYPE=radio NAME='cardiovascular_heart_murmur' VALUE='No' '{$data->get_cardiovascular_heart_murmur_no()}'></td><td>No</td>
1706 </tr>
1707 </table>
1708 </TD>
1709 <TD WIDTH=161px>
1710 <P>Heart Murmur</P>
1711 </TD>
1712 <TD WIDTH=162px VALIGN=TOP>
1713 <P><textarea name='cardiovascular_heart_murmur_text' cols='30' rows='2'>{$data->get_cardiovascular_heart_murmur_text()}</textarea>
1714 </P>
1715 </TD>
1716 </TR>
1717
1718 <TR>
1719 <TD WIDTH=162px>
1720 <P ALIGN=CENTER><BR/>
1721 </P>
1722 </TD>
1723 <TD WIDTH=100px>
1724 <table border=0 cellpadding=0 cellspacing=0>
1725 <tr>
1726 <td><INPUT TYPE=radio NAME='cardiovascular_raynauds' VALUE='Yes' '{$data->get_cardiovascular_raynauds_yes()}'></td><td>Yes</td>
1727 <td><INPUT TYPE=radio NAME='cardiovascular_raynauds' VALUE='No' '{$data->get_cardiovascular_raynauds_no()}'></td><td>No</td>
1728 </tr>
1729 </table>
1730 </TD>
1731 <TD WIDTH=161px>
1732 <P>Raynauds</P>
1733 </TD>
1734 <TD WIDTH=162px VALIGN=TOP>
1735 <P><textarea name='cardiovascular_raynauds_text' cols='30' rows='2'>{$data->get_cardiovascular_raynauds_text()}</textarea>
1736 </P>
1737 </TD>
1738 </TR>
1739
1740 <TR>
1741 <TD WIDTH=162px>
1742 <P ALIGN=CENTER><BR/>
1743 </P>
1744 </TD>
1745 <TD WIDTH=100px>
1746 <table border=0 cellpadding=0 cellspacing=0>
1747 <tr>
1748 <td><INPUT TYPE=radio NAME='cardiovascular_severe_varicose_veins' VALUE='Yes' '{$data->get_cardiovascular_severe_varicose_veins_yes()}'></td><td>Yes</td>
1749 <td><INPUT TYPE=radio NAME='cardiovascular_severe_varicose_veins' VALUE='No' '{$data->get_cardiovascular_severe_varicose_veins_no()}'></td><td>No</td>
1750 </tr>
1751 </table>
1752 </TD>
1753 <TD WIDTH=161px>
1754 <P>Severe Varicose Veins</P>
1755 </TD>
1756 <TD WIDTH=162px VALIGN=TOP>
1757 <P><textarea name='cardiovascular_severe_varicose_veins_text' cols='30' rows='2'>{$data->get_cardiovascular_severe_varicose_veins_text()}</textarea>
1758 </P>
1759 </TD>
1760 </TR>
1761
1762 <TR>
1763 <TD WIDTH=162px>
1764 <P ALIGN=CENTER><BR/>
1765 </P>
1766 </TD>
1767 <TD WIDTH=100px>
1768 <table border=0 cellpadding=0 cellspacing=0>
1769 <tr>
1770 <td><INPUT TYPE=radio NAME='cardiovascular_deep_vein_thrombosis' VALUE='Yes' '{$data->get_cardiovascular_deep_vein_thrombosis_yes()}'></td><td>Yes</td>
1771 <td><INPUT TYPE=radio NAME='cardiovascular_deep_vein_thrombosis' VALUE='No' '{$data->get_cardiovascular_deep_vein_thrombosis_no()}'></td><td>No</td>
1772 </tr>
1773 </table>
1774 </TD>
1775 <TD WIDTH=161px>
1776 <P>Deep Vein Thrombosis</P>
1777 </TD>
1778 <TD WIDTH=162px VALIGN=TOP>
1779 <P><textarea name='cardiovascular_deep_vein_thrombosis_text' cols='30' rows='2'>{$data->get_cardiovascular_deep_vein_thrombosis_text()}</textarea>
1780 </P>
1781 </TD>
1782 </TR>
1783
1784 <TR>
1785 <TD WIDTH=162px>
1786 <P ALIGN=CENTER><BR/>
1787 </P>
1788 </TD>
1789 <TD WIDTH=100px>
1790 <table border=0 cellpadding=0 cellspacing=0>
1791 <tr>
1792 <td><INPUT TYPE=radio NAME='cardiovascular_thrombophlebitis' VALUE='Yes' '{$data->get_cardiovascular_thrombophlebitis_yes()}'></td><td>Yes</td>
1793 <td><INPUT TYPE=radio NAME='cardiovascular_thrombophlebitis' VALUE='No' '{$data->get_cardiovascular_thrombophlebitis_no()}'></td><td>No</td>
1794 </tr>
1795 </table>
1796 </TD>
1797 <TD WIDTH=161px>
1798 <P>Thrombophlebitis</P>
1799 </TD>
1800 <TD WIDTH=162px VALIGN=TOP>
1801 <P><textarea name='cardiovascular_thrombophlebitis_text' cols='30' rows='2'>{$data->get_cardiovascular_thrombophlebitis_text()}</textarea>
1802 </P>
1803 </TD>
1804 </TR>
1805
1806 <TR>
1807 <TD WIDTH=162px>
1808 <P ALIGN=CENTER>RESPIRATIONS:
1809 </P>
1810 </TD>
1811 <TD WIDTH=100px>
1812 <table border=0 cellpadding=0 cellspacing=0>
1813 <tr>
1814 <td><INPUT TYPE=radio NAME='respirations_cough' VALUE='Yes' '{$data->get_respirations_cough_yes()}'></td><td>Yes</td>
1815 <td><INPUT TYPE=radio NAME='respirations_cough' VALUE='No' '{$data->get_respirations_cough_no()}'></td><td>No</td>
1816 </tr>
1817 </table>
1818 </TD>
1819 <TD WIDTH=161px>
1820 <P>cough</P>
1821 </TD>
1822 <TD WIDTH=162px VALIGN=TOP>
1823 <P><textarea name='respirations_cough_text' cols='30' rows='2'>{$data->get_respirations_cough_text()}</textarea>
1824 </P>
1825 </TD>
1826 </TR>
1827
1828 <TR>
1829 <TD WIDTH=162px>
1830 <P ALIGN=CENTER><BR/>
1831 </P>
1832 </TD>
1833 <TD WIDTH=100px>
1834 <table border=0 cellpadding=0 cellspacing=0>
1835 <tr>
1836 <td><INPUT TYPE=radio NAME='respirations_sputum' VALUE='Yes' '{$data->get_respirations_sputum_yes()}'></td><td>Yes</td>
1837 <td><INPUT TYPE=radio NAME='respirations_sputum' VALUE='No' '{$data->get_respirations_sputum_no()}'></td><td>No</td>
1838 </tr>
1839 </table>
1840 </TD>
1841 <TD WIDTH=161px>
1842 <P>sputum</P>
1843 </TD>
1844 <TD WIDTH=162px VALIGN=TOP>
1845 <P><textarea name='respirations_sputum_text' cols='30' rows='2'>{$data->get_respirations_sputum_text()}</textarea>
1846 </P>
1847 </TD>
1848 </TR>
1849
1850 <TR>
1851 <TD WIDTH=162px>
1852 <P ALIGN=CENTER><BR/>
1853 </P>
1854 </TD>
1855 <TD WIDTH=100px>
1856 <table border=0 cellpadding=0 cellspacing=0>
1857 <tr>
1858 <td><INPUT TYPE=radio NAME='respirations_dyspnea' VALUE='Yes' '{$data->get_respirations_dyspnea_yes()}'></td><td>Yes</td>
1859 <td><INPUT TYPE=radio NAME='respirations_dyspnea' VALUE='No' '{$data->get_respirations_dyspnea_no()}'></td><td>No</td>
1860 </tr>
1861 </table>
1862 </TD>
1863 <TD WIDTH=161px>
1864 <P>dyspnea</P>
1865 </TD>
1866 <TD WIDTH=162px VALIGN=TOP>
1867 <P><textarea name='respirations_dyspnea_text' cols='30' rows='2'>{$data->get_respirations_dyspnea_text()}</textarea>
1868 </P>
1869 </TD>
1870 </TR>
1871
1872 <TR>
1873 <TD WIDTH=162px>
1874 <P ALIGN=CENTER><BR/>
1875 </P>
1876 </TD>
1877 <TD WIDTH=100px>
1878 <table border=0 cellpadding=0 cellspacing=0>
1879 <tr>
1880 <td><INPUT TYPE=radio NAME='respirations_wheezes' VALUE='Yes' '{$data->get_respirations_wheezes_yes()}'></td><td>Yes</td>
1881 <td><INPUT TYPE=radio NAME='respirations_wheezes' VALUE='No' '{$data->get_respirations_wheezes_no()}'></td><td>No</td>
1882 </tr>
1883 </table>
1884 </TD>
1885 <TD WIDTH=161px>
1886 <P>wheezes</P>
1887 </TD>
1888 <TD WIDTH=162px VALIGN=TOP>
1889 <P><textarea name='respirations_wheezes_text' cols='30' rows='2'>{$data->get_respirations_wheezes_text()}</textarea>
1890 </P>
1891 </TD>
1892 </TR>
1893
1894 <TR>
1895 <TD WIDTH=162px>
1896 <P ALIGN=CENTER><BR/>
1897 </P>
1898 </TD>
1899 <TD WIDTH=100px>
1900 <table border=0 cellpadding=0 cellspacing=0>
1901 <tr>
1902 <td><INPUT TYPE=radio NAME='respirations_rales' VALUE='Yes' '{$data->get_respirations_rales_yes()}'></td><td>Yes</td>
1903 <td><INPUT TYPE=radio NAME='respirations_rales' VALUE='No' '{$data->get_respirations_rales_no()}'></td><td>No</td>
1904 </tr>
1905 </table>
1906 </TD>
1907 <TD WIDTH=161px>
1908 <P>rales</P>
1909 </TD>
1910 <TD WIDTH=162px VALIGN=TOP>
1911 <P><textarea name='respirations_rales_text' cols='30' rows='2'>{$data->get_respirations_rales_text()}</textarea>
1912 </P>
1913 </TD>
1914 </TR>
1915
1916 <TR>
1917 <TD WIDTH=162px>
1918 <P ALIGN=CENTER><BR/>
1919 </P>
1920 </TD>
1921 <TD WIDTH=100px>
1922 <table border=0 cellpadding=0 cellspacing=0>
1923 <tr>
1924 <td><INPUT TYPE=radio NAME='respirations_labored_breathing' VALUE='Yes' '{$data->get_respirations_labored_breathing_yes()}'></td><td>Yes</td>
1925 <td><INPUT TYPE=radio NAME='respirations_labored_breathing' VALUE='No' '{$data->get_respirations_labored_breathing_no()}'></td><td>No</td>
1926 </tr>
1927 </table>
1928 </TD>
1929 <TD WIDTH=161px>
1930 <P>labored breathing</P>
1931 </TD>
1932 <TD WIDTH=162px VALIGN=TOP>
1933 <P><textarea name='respirations_labored_breathing_text' cols='30' rows='2'>{$data->get_respirations_labored_breathing_text()}</textarea>
1934 </P>
1935 </TD>
1936 </TR>
1937
1938 <TR>
1939 <TD WIDTH=162px>
1940 <P ALIGN=CENTER><BR/>
1941 </P>
1942 </TD>
1943 <TD WIDTH=100px>
1944 <table border=0 cellpadding=0 cellspacing=0>
1945 <tr>
1946 <td><INPUT TYPE=radio NAME='respirations_hemoptysis' VALUE='Yes' '{$data->get_respirations_hemoptysis_yes()}'></td><td>Yes</td>
1947 <td><INPUT TYPE=radio NAME='respirations_hemoptysis' VALUE='No' '{$data->get_respirations_hemoptysis_no()}'></td><td>No</td>
1948 </tr>
1949 </table>
1950 </TD>
1951 <TD WIDTH=161px>
1952 <P>Hemoptysis</P>
1953 </TD>
1954 <TD WIDTH=162px VALIGN=TOP>
1955 <P><textarea name='respirations_hemoptysis_text' cols='30' rows='2'>{$data->get_respirations_hemoptysis_text()}</textarea>
1956 </P>
1957 </TD>
1958 </TR>
1959
1960 <TR>
1961 <TD WIDTH=162px>
1962 <P ALIGN=CENTER>GU
1963 </P>
1964 </TD>
1965 <TD WIDTH=100px>
1966 <table border=0 cellpadding=0 cellspacing=0>
1967 <tr>
1968 <td><INPUT TYPE=radio NAME='gu_frequent_urination' VALUE='Yes' '{$data->get_gu_frequent_urination_yes()}'></td><td>Yes</td>
1969 <td><INPUT TYPE=radio NAME='gu_frequent_urination' VALUE='No' '{$data->get_gu_frequent_urination_no()}'></td><td>No</td>
1970 </tr>
1971 </table>
1972 </TD>
1973 <TD WIDTH=161px>
1974 <P>frequent urination</P>
1975 </TD>
1976 <TD WIDTH=162px VALIGN=TOP>
1977 <P><textarea name='gu_frequent_urination_text' cols='30' rows='2'>{$data->get_gu_frequent_urination_text()}</textarea>
1978 </P>
1979 </TD>
1980 </TR>
1981
1982 <TR>
1983 <TD WIDTH=162px>
1984 <P ALIGN=CENTER><BR/>
1985 </P>
1986 </TD>
1987 <TD WIDTH=100px>
1988 <table border=0 cellpadding=0 cellspacing=0>
1989 <tr>
1990 <td><INPUT TYPE=radio NAME='gu_dysuria' VALUE='Yes' '{$data->get_gu_dysuria_yes()}'></td><td>Yes</td>
1991 <td><INPUT TYPE=radio NAME='gu_dysuria' VALUE='No' '{$data->get_gu_dysuria_no()}'></td><td>No</td>
1992 </tr>
1993 </table>
1994 </TD>
1995 <TD WIDTH=161px>
1996 <P>dysuria</P>
1997 </TD>
1998 <TD WIDTH=162px VALIGN=TOP>
1999 <P><textarea name='gu_dysuria_text' cols='30' rows='2'>{$data->get_gu_dysuria_text()}</textarea>
2000 </P>
2001 </TD>
2002 </TR>
2003
2004 <TR>
2005 <TD WIDTH=162px>
2006 <P ALIGN=CENTER><BR/>
2007 </P>
2008 </TD>
2009 <TD WIDTH=100px>
2010 <table border=0 cellpadding=0 cellspacing=0>
2011 <tr>
2012 <td><INPUT TYPE=radio NAME='gu_dyspareunia' VALUE='Yes' '{$data->get_gu_dyspareunia_yes()}'></td><td>Yes</td>
2013 <td><INPUT TYPE=radio NAME='gu_dyspareunia' VALUE='No' '{$data->get_gu_dyspareunia_no()}'></td><td>No</td>
2014 </tr>
2015 </table>
2016 </TD>
2017 <TD WIDTH=161px>
2018 <P>dyspareunia</P>
2019 </TD>
2020 <TD WIDTH=162px VALIGN=TOP>
2021 <P><textarea name='gu_dyspareunia_text' cols='30' rows='2'>{$data->get_gu_dyspareunia_text()}</textarea>
2022 </P>
2023 </TD>
2024 </TR>
2025
2026 <TR>
2027 <TD WIDTH=162px>
2028 <P ALIGN=CENTER><BR/>
2029 </P>
2030 </TD>
2031 <TD WIDTH=100px>
2032 <table border=0 cellpadding=0 cellspacing=0>
2033 <tr>
2034 <td><INPUT TYPE=radio NAME='gu_discharge' VALUE='Yes' '{$data->get_gu_discharge_yes()}'></td><td>Yes</td>
2035 <td><INPUT TYPE=radio NAME='gu_discharge' VALUE='No' '{$data->get_gu_discharge_no()}'></td><td>No</td>
2036 </tr>
2037 </table>
2038 </TD>
2039 <TD WIDTH=161px>
2040 <P>discharge</P>
2041 </TD>
2042 <TD WIDTH=162px VALIGN=TOP>
2043 <P><textarea name='gu_discharge_text' cols='30' rows='2'>{$data->get_gu_discharge_text()}</textarea>
2044 </P>
2045 </TD>
2046 </TR>
2047
2048 <TR>
2049 <TD WIDTH=162px>
2050 <P ALIGN=CENTER><BR/>
2051 </P>
2052 </TD>
2053 <TD WIDTH=100px>
2054 <table border=0 cellpadding=0 cellspacing=0>
2055 <tr>
2056 <td><INPUT TYPE=radio NAME='gu_odor' VALUE='Yes' '{$data->get_gu_odor_yes()}'></td><td>Yes</td>
2057 <td><INPUT TYPE=radio NAME='gu_odor' VALUE='No' '{$data->get_gu_odor_no()}'></td><td>No</td>
2058 </tr>
2059 </table>
2060 </TD>
2061 <TD WIDTH=161px>
2062 <P>odor</P>
2063 </TD>
2064 <TD WIDTH=162px VALIGN=TOP>
2065 <P><textarea name='gu_odor_text' cols='30' rows='2'>{$data->get_gu_odor_text()}</textarea>
2066 </P>
2067 </TD>
2068 </TR>
2069
2070 <TR>
2071 <TD WIDTH=162px>
2072 <P ALIGN=CENTER><BR/>
2073 </P>
2074 </TD>
2075 <TD WIDTH=100px>
2076 <table border=0 cellpadding=0 cellspacing=0>
2077 <tr>
2078 <td><INPUT TYPE=radio NAME='gu_fertility_problems' VALUE='Yes' '{$data->get_gu_fertility_problems_yes()}'></td><td>Yes</td>
2079 <td><INPUT TYPE=radio NAME='gu_fertility_problems' VALUE='No' '{$data->get_gu_fertility_problems_no()}'></td><td>No</td>
2080 </tr>
2081 </table>
2082 </TD>
2083 <TD WIDTH=161px>
2084 <P>fertility problems</P>
2085 </TD>
2086 <TD WIDTH=162px VALIGN=TOP>
2087 <P><textarea name='gu_fertility_problems_text' cols='30' rows='2'>{$data->get_gu_fertility_problems_text()}</textarea>
2088 </P>
2089 </TD>
2090 </TR>
2091
2092 <TR>
2093 <TD WIDTH=162px>
2094 <P ALIGN=CENTER><BR/>
2095 </P>
2096 </TD>
2097 <TD WIDTH=100px>
2098 <table border=0 cellpadding=0 cellspacing=0>
2099 <tr>
2100 <td><INPUT TYPE=radio NAME='gu_flank_pain_kidney_stone' VALUE='Yes' '{$data->get_gu_flank_pain_kidney_stone_yes()}'></td><td>Yes</td>
2101 <td><INPUT TYPE=radio NAME='gu_flank_pain_kidney_stone' VALUE='No' '{$data->get_gu_flank_pain_kidney_stone_no()}'></td><td>No</td>
2102 </tr>
2103 </table>
2104 </TD>
2105 <TD WIDTH=161px>
2106 <P>Flank Pain Kidney Stone</P>
2107 </TD>
2108 <TD WIDTH=162px VALIGN=TOP>
2109 <P><textarea name='gu_flank_pain_kidney_stone_text' cols='30' rows='2'>{$data->get_gu_flank_pain_kidney_stone_text()}</textarea>
2110 </P>
2111 </TD>
2112 </TR>
2113
2114 <TR>
2115 <TD WIDTH=162px>
2116 <P ALIGN=CENTER><BR/>
2117 </P>
2118 </TD>
2119 <TD WIDTH=100px>
2120 <table border=0 cellpadding=0 cellspacing=0>
2121 <tr>
2122 <td><INPUT TYPE=radio NAME='gu_polyuria' VALUE='Yes' '{$data->get_gu_polyuria_yes()}'></td><td>Yes</td>
2123 <td><INPUT TYPE=radio NAME='gu_polyuria' VALUE='No' '{$data->get_gu_polyuria_no()}'></td><td>No</td>
2124 </tr>
2125 </table>
2126 </TD>
2127 <TD WIDTH=161px>
2128 <P>Polyuria</P>
2129 </TD>
2130 <TD WIDTH=162px VALIGN=TOP>
2131 <P><textarea name='gu_polyuria_text' cols='30' rows='2'>{$data->get_gu_polyuria_text()}</textarea>
2132 </P>
2133 </TD>
2134 </TR>
2135
2136 <TR>
2137 <TD WIDTH=162px>
2138 <P ALIGN=CENTER><BR/>
2139 </P>
2140 </TD>
2141 <TD WIDTH=100px>
2142 <table border=0 cellpadding=0 cellspacing=0>
2143 <tr>
2144 <td><INPUT TYPE=radio NAME='gu_hematuria' VALUE='Yes' '{$data->get_gu_hematuria_yes()}'></td><td>Yes</td>
2145 <td><INPUT TYPE=radio NAME='gu_hematuria' VALUE='No' '{$data->get_gu_hematuria_no()}'></td><td>No</td>
2146 </tr>
2147 </table>
2148 </TD>
2149 <TD WIDTH=161px>
2150 <P>Hematuria</P>
2151 </TD>
2152 <TD WIDTH=162px VALIGN=TOP>
2153 <P><textarea name='gu_hematuria_text' cols='30' rows='2'>{$data->get_gu_hematuria_text()}</textarea>
2154 </P>
2155 </TD>
2156 </TR>
2157
2158 <TR>
2159 <TD WIDTH=162px>
2160 <P ALIGN=CENTER><BR/>
2161 </P>
2162 </TD>
2163 <TD WIDTH=100px>
2164 <table border=0 cellpadding=0 cellspacing=0>
2165 <tr>
2166 <td><INPUT TYPE=radio NAME='gu_pyuria' VALUE='Yes' '{$data->get_gu_pyuria_yes()}'></td><td>Yes</td>
2167 <td><INPUT TYPE=radio NAME='gu_pyuria' VALUE='No' '{$data->get_gu_pyuria_no()}'></td><td>No</td>
2168 </tr>
2169 </table>
2170 </TD>
2171 <TD WIDTH=161px>
2172 <P>Pyuria</P>
2173 </TD>
2174 <TD WIDTH=162px VALIGN=TOP>
2175 <P><textarea name='gu_pyuria_text' cols='30' rows='2'>{$data->get_gu_pyuria_text()}</textarea>
2176 </P>
2177 </TD>
2178 </TR>
2179
2180 <TR>
2181 <TD WIDTH=162px>
2182 <P ALIGN=CENTER><BR/>
2183 </P>
2184 </TD>
2185 <TD WIDTH=100px>
2186 <table border=0 cellpadding=0 cellspacing=0>
2187 <tr>
2188 <td><INPUT TYPE=radio NAME='gu_umbilical_hernia' VALUE='Yes' '{$data->get_gu_umbilical_hernia_yes()}'></td><td>Yes</td>
2189 <td><INPUT TYPE=radio NAME='gu_umbilical_hernia' VALUE='No' '{$data->get_gu_umbilical_hernia_no()}'></td><td>No</td>
2190 </tr>
2191 </table>
2192 </TD>
2193 <TD WIDTH=161px>
2194 <P>Umbilical Hernia</P>
2195 </TD>
2196 <TD WIDTH=162px VALIGN=TOP>
2197 <P><textarea name='gu_umbilical_hernia_text' cols='30' rows='2'>{$data->get_gu_umbilical_hernia_text()}</textarea>
2198 </P>
2199 </TD>
2200 </TR>
2201
2202 <TR>
2203 <TD WIDTH=162px>
2204 <P ALIGN=CENTER><BR/>
2205 </P>
2206 </TD>
2207 <TD WIDTH=100px>
2208 <table border=0 cellpadding=0 cellspacing=0>
2209 <tr>
2210 <td><INPUT TYPE=radio NAME='gu_incontinence' VALUE='Yes' '{$data->get_gu_incontinence_yes()}'></td><td>Yes</td>
2211 <td><INPUT TYPE=radio NAME='gu_incontinence' VALUE='No' '{$data->get_gu_incontinence_no()}'></td><td>No</td>
2212 </tr>
2213 </table>
2214 </TD>
2215 <TD WIDTH=161px>
2216 <P>Incontinence</P>
2217 </TD>
2218 <TD WIDTH=162px VALIGN=TOP>
2219 <P><textarea name='gu_incontinence_text' cols='30' rows='2'>{$data->get_gu_incontinence_text()}</textarea>
2220 </P>
2221 </TD>
2222 </TR>
2223
2224 <TR>
2225 <TD WIDTH=162px>
2226 <P ALIGN=CENTER><BR/>
2227 </P>
2228 </TD>
2229 <TD WIDTH=100px>
2230 <table border=0 cellpadding=0 cellspacing=0>
2231 <tr>
2232 <td><INPUT TYPE=radio NAME='gu_nocturia' VALUE='Yes' '{$data->get_gu_nocturia_yes()}'></td><td>Yes</td>
2233 <td><INPUT TYPE=radio NAME='gu_nocturia' VALUE='No' '{$data->get_gu_nocturia_no()}'></td><td>No</td>
2234 </tr>
2235 </table>
2236 </TD>
2237 <TD WIDTH=161px>
2238 <P>Nocturia</P>
2239 </TD>
2240 <TD WIDTH=162px VALIGN=TOP>
2241 <P><textarea name='gu_nocturia_text' cols='30' rows='2'>{$data->get_gu_nocturia_text()}</textarea>
2242 </P>
2243 </TD>
2244 </TR>
2245
2246 <TR>
2247 <TD WIDTH=162px>
2248 <P ALIGN=CENTER><BR/>
2249 </P>
2250 </TD>
2251 <TD WIDTH=100px>
2252 <table border=0 cellpadding=0 cellspacing=0>
2253 <tr>
2254 <td><INPUT TYPE=radio NAME='gu_urinary_urgency' VALUE='Yes' '{$data->get_gu_urinary_urgency_yes()}'></td><td>Yes</td>
2255 <td><INPUT TYPE=radio NAME='gu_urinary_urgency' VALUE='No' '{$data->get_gu_urinary_urgency_no()}'></td><td>No</td>
2256 </tr>
2257 </table>
2258 </TD>
2259 <TD WIDTH=161px>
2260 <P>Urinary Urgency</P>
2261 </TD>
2262 <TD WIDTH=162px VALIGN=TOP>
2263 <P><textarea name='gu_urinary_urgency_text' cols='30' rows='2'>{$data->get_gu_urinary_urgency_text()}</textarea>
2264 </P>
2265 </TD>
2266 </TR>
2267
2268 <TR>
2269 <TD WIDTH=162px>
2270 <P ALIGN=CENTER><BR/>
2271 </P>
2272 </TD>
2273 <TD WIDTH=100px>
2274 <table border=0 cellpadding=0 cellspacing=0>
2275 <tr>
2276 <td><INPUT TYPE=radio NAME='gu_recurrent_utis' VALUE='Yes' '{$data->get_gu_recurrent_utis_yes()}'></td><td>Yes</td>
2277 <td><INPUT TYPE=radio NAME='gu_recurrent_utis' VALUE='No' '{$data->get_gu_recurrent_utis_no()}'></td><td>No</td>
2278 </tr>
2279 </table>
2280 </TD>
2281 <TD WIDTH=161px>
2282 <P>Recurrent UTIs</P>
2283 </TD>
2284 <TD WIDTH=162px VALIGN=TOP>
2285 <P><textarea name='gu_recurrent_utis_text' cols='30' rows='2'>{$data->get_gu_recurrent_utis_text()}</textarea>
2286 </P>
2287 </TD>
2288 </TR>
2289
2290 <TR>
2291 <TD WIDTH=162px>
2292 <P ALIGN=CENTER><BR/>
2293 </P>
2294 </TD>
2295 <TD WIDTH=100px>
2296 <table border=0 cellpadding=0 cellspacing=0>
2297 <tr>
2298 <td><INPUT TYPE=radio NAME='gu_venereal_disease' VALUE='Yes' '{$data->get_gu_venereal_disease_yes()}'></td><td>Yes</td>
2299 <td><INPUT TYPE=radio NAME='gu_venereal_disease' VALUE='No' '{$data->get_gu_venereal_disease_no()}'></td><td>No</td>
2300 </tr>
2301 </table>
2302 </TD>
2303 <TD WIDTH=161px>
2304 <P>Venereal Disease</P>
2305 </TD>
2306 <TD WIDTH=162px VALIGN=TOP>
2307 <P><textarea name='gu_venereal_disease_text' cols='30' rows='2'>{$data->get_gu_venereal_disease_text()}</textarea>
2308 </P>
2309 </TD>
2310 </TR>
2311
2312 <TR>
2313 <TD WIDTH=162px>
2314 <P ALIGN=CENTER>MALE GU
2315 </P>
2316 </TD>
2317 <TD WIDTH=100px>
2318 <table border=0 cellpadding=0 cellspacing=0>
2319 <tr>
2320 <td><INPUT TYPE=radio NAME='male_gu_erectile_dysfunction' VALUE='Yes' '{$data->get_male_gu_erectile_dysfunction_yes()}'></td><td>Yes</td>
2321 <td><INPUT TYPE=radio NAME='male_gu_erectile_dysfunction' VALUE='No' '{$data->get_male_gu_erectile_dysfunction_no()}'></td><td>No</td>
2322 </tr>
2323 </table>
2324 </TD>
2325 <TD WIDTH=161px>
2326 <P>Erectile Dysfunction</P>
2327 </TD>
2328 <TD WIDTH=162px VALIGN=TOP>
2329 <P><textarea name='male_gu_erectile_dysfunction_text' cols='30' rows='2'>{$data->get_male_gu_erectile_dysfunction_text()}</textarea>
2330 </P>
2331 </TD>
2332 </TR>
2333
2334 <TR>
2335 <TD WIDTH=162px>
2336 <P ALIGN=CENTER><BR/>
2337 </P>
2338 </TD>
2339 <TD WIDTH=100px>
2340 <table border=0 cellpadding=0 cellspacing=0>
2341 <tr>
2342 <td><INPUT TYPE=radio NAME='male_gu_inguinal_hernia' VALUE='Yes' '{$data->get_male_gu_inguinal_hernia_yes()}'></td><td>Yes</td>
2343 <td><INPUT TYPE=radio NAME='male_gu_inguinal_hernia' VALUE='No' '{$data->get_male_gu_inguinal_hernia_no()}'></td><td>No</td>
2344 </tr>
2345 </table>
2346 </TD>
2347 <TD WIDTH=161px>
2348 <P>Inguinal Hernia</P>
2349 </TD>
2350 <TD WIDTH=162px VALIGN=TOP>
2351 <P><textarea name='male_gu_inguinal_hernia_text' cols='30' rows='2'>{$data->get_male_gu_inguinal_hernia_text()}</textarea>
2352 </P>
2353 </TD>
2354 </TR>
2355
2356 <TR>
2357 <TD WIDTH=162px>
2358 <P ALIGN=CENTER><BR/>
2359 </P>
2360 </TD>
2361 <TD WIDTH=100px>
2362 <table border=0 cellpadding=0 cellspacing=0>
2363 <tr>
2364 <td><INPUT TYPE=radio NAME='male_gu_penile_lesions' VALUE='Yes' '{$data->get_male_gu_penile_lesions_yes()}'></td><td>Yes</td>
2365 <td><INPUT TYPE=radio NAME='male_gu_penile_lesions' VALUE='No' '{$data->get_male_gu_penile_lesions_no()}'></td><td>No</td>
2366 </tr>
2367 </table>
2368 </TD>
2369 <TD WIDTH=161px>
2370 <P>Penile Lesions</P>
2371 </TD>
2372 <TD WIDTH=162px VALIGN=TOP>
2373 <P><textarea name='male_gu_penile_lesions_text' cols='30' rows='2'>{$data->get_male_gu_penile_lesions_text()}</textarea>
2374 </P>
2375 </TD>
2376 </TR>
2377
2378 <TR>
2379 <TD WIDTH=162px>
2380 <P ALIGN=CENTER><BR/>
2381 </P>
2382 </TD>
2383 <TD WIDTH=100px>
2384 <table border=0 cellpadding=0 cellspacing=0>
2385 <tr>
2386 <td><INPUT TYPE=radio NAME='male_gu_scrotal_mass' VALUE='Yes' '{$data->get_male_gu_scrotal_mass_yes()}'></td><td>Yes</td>
2387 <td><INPUT TYPE=radio NAME='male_gu_scrotal_mass' VALUE='No' '{$data->get_male_gu_scrotal_mass_no()}'></td><td>No</td>
2388 </tr>
2389 </table>
2390 </TD>
2391 <TD WIDTH=161px>
2392 <P>Scrotal Mass</P>
2393 </TD>
2394 <TD WIDTH=162px VALIGN=TOP>
2395 <P><textarea name='male_gu_scrotal_mass_text' cols='30' rows='2'>{$data->get_male_gu_scrotal_mass_text()}</textarea>
2396 </P>
2397 </TD>
2398 </TR>
2399
2400 <TR>
2401 <TD WIDTH=162px>
2402 <P ALIGN=CENTER><BR/>
2403 </P>
2404 </TD>
2405 <TD WIDTH=100px>
2406 <table border=0 cellpadding=0 cellspacing=0>
2407 <tr>
2408 <td><INPUT TYPE=radio NAME='male_gu_testicular_pain' VALUE='Yes' '{$data->get_male_gu_testicular_pain_yes()}'></td><td>Yes</td>
2409 <td><INPUT TYPE=radio NAME='male_gu_testicular_pain' VALUE='No' '{$data->get_male_gu_testicular_pain_no()}'></td><td>No</td>
2410 </tr>
2411 </table>
2412 </TD>
2413 <TD WIDTH=161px>
2414 <P>Testicular Pain</P>
2415 </TD>
2416 <TD WIDTH=162px VALIGN=TOP>
2417 <P><textarea name='male_gu_testicular_pain_text' cols='30' rows='2'>{$data->get_male_gu_testicular_pain_text()}</textarea>
2418 </P>
2419 </TD>
2420 </TR>
2421
2422 <TR>
2423 <TD WIDTH=162px>
2424 <P ALIGN=CENTER><BR/>
2425 </P>
2426 </TD>
2427 <TD WIDTH=100px>
2428 <table border=0 cellpadding=0 cellspacing=0>
2429 <tr>
2430 <td><INPUT TYPE=radio NAME='male_gu_urethral_discharge' VALUE='Yes' '{$data->get_male_gu_urethral_discharge_yes()}'></td><td>Yes</td>
2431 <td><INPUT TYPE=radio NAME='male_gu_urethral_discharge' VALUE='No' '{$data->get_male_gu_urethral_discharge_no()}'></td><td>No</td>
2432 </tr>
2433 </table>
2434 </TD>
2435 <TD WIDTH=161px>
2436 <P>Urethral Discharge</P>
2437 </TD>
2438 <TD WIDTH=162px VALIGN=TOP>
2439 <P><textarea name='male_gu_urethral_discharge_text' cols='30' rows='2'>{$data->get_male_gu_urethral_discharge_text()}</textarea>
2440 </P>
2441 </TD>
2442 </TR>
2443
2444 <TR>
2445 <TD WIDTH=162px>
2446 <P ALIGN=CENTER><BR/>
2447 </P>
2448 </TD>
2449 <TD WIDTH=100px>
2450 <table border=0 cellpadding=0 cellspacing=0>
2451 <tr>
2452 <td><INPUT TYPE=radio NAME='male_gu_weak_urinary_stream' VALUE='Yes' '{$data->get_male_gu_weak_urinary_stream_yes()}'></td><td>Yes</td>
2453 <td><INPUT TYPE=radio NAME='male_gu_weak_urinary_stream' VALUE='No' '{$data->get_male_gu_weak_urinary_stream_no()}'></td><td>No</td>
2454 </tr>
2455 </table>
2456 </TD>
2457 <TD WIDTH=161px>
2458 <P>Weak Urinary Stream</P>
2459 </TD>
2460 <TD WIDTH=162px VALIGN=TOP>
2461 <P><textarea name='male_gu_weak_urinary_stream_text' cols='30' rows='2'>{$data->get_male_gu_weak_urinary_stream_text()}</textarea>
2462 </P>
2463 </TD>
2464 </TR>
2465
2466 <TR>
2467 <TD WIDTH=162px>
2468 <P ALIGN=CENTER>FEMALE GU
2469 </P>
2470 </TD>
2471 <TD WIDTH=100px>
2472 <table border=0 cellpadding=0 cellspacing=0>
2473 <tr>
2474 <td><INPUT TYPE=radio NAME='female_gu_abnormal_menses' VALUE='Yes' '{$data->get_female_gu_abnormal_menses_yes()}'></td><td>Yes</td>
2475 <td><INPUT TYPE=radio NAME='female_gu_abnormal_menses' VALUE='No' '{$data->get_female_gu_abnormal_menses_no()}'></td><td>No</td>
2476 </tr>
2477 </table>
2478 </TD>
2479 <TD WIDTH=161px>
2480 <P>Abnormal Menses</P>
2481 </TD>
2482 <TD WIDTH=162px VALIGN=TOP>
2483 <P><textarea name='female_gu_abnormal_menses_text' cols='30' rows='2'>{$data->get_female_gu_abnormal_menses_text()}</textarea>
2484 </P>
2485 </TD>
2486 </TR>
2487
2488 <TR>
2489 <TD WIDTH=162px>
2490 <P ALIGN=CENTER><BR/>
2491 </P>
2492 </TD>
2493 <TD WIDTH=100px>
2494 <table border=0 cellpadding=0 cellspacing=0>
2495 <tr>
2496 <td><INPUT TYPE=radio NAME='female_gu_abnormal_vaginal_bleeding' VALUE='Yes' '{$data->get_female_gu_abnormal_vaginal_bleeding_yes()}'></td><td>Yes</td>
2497 <td><INPUT TYPE=radio NAME='female_gu_abnormal_vaginal_bleeding' VALUE='No' '{$data->get_female_gu_abnormal_vaginal_bleeding_no()}'></td><td>No</td>
2498 </tr>
2499 </table>
2500 </TD>
2501 <TD WIDTH=161px>
2502 <P>Abnormal Vaginal Bleeding</P>
2503 </TD>
2504 <TD WIDTH=162px VALIGN=TOP>
2505 <P><textarea name='female_gu_abnormal_vaginal_bleeding_text' cols='30' rows='2'>{$data->get_female_gu_abnormal_vaginal_bleeding_text()}</textarea>
2506 </P>
2507 </TD>
2508 </TR>
2509
2510 <TR>
2511 <TD WIDTH=162px>
2512 <P ALIGN=CENTER><BR/>
2513 </P>
2514 </TD>
2515 <TD WIDTH=100px>
2516 <table border=0 cellpadding=0 cellspacing=0>
2517 <tr>
2518 <td><INPUT TYPE=radio NAME='female_gu_vaginal_discharge' VALUE='Yes' '{$data->get_female_gu_vaginal_discharge_yes()}'></td><td>Yes</td>
2519 <td><INPUT TYPE=radio NAME='female_gu_vaginal_discharge' VALUE='No' '{$data->get_female_gu_vaginal_discharge_no()}'></td><td>No</td>
2520 </tr>
2521 </table>
2522 </TD>
2523 <TD WIDTH=161px>
2524 <P>Vaginal Discharge </P>
2525 </TD>
2526 <TD WIDTH=162px VALIGN=TOP>
2527 <P><textarea name='female_gu_vaginal_discharge_text' cols='30' rows='2'>{$data->get_female_gu_vaginal_discharge_text()}</textarea>
2528 </P>
2529 </TD>
2530 </TR>
2531
2532 <TR>
2533 <TD WIDTH=162px>
2534 <P ALIGN=CENTER>GI
2535 </P>
2536 </TD>
2537 <TD WIDTH=100px>
2538 <table border=0 cellpadding=0 cellspacing=0>
2539 <tr>
2540 <td><INPUT TYPE=radio NAME='gi_abdominal_pain' VALUE='Yes' '{$data->get_gi_abdominal_pain_yes()}'></td><td>Yes</td>
2541 <td><INPUT TYPE=radio NAME='gi_abdominal_pain' VALUE='No' '{$data->get_gi_abdominal_pain_no()}'></td><td>No</td>
2542 </tr>
2543 </table>
2544 </TD>
2545 <TD WIDTH=161px>
2546 <P>abdominal pain</P>
2547 </TD>
2548 <TD WIDTH=162px VALIGN=TOP>
2549 <P><textarea name='gi_abdominal_pain_text' cols='30' rows='2'>{$data->get_gi_abdominal_pain_text()}</textarea>
2550 </P>
2551 </TD>
2552 </TR>
2553
2554 <TR>
2555 <TD WIDTH=162px>
2556 <P ALIGN=CENTER><BR/>
2557 </P>
2558 </TD>
2559 <TD WIDTH=100px>
2560 <table border=0 cellpadding=0 cellspacing=0>
2561 <tr>
2562 <td><INPUT TYPE=radio NAME='gi_cramps' VALUE='Yes' '{$data->get_gi_cramps_yes()}'></td><td>Yes</td>
2563 <td><INPUT TYPE=radio NAME='gi_cramps' VALUE='No' '{$data->get_gi_cramps_no()}'></td><td>No</td>
2564 </tr>
2565 </table>
2566 </TD>
2567 <TD WIDTH=161px>
2568 <P>cramps</P>
2569 </TD>
2570 <TD WIDTH=162px VALIGN=TOP>
2571 <P><textarea name='gi_cramps_text' cols='30' rows='2'>{$data->get_gi_cramps_text()}</textarea>
2572 </P>
2573 </TD>
2574 </TR>
2575
2576 <TR>
2577 <TD WIDTH=162px>
2578 <P ALIGN=CENTER><BR/>
2579 </P>
2580 </TD>
2581 <TD WIDTH=100px>
2582 <table border=0 cellpadding=0 cellspacing=0>
2583 <tr>
2584 <td><INPUT TYPE=radio NAME='gi_tenderness' VALUE='Yes' '{$data->get_gi_tenderness_yes()}'></td><td>Yes</td>
2585 <td><INPUT TYPE=radio NAME='gi_tenderness' VALUE='No' '{$data->get_gi_tenderness_no()}'></td><td>No</td>
2586 </tr>
2587 </table>
2588 </TD>
2589 <TD WIDTH=161px>
2590 <P>tenderness</P>
2591 </TD>
2592 <TD WIDTH=162px VALIGN=TOP>
2593 <P><textarea name='gi_tenderness_text' cols='30' rows='2'>{$data->get_gi_tenderness_text()}</textarea>
2594 </P>
2595 </TD>
2596 </TR>
2597
2598 <TR>
2599 <TD WIDTH=162px>
2600 <P ALIGN=CENTER><BR/>
2601 </P>
2602 </TD>
2603 <TD WIDTH=100px>
2604 <table border=0 cellpadding=0 cellspacing=0>
2605 <tr>
2606 <td><INPUT TYPE=radio NAME='gi_vomiting' VALUE='Yes' '{$data->get_gi_vomiting_yes()}'></td><td>Yes</td>
2607 <td><INPUT TYPE=radio NAME='gi_vomiting' VALUE='No' '{$data->get_gi_vomiting_no()}'></td><td>No</td>
2608 </tr>
2609 </table>
2610 </TD>
2611 <TD WIDTH=161px>
2612 <P>vomiting</P>
2613 </TD>
2614 <TD WIDTH=162px VALIGN=TOP>
2615 <P><textarea name='gi_vomiting_text' cols='30' rows='2'>{$data->get_gi_vomiting_text()}</textarea>
2616 </P>
2617 </TD>
2618 </TR>
2619
2620 <TR>
2621 <TD WIDTH=162px>
2622 <P ALIGN=CENTER><BR/>
2623 </P>
2624 </TD>
2625 <TD WIDTH=100px>
2626 <table border=0 cellpadding=0 cellspacing=0>
2627 <tr>
2628 <td><INPUT TYPE=radio NAME='gi_frequent_diarrhea' VALUE='Yes' '{$data->get_gi_frequent_diarrhea_yes()}'></td><td>Yes</td>
2629 <td><INPUT TYPE=radio NAME='gi_frequent_diarrhea' VALUE='No' '{$data->get_gi_frequent_diarrhea_no()}'></td><td>No</td>
2630 </tr>
2631 </table>
2632 </TD>
2633 <TD WIDTH=161px>
2634 <P>frequent diarrhea</P>
2635 </TD>
2636 <TD WIDTH=162px VALIGN=TOP>
2637 <P><textarea name='gi_frequent_diarrhea_text' cols='30' rows='2'>{$data->get_gi_frequent_diarrhea_text()}</textarea>
2638 </P>
2639 </TD>
2640 </TR>
2641
2642 <TR>
2643 <TD WIDTH=162px>
2644 <P ALIGN=CENTER><BR/>
2645 </P>
2646 </TD>
2647 <TD WIDTH=100px>
2648 <table border=0 cellpadding=0 cellspacing=0>
2649 <tr>
2650 <td><INPUT TYPE=radio NAME='gi_significant_constipation' VALUE='Yes' '{$data->get_gi_significant_constipation_yes()}'></td><td>Yes</td>
2651 <td><INPUT TYPE=radio NAME='gi_significant_constipation' VALUE='No' '{$data->get_gi_significant_constipation_no()}'></td><td>No</td>
2652 </tr>
2653 </table>
2654 </TD>
2655 <TD WIDTH=161px>
2656 <P>significant constipation</P>
2657 </TD>
2658 <TD WIDTH=162px VALIGN=TOP>
2659 <P><textarea name='gi_significant_constipation_text' cols='30' rows='2'>{$data->get_gi_significant_constipation_text()}</textarea>
2660 </P>
2661 </TD>
2662 </TR>
2663
2664 <TR>
2665 <TD WIDTH=162px>
2666 <P ALIGN=CENTER><BR/>
2667 </P>
2668 </TD>
2669 <TD WIDTH=100px>
2670 <table border=0 cellpadding=0 cellspacing=0>
2671 <tr>
2672 <td><INPUT TYPE=radio NAME='gi_excessive_belching' VALUE='Yes' '{$data->get_gi_excessive_belching_yes()}'></td><td>Yes</td>
2673 <td><INPUT TYPE=radio NAME='gi_excessive_belching' VALUE='No' '{$data->get_gi_excessive_belching_no()}'></td><td>No</td>
2674 </tr>
2675 </table>
2676 </TD>
2677 <TD WIDTH=161px>
2678 <P>Excessive Belching</P>
2679 </TD>
2680 <TD WIDTH=162px VALIGN=TOP>
2681 <P><textarea name='gi_excessive_belching_text' cols='30' rows='2'>{$data->get_gi_excessive_belching_text()}</textarea>
2682 </P>
2683 </TD>
2684 </TR>
2685
2686 <TR>
2687 <TD WIDTH=162px>
2688 <P ALIGN=CENTER><BR/>
2689 </P>
2690 </TD>
2691 <TD WIDTH=100px>
2692 <table border=0 cellpadding=0 cellspacing=0>
2693 <tr>
2694 <td><INPUT TYPE=radio NAME='gi_changed_bowel_habits' VALUE='Yes' '{$data->get_gi_changed_bowel_habits_yes()}'></td><td>Yes</td>
2695 <td><INPUT TYPE=radio NAME='gi_changed_bowel_habits' VALUE='No' '{$data->get_gi_changed_bowel_habits_no()}'></td><td>No</td>
2696 </tr>
2697 </table>
2698 </TD>
2699 <TD WIDTH=161px>
2700 <P>Changed Bowel Habits</P>
2701 </TD>
2702 <TD WIDTH=162px VALIGN=TOP>
2703 <P><textarea name='gi_changed_bowel_habits_text' cols='30' rows='2'>{$data->get_gi_changed_bowel_habits_text()}</textarea>
2704 </P>
2705 </TD>
2706 </TR>
2707
2708 <TR>
2709 <TD WIDTH=162px>
2710 <P ALIGN=CENTER><BR/>
2711 </P>
2712 </TD>
2713 <TD WIDTH=100px>
2714 <table border=0 cellpadding=0 cellspacing=0>
2715 <tr>
2716 <td><INPUT TYPE=radio NAME='gi_excessive_flatulence' VALUE='Yes' '{$data->get_gi_excessive_flatulence_yes()}'></td><td>Yes</td>
2717 <td><INPUT TYPE=radio NAME='gi_excessive_flatulence' VALUE='No' '{$data->get_gi_excessive_flatulence_no()}'></td><td>No</td>
2718 </tr>
2719 </table>
2720 </TD>
2721 <TD WIDTH=161px>
2722 <P>Excessive Flatulence</P>
2723 </TD>
2724 <TD WIDTH=162px VALIGN=TOP>
2725 <P><textarea name='gi_excessive_flatulence_text' cols='30' rows='2'>{$data->get_gi_excessive_flatulence_text()}</textarea>
2726 </P>
2727 </TD>
2728 </TR>
2729
2730 <TR>
2731 <TD WIDTH=162px>
2732 <P ALIGN=CENTER><BR/>
2733 </P>
2734 </TD>
2735 <TD WIDTH=100px>
2736 <table border=0 cellpadding=0 cellspacing=0>
2737 <tr>
2738 <td><INPUT TYPE=radio NAME='gi_hematemesis' VALUE='Yes' '{$data->get_gi_hematemesis_yes()}'></td><td>Yes</td>
2739 <td><INPUT TYPE=radio NAME='gi_hematemesis' VALUE='No' '{$data->get_gi_hematemesis_no()}'></td><td>No</td>
2740 </tr>
2741 </table>
2742 </TD>
2743 <TD WIDTH=161px>
2744 <P>Hematemesis</P>
2745 </TD>
2746 <TD WIDTH=162px VALIGN=TOP>
2747 <P><textarea name='gi_hematemesis_text' cols='30' rows='2'>{$data->get_gi_hematemesis_text()}</textarea>
2748 </P>
2749 </TD>
2750 </TR>
2751
2752 <TR>
2753 <TD WIDTH=162px>
2754 <P ALIGN=CENTER><BR/>
2755 </P>
2756 </TD>
2757 <TD WIDTH=100px>
2758 <table border=0 cellpadding=0 cellspacing=0>
2759 <tr>
2760 <td><INPUT TYPE=radio NAME='gi_hemorrhoids' VALUE='Yes' '{$data->get_gi_hemorrhoids_yes()}'></td><td>Yes</td>
2761 <td><INPUT TYPE=radio NAME='gi_hemorrhoids' VALUE='No' '{$data->get_gi_hemorrhoids_no()}'></td><td>No</td>
2762 </tr>
2763 </table>
2764 </TD>
2765 <TD WIDTH=161px>
2766 <P>Hemorrhoids</P>
2767 </TD>
2768 <TD WIDTH=162px VALIGN=TOP>
2769 <P><textarea name='gi_hemorrhoids_text' cols='30' rows='2'>{$data->get_gi_hemorrhoids_text()}</textarea>
2770 </P>
2771 </TD>
2772 </TR>
2773
2774 <TR>
2775 <TD WIDTH=162px>
2776 <P ALIGN=CENTER><BR/>
2777 </P>
2778 </TD>
2779 <TD WIDTH=100px>
2780 <table border=0 cellpadding=0 cellspacing=0>
2781 <tr>
2782 <td><INPUT TYPE=radio NAME='gi_hepatitis' VALUE='Yes' '{$data->get_gi_hepatitis_yes()}'></td><td>Yes</td>
2783 <td><INPUT TYPE=radio NAME='gi_hepatitis' VALUE='No' '{$data->get_gi_hepatitis_no()}'></td><td>No</td>
2784 </tr>
2785 </table>
2786 </TD>
2787 <TD WIDTH=161px>
2788 <P>Hepatitis</P>
2789 </TD>
2790 <TD WIDTH=162px VALIGN=TOP>
2791 <P><textarea name='gi_hepatitis_text' cols='30' rows='2'>{$data->get_gi_hepatitis_text()}</textarea>
2792 </P>
2793 </TD>
2794 </TR>
2795
2796 <TR>
2797 <TD WIDTH=162px>
2798 <P ALIGN=CENTER><BR/>
2799 </P>
2800 </TD>
2801 <TD WIDTH=100px>
2802 <table border=0 cellpadding=0 cellspacing=0>
2803 <tr>
2804 <td><INPUT TYPE=radio NAME='gi_jaundice' VALUE='Yes' '{$data->get_gi_jaundice_yes()}'></td><td>Yes</td>
2805 <td><INPUT TYPE=radio NAME='gi_jaundice' VALUE='No' '{$data->get_gi_jaundice_no()}'></td><td>No</td>
2806 </tr>
2807 </table>
2808 </TD>
2809 <TD WIDTH=161px>
2810 <P>Jaundice</P>
2811 </TD>
2812 <TD WIDTH=162px VALIGN=TOP>
2813 <P><textarea name='gi_jaundice_text' cols='30' rows='2'>{$data->get_gi_jaundice_text()}</textarea>
2814 </P>
2815 </TD>
2816 </TR>
2817
2818 <TR>
2819 <TD WIDTH=162px>
2820 <P ALIGN=CENTER><BR/>
2821 </P>
2822 </TD>
2823 <TD WIDTH=100px>
2824 <table border=0 cellpadding=0 cellspacing=0>
2825 <tr>
2826 <td><INPUT TYPE=radio NAME='gi_lactose_intolerance' VALUE='Yes' '{$data->get_gi_lactose_intolerance_yes()}'></td><td>Yes</td>
2827 <td><INPUT TYPE=radio NAME='gi_lactose_intolerance' VALUE='No' '{$data->get_gi_lactose_intolerance_no()}'></td><td>No</td>
2828 </tr>
2829 </table>
2830 </TD>
2831 <TD WIDTH=161px>
2832 <P>Lactose Intolerance</P>
2833 </TD>
2834 <TD WIDTH=162px VALIGN=TOP>
2835 <P><textarea name='gi_lactose_intolerance_text' cols='30' rows='2'>{$data->get_gi_lactose_intolerance_text()}</textarea>
2836 </P>
2837 </TD>
2838 </TR>
2839
2840 <TR>
2841 <TD WIDTH=162px>
2842 <P ALIGN=CENTER><BR/>
2843 </P>
2844 </TD>
2845 <TD WIDTH=100px>
2846 <table border=0 cellpadding=0 cellspacing=0>
2847 <tr>
2848 <td><INPUT TYPE=radio NAME='gi_chronic_laxative_use' VALUE='Yes' '{$data->get_gi_chronic_laxative_use_yes()}'></td><td>Yes</td>
2849 <td><INPUT TYPE=radio NAME='gi_chronic_laxative_use' VALUE='No' '{$data->get_gi_chronic_laxative_use_no()}'></td><td>No</td>
2850 </tr>
2851 </table>
2852 </TD>
2853 <TD WIDTH=161px>
2854 <P>Chronic Laxative Use</P>
2855 </TD>
2856 <TD WIDTH=162px VALIGN=TOP>
2857 <P><textarea name='gi_chronic_laxative_use_text' cols='30' rows='2'>{$data->get_gi_chronic_laxative_use_text()}</textarea>
2858 </P>
2859 </TD>
2860 </TR>
2861
2862 <TR>
2863 <TD WIDTH=162px>
2864 <P ALIGN=CENTER><BR/>
2865 </P>
2866 </TD>
2867 <TD WIDTH=100px>
2868 <table border=0 cellpadding=0 cellspacing=0>
2869 <tr>
2870 <td><INPUT TYPE=radio NAME='gi_melena' VALUE='Yes' '{$data->get_gi_melena_yes()}'></td><td>Yes</td>
2871 <td><INPUT TYPE=radio NAME='gi_melena' VALUE='No' '{$data->get_gi_melena_no()}'></td><td>No</td>
2872 </tr>
2873 </table>
2874 </TD>
2875 <TD WIDTH=161px>
2876 <P>Melena</P>
2877 </TD>
2878 <TD WIDTH=162px VALIGN=TOP>
2879 <P><textarea name='gi_melena_text' cols='30' rows='2'>{$data->get_gi_melena_text()}</textarea>
2880 </P>
2881 </TD>
2882 </TR>
2883
2884 <TR>
2885 <TD WIDTH=162px>
2886 <P ALIGN=CENTER><BR/>
2887 </P>
2888 </TD>
2889 <TD WIDTH=100px>
2890 <table border=0 cellpadding=0 cellspacing=0>
2891 <tr>
2892 <td><INPUT TYPE=radio NAME='gi_frequent_nausea' VALUE='Yes' '{$data->get_gi_frequent_nausea_yes()}'></td><td>Yes</td>
2893 <td><INPUT TYPE=radio NAME='gi_frequent_nausea' VALUE='No' '{$data->get_gi_frequent_nausea_no()}'></td><td>No</td>
2894 </tr>
2895 </table>
2896 </TD>
2897 <TD WIDTH=161px>
2898 <P>Frequent Nausea</P>
2899 </TD>
2900 <TD WIDTH=162px VALIGN=TOP>
2901 <P><textarea name='gi_frequent_nausea_text' cols='30' rows='2'>{$data->get_gi_frequent_nausea_text()}</textarea>
2902 </P>
2903 </TD>
2904 </TR>
2905
2906 <TR>
2907 <TD WIDTH=162px>
2908 <P ALIGN=CENTER><BR/>
2909 </P>
2910 </TD>
2911 <TD WIDTH=100px>
2912 <table border=0 cellpadding=0 cellspacing=0>
2913 <tr>
2914 <td><INPUT TYPE=radio NAME='gi_rectal_bleeding' VALUE='Yes' '{$data->get_gi_rectal_bleeding_yes()}'></td><td>Yes</td>
2915 <td><INPUT TYPE=radio NAME='gi_rectal_bleeding' VALUE='No' '{$data->get_gi_rectal_bleeding_no()}'></td><td>No</td>
2916 </tr>
2917 </table>
2918 </TD>
2919 <TD WIDTH=161px>
2920 <P>Rectal Bleeding</P>
2921 </TD>
2922 <TD WIDTH=162px VALIGN=TOP>
2923 <P><textarea name='gi_rectal_bleeding_text' cols='30' rows='2'>{$data->get_gi_rectal_bleeding_text()}</textarea>
2924 </P>
2925 </TD>
2926 </TR>
2927
2928 <TR>
2929 <TD WIDTH=162px>
2930 <P ALIGN=CENTER><BR/>
2931 </P>
2932 </TD>
2933 <TD WIDTH=100px>
2934 <table border=0 cellpadding=0 cellspacing=0>
2935 <tr>
2936 <td><INPUT TYPE=radio NAME='gi_rectal_pain' VALUE='Yes' '{$data->get_gi_rectal_pain_yes()}'></td><td>Yes</td>
2937 <td><INPUT TYPE=radio NAME='gi_rectal_pain' VALUE='No' '{$data->get_gi_rectal_pain_no()}'></td><td>No</td>
2938 </tr>
2939 </table>
2940 </TD>
2941 <TD WIDTH=161px>
2942 <P>Rectal Pain</P>
2943 </TD>
2944 <TD WIDTH=162px VALIGN=TOP>
2945 <P><textarea name='gi_rectal_pain_text' cols='30' rows='2'>{$data->get_gi_rectal_pain_text()}</textarea>
2946 </P>
2947 </TD>
2948 </TR>
2949
2950 <TR>
2951 <TD WIDTH=162px>
2952 <P ALIGN=CENTER><BR/>
2953 </P>
2954 </TD>
2955 <TD WIDTH=100px>
2956 <table border=0 cellpadding=0 cellspacing=0>
2957 <tr>
2958 <td><INPUT TYPE=radio NAME='gi_stool_caliber_change' VALUE='Yes' '{$data->get_gi_stool_caliber_change_yes()}'></td><td>Yes</td>
2959 <td><INPUT TYPE=radio NAME='gi_stool_caliber_change' VALUE='No' '{$data->get_gi_stool_caliber_change_no()}'></td><td>No</td>
2960 </tr>
2961 </table>
2962 </TD>
2963 <TD WIDTH=161px>
2964 <P>Stool Caliber Change</P>
2965 </TD>
2966 <TD WIDTH=162px VALIGN=TOP>
2967 <P><textarea name='gi_stool_caliber_change_text' cols='30' rows='2'>{$data->get_gi_stool_caliber_change_text()}</textarea>
2968 </P>
2969 </TD>
2970 </TR>
2971
2972 <TR>
2973 <TD WIDTH=162px>
2974 <P ALIGN=CENTER>INTEGUMENT:
2975 </P>
2976 </TD>
2977 <TD WIDTH=100px>
2978 <table border=0 cellpadding=0 cellspacing=0>
2979 <tr>
2980 <td><INPUT TYPE=radio NAME='integument_pallor' VALUE='Yes' '{$data->get_integument_pallor_yes()}'></td><td>Yes</td>
2981 <td><INPUT TYPE=radio NAME='integument_pallor' VALUE='No' '{$data->get_integument_pallor_no()}'></td><td>No</td>
2982 </tr>
2983 </table>
2984 </TD>
2985 <TD WIDTH=161px>
2986 <P>pallor</P>
2987 </TD>
2988 <TD WIDTH=162px VALIGN=TOP>
2989 <P><textarea name='integument_pallor_text' cols='30' rows='2'>{$data->get_integument_pallor_text()}</textarea>
2990 </P>
2991 </TD>
2992 </TR>
2993
2994 <TR>
2995 <TD WIDTH=162px>
2996 <P ALIGN=CENTER><BR/>
2997 </P>
2998 </TD>
2999 <TD WIDTH=100px>
3000 <table border=0 cellpadding=0 cellspacing=0>
3001 <tr>
3002 <td><INPUT TYPE=radio NAME='integument_diaphoresis' VALUE='Yes' '{$data->get_integument_diaphoresis_yes()}'></td><td>Yes</td>
3003 <td><INPUT TYPE=radio NAME='integument_diaphoresis' VALUE='No' '{$data->get_integument_diaphoresis_no()}'></td><td>No</td>
3004 </tr>
3005 </table>
3006 </TD>
3007 <TD WIDTH=161px>
3008 <P>diaphoresis</P>
3009 </TD>
3010 <TD WIDTH=162px VALIGN=TOP>
3011 <P><textarea name='integument_diaphoresis_text' cols='30' rows='2'>{$data->get_integument_diaphoresis_text()}</textarea>
3012 </P>
3013 </TD>
3014 </TR>
3015
3016 <TR>
3017 <TD WIDTH=162px>
3018 <P ALIGN=CENTER><BR/>
3019 </P>
3020 </TD>
3021 <TD WIDTH=100px>
3022 <table border=0 cellpadding=0 cellspacing=0>
3023 <tr>
3024 <td><INPUT TYPE=radio NAME='integument_rash' VALUE='Yes' '{$data->get_integument_rash_yes()}'></td><td>Yes</td>
3025 <td><INPUT TYPE=radio NAME='integument_rash' VALUE='No' '{$data->get_integument_rash_no()}'></td><td>No</td>
3026 </tr>
3027 </table>
3028 </TD>
3029 <TD WIDTH=161px>
3030 <P>rash</P>
3031 </TD>
3032 <TD WIDTH=162px VALIGN=TOP>
3033 <P><textarea name='integument_rash_text' cols='30' rows='2'>{$data->get_integument_rash_text()}</textarea>
3034 </P>
3035 </TD>
3036 </TR>
3037
3038 <TR>
3039 <TD WIDTH=162px>
3040 <P ALIGN=CENTER><BR/>
3041 </P>
3042 </TD>
3043 <TD WIDTH=100px>
3044 <table border=0 cellpadding=0 cellspacing=0>
3045 <tr>
3046 <td><INPUT TYPE=radio NAME='integument_itching' VALUE='Yes' '{$data->get_integument_itching_yes()}'></td><td>Yes</td>
3047 <td><INPUT TYPE=radio NAME='integument_itching' VALUE='No' '{$data->get_integument_itching_no()}'></td><td>No</td>
3048 </tr>
3049 </table>
3050 </TD>
3051 <TD WIDTH=161px>
3052 <P>itching</P>
3053 </TD>
3054 <TD WIDTH=162px VALIGN=TOP>
3055 <P><textarea name='integument_itching_text' cols='30' rows='2'>{$data->get_integument_itching_text()}</textarea>
3056 </P>
3057 </TD>
3058 </TR>
3059
3060 <TR>
3061 <TD WIDTH=162px>
3062 <P ALIGN=CENTER><BR/>
3063 </P>
3064 </TD>
3065 <TD WIDTH=100px>
3066 <table border=0 cellpadding=0 cellspacing=0>
3067 <tr>
3068 <td><INPUT TYPE=radio NAME='integument_ulcers' VALUE='Yes' '{$data->get_integument_ulcers_yes()}'></td><td>Yes</td>
3069 <td><INPUT TYPE=radio NAME='integument_ulcers' VALUE='No' '{$data->get_integument_ulcers_no()}'></td><td>No</td>
3070 </tr>
3071 </table>
3072 </TD>
3073 <TD WIDTH=161px>
3074 <P>ulcers</P>
3075 </TD>
3076 <TD WIDTH=162px VALIGN=TOP>
3077 <P><textarea name='integument_ulcers_text' cols='30' rows='2'>{$data->get_integument_ulcers_text()}</textarea>
3078 </P>
3079 </TD>
3080 </TR>
3081
3082 <TR>
3083 <TD WIDTH=162px>
3084 <P ALIGN=CENTER><BR/>
3085 </P>
3086 </TD>
3087 <TD WIDTH=100px>
3088 <table border=0 cellpadding=0 cellspacing=0>
3089 <tr>
3090 <td><INPUT TYPE=radio NAME='integument_abscess' VALUE='Yes' '{$data->get_integument_abscess_yes()}'></td><td>Yes</td>
3091 <td><INPUT TYPE=radio NAME='integument_abscess' VALUE='No' '{$data->get_integument_abscess_no()}'></td><td>No</td>
3092 </tr>
3093 </table>
3094 </TD>
3095 <TD WIDTH=161px>
3096 <P>abscess</P>
3097 </TD>
3098 <TD WIDTH=162px VALIGN=TOP>
3099 <P><textarea name='integument_abscess_text' cols='30' rows='2'>{$data->get_integument_abscess_text()}</textarea>
3100 </P>
3101 </TD>
3102 </TR>
3103
3104 <TR>
3105 <TD WIDTH=162px>
3106 <P ALIGN=CENTER><BR/>
3107 </P>
3108 </TD>
3109 <TD WIDTH=100px>
3110 <table border=0 cellpadding=0 cellspacing=0>
3111 <tr>
3112 <td><INPUT TYPE=radio NAME='integument_nodules' VALUE='Yes' '{$data->get_integument_nodules_yes()}'></td><td>Yes</td>
3113 <td><INPUT TYPE=radio NAME='integument_nodules' VALUE='No' '{$data->get_integument_nodules_no()}'></td><td>No</td>
3114 </tr>
3115 </table>
3116 </TD>
3117 <TD WIDTH=161px>
3118 <P>nodules</P>
3119 </TD>
3120 <TD WIDTH=162px VALIGN=TOP>
3121 <P><textarea name='integument_nodules_text' cols='30' rows='2'>{$data->get_integument_nodules_text()}</textarea>
3122 </P>
3123 </TD>
3124 </TR>
3125
3126 <TR>
3127 <TD WIDTH=162px>
3128 <P ALIGN=CENTER><BR/>
3129 </P>
3130 </TD>
3131 <TD WIDTH=100px>
3132 <table border=0 cellpadding=0 cellspacing=0>
3133 <tr>
3134 <td><INPUT TYPE=radio NAME='integument_acne' VALUE='Yes' '{$data->get_integument_acne_yes()}'></td><td>Yes</td>
3135 <td><INPUT TYPE=radio NAME='integument_acne' VALUE='No' '{$data->get_integument_acne_no()}'></td><td>No</td>
3136 </tr>
3137 </table>
3138 </TD>
3139 <TD WIDTH=161px>
3140 <P>Acne</P>
3141 </TD>
3142 <TD WIDTH=162px VALIGN=TOP>
3143 <P><textarea name='integument_acne_text' cols='30' rows='2'>{$data->get_integument_acne_text()}</textarea>
3144 </P>
3145 </TD>
3146 </TR>
3147
3148 <TR>
3149 <TD WIDTH=162px>
3150 <P ALIGN=CENTER><BR/>
3151 </P>
3152 </TD>
3153 <TD WIDTH=100px>
3154 <table border=0 cellpadding=0 cellspacing=0>
3155 <tr>
3156 <td><INPUT TYPE=radio NAME='integument_recurrent_boils' VALUE='Yes' '{$data->get_integument_recurrent_boils_yes()}'></td><td>Yes</td>
3157 <td><INPUT TYPE=radio NAME='integument_recurrent_boils' VALUE='No' '{$data->get_integument_recurrent_boils_no()}'></td><td>No</td>
3158 </tr>
3159 </table>
3160 </TD>
3161 <TD WIDTH=161px>
3162 <P>Recurrent Boils</P>
3163 </TD>
3164 <TD WIDTH=162px VALIGN=TOP>
3165 <P><textarea name='integument_recurrent_boils_text' cols='30' rows='2'>{$data->get_integument_recurrent_boils_text()}</textarea>
3166 </P>
3167 </TD>
3168 </TR>
3169
3170 <TR>
3171 <TD WIDTH=162px>
3172 <P ALIGN=CENTER><BR/>
3173 </P>
3174 </TD>
3175 <TD WIDTH=100px>
3176 <table border=0 cellpadding=0 cellspacing=0>
3177 <tr>
3178 <td><INPUT TYPE=radio NAME='integument_chronic_eczema' VALUE='Yes' '{$data->get_integument_chronic_eczema_yes()}'></td><td>Yes</td>
3179 <td><INPUT TYPE=radio NAME='integument_chronic_eczema' VALUE='No' '{$data->get_integument_chronic_eczema_no()}'></td><td>No</td>
3180 </tr>
3181 </table>
3182 </TD>
3183 <TD WIDTH=161px>
3184 <P>Chronic Eczema</P>
3185 </TD>
3186 <TD WIDTH=162px VALIGN=TOP>
3187 <P><textarea name='integument_chronic_eczema_text' cols='30' rows='2'>{$data->get_integument_chronic_eczema_text()}</textarea>
3188 </P>
3189 </TD>
3190 </TR>
3191
3192 <TR>
3193 <TD WIDTH=162px>
3194 <P ALIGN=CENTER><BR/>
3195 </P>
3196 </TD>
3197 <TD WIDTH=100px>
3198 <table border=0 cellpadding=0 cellspacing=0>
3199 <tr>
3200 <td><INPUT TYPE=radio NAME='integument_changing_moles' VALUE='Yes' '{$data->get_integument_changing_moles_yes()}'></td><td>Yes</td>
3201 <td><INPUT TYPE=radio NAME='integument_changing_moles' VALUE='No' '{$data->get_integument_changing_moles_no()}'></td><td>No</td>
3202 </tr>
3203 </table>
3204 </TD>
3205 <TD WIDTH=161px>
3206 <P>Changing Moles</P>
3207 </TD>
3208 <TD WIDTH=162px VALIGN=TOP>
3209 <P><textarea name='integument_changing_moles_text' cols='30' rows='2'>{$data->get_integument_changing_moles_text()}</textarea>
3210 </P>
3211 </TD>
3212 </TR>
3213
3214 <TR>
3215 <TD WIDTH=162px>
3216 <P ALIGN=CENTER><BR/>
3217 </P>
3218 </TD>
3219 <TD WIDTH=100px>
3220 <table border=0 cellpadding=0 cellspacing=0>
3221 <tr>
3222 <td><INPUT TYPE=radio NAME='integument_nail_abnormalities' VALUE='Yes' '{$data->get_integument_nail_abnormalities_yes()}'></td><td>Yes</td>
3223 <td><INPUT TYPE=radio NAME='integument_nail_abnormalities' VALUE='No' '{$data->get_integument_nail_abnormalities_no()}'></td><td>No</td>
3224 </tr>
3225 </table>
3226 </TD>
3227 <TD WIDTH=161px>
3228 <P>Nail Abnormalities</P>
3229 </TD>
3230 <TD WIDTH=162px VALIGN=TOP>
3231 <P><textarea name='integument_nail_abnormalities_text' cols='30' rows='2'>{$data->get_integument_nail_abnormalities_text()}</textarea>
3232 </P>
3233 </TD>
3234 </TR>
3235
3236 <TR>
3237 <TD WIDTH=162px>
3238 <P ALIGN=CENTER><BR/>
3239 </P>
3240 </TD>
3241 <TD WIDTH=100px>
3242 <table border=0 cellpadding=0 cellspacing=0>
3243 <tr>
3244 <td><INPUT TYPE=radio NAME='integument_psoriasis' VALUE='Yes' '{$data->get_integument_psoriasis_yes()}'></td><td>Yes</td>
3245 <td><INPUT TYPE=radio NAME='integument_psoriasis' VALUE='No' '{$data->get_integument_psoriasis_no()}'></td><td>No</td>
3246 </tr>
3247 </table>
3248 </TD>
3249 <TD WIDTH=161px>
3250 <P>Psoriasis</P>
3251 </TD>
3252 <TD WIDTH=162px VALIGN=TOP>
3253 <P><textarea name='integument_psoriasis_text' cols='30' rows='2'>{$data->get_integument_psoriasis_text()}</textarea>
3254 </P>
3255 </TD>
3256 </TR>
3257
3258 <TR>
3259 <TD WIDTH=162px>
3260 <P ALIGN=CENTER><BR/>
3261 </P>
3262 </TD>
3263 <TD WIDTH=100px>
3264 <table border=0 cellpadding=0 cellspacing=0>
3265 <tr>
3266 <td><INPUT TYPE=radio NAME='integument_recurrent_hives' VALUE='Yes' '{$data->get_integument_recurrent_hives_yes()}'></td><td>Yes</td>
3267 <td><INPUT TYPE=radio NAME='integument_recurrent_hives' VALUE='No' '{$data->get_integument_recurrent_hives_no()}'></td><td>No</td>
3268 </tr>
3269 </table>
3270 </TD>
3271 <TD WIDTH=161px>
3272 <P>Recurrent Hives</P>
3273 </TD>
3274 <TD WIDTH=162px VALIGN=TOP>
3275 <P><textarea name='integument_recurrent_hives_text' cols='30' rows='2'>{$data->get_integument_recurrent_hives_text()}</textarea>
3276 </P>
3277 </TD>
3278 </TR>
3279
3280 <TR>
3281 <TD WIDTH=162px>
3282 <P ALIGN=CENTER>MUSCULOSKELETAL:
3283 </P>
3284 </TD>
3285 <TD WIDTH=100px>
3286 <table border=0 cellpadding=0 cellspacing=0>
3287 <tr>
3288 <td><INPUT TYPE=radio NAME='musculoskeletal_deformity' VALUE='Yes' '{$data->get_musculoskeletal_deformity_yes()}'></td><td>Yes</td>
3289 <td><INPUT TYPE=radio NAME='musculoskeletal_deformity' VALUE='No' '{$data->get_musculoskeletal_deformity_no()}'></td><td>No</td>
3290 </tr>
3291 </table>
3292 </TD>
3293 <TD WIDTH=161px>
3294 <P>deformity</P>
3295 </TD>
3296 <TD WIDTH=162px VALIGN=TOP>
3297 <P><textarea name='musculoskeletal_deformity_text' cols='30' rows='2'>{$data->get_musculoskeletal_deformity_text()}</textarea>
3298 </P>
3299 </TD>
3300 </TR>
3301
3302 <TR>
3303 <TD WIDTH=162px>
3304 <P ALIGN=CENTER><BR/>
3305 </P>
3306 </TD>
3307 <TD WIDTH=100px>
3308 <table border=0 cellpadding=0 cellspacing=0>
3309 <tr>
3310 <td><INPUT TYPE=radio NAME='musculoskeletal_edema' VALUE='Yes' '{$data->get_musculoskeletal_edema_yes()}'></td><td>Yes</td>
3311 <td><INPUT TYPE=radio NAME='musculoskeletal_edema' VALUE='No' '{$data->get_musculoskeletal_edema_no()}'></td><td>No</td>
3312 </tr>
3313 </table>
3314 </TD>
3315 <TD WIDTH=161px>
3316 <P>edema</P>
3317 </TD>
3318 <TD WIDTH=162px VALIGN=TOP>
3319 <P><textarea name='musculoskeletal_edema_text' cols='30' rows='2'>{$data->get_musculoskeletal_edema_text()}</textarea>
3320 </P>
3321 </TD>
3322 </TR>
3323
3324 <TR>
3325 <TD WIDTH=162px>
3326 <P ALIGN=CENTER><BR/>
3327 </P>
3328 </TD>
3329 <TD WIDTH=100px>
3330 <table border=0 cellpadding=0 cellspacing=0>
3331 <tr>
3332 <td><INPUT TYPE=radio NAME='musculoskeletal_pain' VALUE='Yes' '{$data->get_musculoskeletal_pain_yes()}'></td><td>Yes</td>
3333 <td><INPUT TYPE=radio NAME='musculoskeletal_pain' VALUE='No' '{$data->get_musculoskeletal_pain_no()}'></td><td>No</td>
3334 </tr>
3335 </table>
3336 </TD>
3337 <TD WIDTH=161px>
3338 <P>pain</P>
3339 </TD>
3340 <TD WIDTH=162px VALIGN=TOP>
3341 <P><textarea name='musculoskeletal_pain_text' cols='30' rows='2'>{$data->get_musculoskeletal_pain_text()}</textarea>
3342 </P>
3343 </TD>
3344 </TR>
3345
3346 <TR>
3347 <TD WIDTH=162px>
3348 <P ALIGN=CENTER><BR/>
3349 </P>
3350 </TD>
3351 <TD WIDTH=100px>
3352 <table border=0 cellpadding=0 cellspacing=0>
3353 <tr>
3354 <td><INPUT TYPE=radio NAME='musculoskeletal_limited_rom' VALUE='Yes' '{$data->get_musculoskeletal_limited_rom_yes()}'></td><td>Yes</td>
3355 <td><INPUT TYPE=radio NAME='musculoskeletal_limited_rom' VALUE='No' '{$data->get_musculoskeletal_limited_rom_no()}'></td><td>No</td>
3356 </tr>
3357 </table>
3358 </TD>
3359 <TD WIDTH=161px>
3360 <P>limited ROM</P>
3361 </TD>
3362 <TD WIDTH=162px VALIGN=TOP>
3363 <P><textarea name='musculoskeletal_limited_rom_text' cols='30' rows='2'>{$data->get_musculoskeletal_limited_rom_text()}</textarea>
3364 </P>
3365 </TD>
3366 </TR>
3367
3368 <TR>
3369 <TD WIDTH=162px>
3370 <P ALIGN=CENTER><BR/>
3371 </P>
3372 </TD>
3373 <TD WIDTH=100px>
3374 <table border=0 cellpadding=0 cellspacing=0>
3375 <tr>
3376 <td><INPUT TYPE=radio NAME='musculoskeletal_gait' VALUE='Yes' '{$data->get_musculoskeletal_gait_yes()}'></td><td>Yes</td>
3377 <td><INPUT TYPE=radio NAME='musculoskeletal_gait' VALUE='No' '{$data->get_musculoskeletal_gait_no()}'></td><td>No</td>
3378 </tr>
3379 </table>
3380 </TD>
3381 <TD WIDTH=161px>
3382 <P>gait</P>
3383 </TD>
3384 <TD WIDTH=162px VALIGN=TOP>
3385 <P><textarea name='musculoskeletal_gait_text' cols='30' rows='2'>{$data->get_musculoskeletal_gait_text()}</textarea>
3386 </P>
3387 </TD>
3388 </TR>
3389
3390 <TR>
3391 <TD WIDTH=162px>
3392 <P ALIGN=CENTER><BR/>
3393 </P>
3394 </TD>
3395 <TD WIDTH=100px>
3396 <table border=0 cellpadding=0 cellspacing=0>
3397 <tr>
3398 <td><INPUT TYPE=radio NAME='musculoskeletal_arthritis' VALUE='Yes' '{$data->get_musculoskeletal_arthritis_yes()}'></td><td>Yes</td>
3399 <td><INPUT TYPE=radio NAME='musculoskeletal_arthritis' VALUE='No' '{$data->get_musculoskeletal_arthritis_no()}'></td><td>No</td>
3400 </tr>
3401 </table>
3402 </TD>
3403 <TD WIDTH=161px>
3404 <P>Arthritis</P>
3405 </TD>
3406 <TD WIDTH=162px VALIGN=TOP>
3407 <P><textarea name='musculoskeletal_arthritis_text' cols='30' rows='2'>{$data->get_musculoskeletal_arthritis_text()}</textarea>
3408 </P>
3409 </TD>
3410 </TR>
3411
3412 <TR>
3413 <TD WIDTH=162px>
3414 <P ALIGN=CENTER><BR/>
3415 </P>
3416 </TD>
3417 <TD WIDTH=100px>
3418 <table border=0 cellpadding=0 cellspacing=0>
3419 <tr>
3420 <td><INPUT TYPE=radio NAME='musculoskeletal_neck_pain' VALUE='Yes' '{$data->get_musculoskeletal_neck_pain_yes()}'></td><td>Yes</td>
3421 <td><INPUT TYPE=radio NAME='musculoskeletal_neck_pain' VALUE='No' '{$data->get_musculoskeletal_neck_pain_no()}'></td><td>No</td>
3422 </tr>
3423 </table>
3424 </TD>
3425 <TD WIDTH=161px>
3426 <P>Neck Pain</P>
3427 </TD>
3428 <TD WIDTH=162px VALIGN=TOP>
3429 <P><textarea name='musculoskeletal_neck_pain_text' cols='30' rows='2'>{$data->get_musculoskeletal_neck_pain_text()}</textarea>
3430 </P>
3431 </TD>
3432 </TR>
3433
3434 <TR>
3435 <TD WIDTH=162px>
3436 <P ALIGN=CENTER><BR/>
3437 </P>
3438 </TD>
3439 <TD WIDTH=100px>
3440 <table border=0 cellpadding=0 cellspacing=0>
3441 <tr>
3442 <td><INPUT TYPE=radio NAME='musculoskeletal_mid_back_pain' VALUE='Yes' '{$data->get_musculoskeletal_mid_back_pain_yes()}'></td><td>Yes</td>
3443 <td><INPUT TYPE=radio NAME='musculoskeletal_mid_back_pain' VALUE='No' '{$data->get_musculoskeletal_mid_back_pain_no()}'></td><td>No</td>
3444 </tr>
3445 </table>
3446 </TD>
3447 <TD WIDTH=161px>
3448 <P>Mid Back Pain</P>
3449 </TD>
3450 <TD WIDTH=162px VALIGN=TOP>
3451 <P><textarea name='musculoskeletal_mid_back_pain_text' cols='30' rows='2'>{$data->get_musculoskeletal_mid_back_pain_text()}</textarea>
3452 </P>
3453 </TD>
3454 </TR>
3455
3456 <TR>
3457 <TD WIDTH=162px>
3458 <P ALIGN=CENTER><BR/>
3459 </P>
3460 </TD>
3461 <TD WIDTH=100px>
3462 <table border=0 cellpadding=0 cellspacing=0>
3463 <tr>
3464 <td><INPUT TYPE=radio NAME='musculoskeletal_low_back_pain' VALUE='Yes' '{$data->get_musculoskeletal_low_back_pain_yes()}'></td><td>Yes</td>
3465 <td><INPUT TYPE=radio NAME='musculoskeletal_low_back_pain' VALUE='No' '{$data->get_musculoskeletal_low_back_pain_no()}'></td><td>No</td>
3466 </tr>
3467 </table>
3468 </TD>
3469 <TD WIDTH=161px>
3470 <P>Low Back Pain</P>
3471 </TD>
3472 <TD WIDTH=162px VALIGN=TOP>
3473 <P><textarea name='musculoskeletal_low_back_pain_text' cols='30' rows='2'>{$data->get_musculoskeletal_low_back_pain_text()}</textarea>
3474 </P>
3475 </TD>
3476 </TR>
3477
3478 <TR>
3479 <TD WIDTH=162px>
3480 <P ALIGN=CENTER><BR/>
3481 </P>
3482 </TD>
3483 <TD WIDTH=100px>
3484 <table border=0 cellpadding=0 cellspacing=0>
3485 <tr>
3486 <td><INPUT TYPE=radio NAME='musculoskeletal_bursitis' VALUE='Yes' '{$data->get_musculoskeletal_bursitis_yes()}'></td><td>Yes</td>
3487 <td><INPUT TYPE=radio NAME='musculoskeletal_bursitis' VALUE='No' '{$data->get_musculoskeletal_bursitis_no()}'></td><td>No</td>
3488 </tr>
3489 </table>
3490 </TD>
3491 <TD WIDTH=161px>
3492 <P>Bursitis</P>
3493 </TD>
3494 <TD WIDTH=162px VALIGN=TOP>
3495 <P><textarea name='musculoskeletal_bursitis_text' cols='30' rows='2'>{$data->get_musculoskeletal_bursitis_text()}</textarea>
3496 </P>
3497 </TD>
3498 </TR>
3499
3500 <TR>
3501 <TD WIDTH=162px>
3502 <P ALIGN=CENTER><BR/>
3503 </P>
3504 </TD>
3505 <TD WIDTH=100px>
3506 <table border=0 cellpadding=0 cellspacing=0>
3507 <tr>
3508 <td><INPUT TYPE=radio NAME='musculoskeletal_gout' VALUE='Yes' '{$data->get_musculoskeletal_gout_yes()}'></td><td>Yes</td>
3509 <td><INPUT TYPE=radio NAME='musculoskeletal_gout' VALUE='No' '{$data->get_musculoskeletal_gout_no()}'></td><td>No</td>
3510 </tr>
3511 </table>
3512 </TD>
3513 <TD WIDTH=161px>
3514 <P>Gout</P>
3515 </TD>
3516 <TD WIDTH=162px VALIGN=TOP>
3517 <P><textarea name='musculoskeletal_gout_text' cols='30' rows='2'>{$data->get_musculoskeletal_gout_text()}</textarea>
3518 </P>
3519 </TD>
3520 </TR>
3521
3522 <TR>
3523 <TD WIDTH=162px>
3524 <P ALIGN=CENTER><BR/>
3525 </P>
3526 </TD>
3527 <TD WIDTH=100px>
3528 <table border=0 cellpadding=0 cellspacing=0>
3529 <tr>
3530 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_injury' VALUE='Yes' '{$data->get_musculoskeletal_joint_injury_yes()}'></td><td>Yes</td>
3531 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_injury' VALUE='No' '{$data->get_musculoskeletal_joint_injury_no()}'></td><td>No</td>
3532 </tr>
3533 </table>
3534 </TD>
3535 <TD WIDTH=161px>
3536 <P>Joint Injury</P>
3537 </TD>
3538 <TD WIDTH=162px VALIGN=TOP>
3539 <P><textarea name='musculoskeletal_joint_injury_text' cols='30' rows='2'>{$data->get_musculoskeletal_joint_injury_text()}</textarea>
3540 </P>
3541 </TD>
3542 </TR>
3543
3544 <TR>
3545 <TD WIDTH=162px>
3546 <P ALIGN=CENTER><BR/>
3547 </P>
3548 </TD>
3549 <TD WIDTH=100px>
3550 <table border=0 cellpadding=0 cellspacing=0>
3551 <tr>
3552 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_pain' VALUE='Yes' '{$data->get_musculoskeletal_joint_pain_yes()}'></td><td>Yes</td>
3553 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_pain' VALUE='No' '{$data->get_musculoskeletal_joint_pain_no()}'></td><td>No</td>
3554 </tr>
3555 </table>
3556 </TD>
3557 <TD WIDTH=161px>
3558 <P>Joint Pain</P>
3559 </TD>
3560 <TD WIDTH=162px VALIGN=TOP>
3561 <P><textarea name='musculoskeletal_joint_pain_text' cols='30' rows='2'>{$data->get_musculoskeletal_joint_pain_text()}</textarea>
3562 </P>
3563 </TD>
3564 </TR>
3565
3566 <TR>
3567 <TD WIDTH=162px>
3568 <P ALIGN=CENTER><BR/>
3569 </P>
3570 </TD>
3571 <TD WIDTH=100px>
3572 <table border=0 cellpadding=0 cellspacing=0>
3573 <tr>
3574 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_swelling' VALUE='Yes' '{$data->get_musculoskeletal_joint_swelling_yes()}'></td><td>Yes</td>
3575 <td><INPUT TYPE=radio NAME='musculoskeletal_joint_swelling' VALUE='No' '{$data->get_musculoskeletal_joint_swelling_no()}'></td><td>No</td>
3576 </tr>
3577 </table>
3578 </TD>
3579 <TD WIDTH=161px>
3580 <P>Joint Swelling</P>
3581 </TD>
3582 <TD WIDTH=162px VALIGN=TOP>
3583 <P><textarea name='musculoskeletal_joint_swelling_text' cols='30' rows='2'>{$data->get_musculoskeletal_joint_swelling_text()}</textarea>
3584 </P>
3585 </TD>
3586 </TR>
3587
3588 <TR>
3589 <TD WIDTH=162px>
3590 <P ALIGN=CENTER><BR/>
3591 </P>
3592 </TD>
3593 <TD WIDTH=100px>
3594 <table border=0 cellpadding=0 cellspacing=0>
3595 <tr>
3596 <td><INPUT TYPE=radio NAME='musculoskeletal_myalgias' VALUE='Yes' '{$data->get_musculoskeletal_myalgias_yes()}'></td><td>Yes</td>
3597 <td><INPUT TYPE=radio NAME='musculoskeletal_myalgias' VALUE='No' '{$data->get_musculoskeletal_myalgias_no()}'></td><td>No</td>
3598 </tr>
3599 </table>
3600 </TD>
3601 <TD WIDTH=161px>
3602 <P>Myalgias</P>
3603 </TD>
3604 <TD WIDTH=162px VALIGN=TOP>
3605 <P><textarea name='musculoskeletal_myalgias_text' cols='30' rows='2'>{$data->get_musculoskeletal_myalgias_text()}</textarea>
3606 </P>
3607 </TD>
3608 </TR>
3609
3610 <TR>
3611 <TD WIDTH=162px>
3612 <P ALIGN=CENTER><BR/>
3613 </P>
3614 </TD>
3615 <TD WIDTH=100px>
3616 <table border=0 cellpadding=0 cellspacing=0>
3617 <tr>
3618 <td><INPUT TYPE=radio NAME='musculoskeletal_sciatica' VALUE='Yes' '{$data->get_musculoskeletal_sciatica_yes()}'></td><td>Yes</td>
3619 <td><INPUT TYPE=radio NAME='musculoskeletal_sciatica' VALUE='No' '{$data->get_musculoskeletal_sciatica_no()}'></td><td>No</td>
3620 </tr>
3621 </table>
3622 </TD>
3623 <TD WIDTH=161px>
3624 <P>Sciatica</P>
3625 </TD>
3626 <TD WIDTH=162px VALIGN=TOP>
3627 <P><textarea name='musculoskeletal_sciatica_text' cols='30' rows='2'>{$data->get_musculoskeletal_sciatica_text()}</textarea>
3628 </P>
3629 </TD>
3630 </TR>
3631
3632 <TR>
3633 <TD WIDTH=162px>
3634 <P ALIGN=CENTER><BR/>
3635 </P>
3636 </TD>
3637 <TD WIDTH=100px>
3638 <table border=0 cellpadding=0 cellspacing=0>
3639 <tr>
3640 <td><INPUT TYPE=radio NAME='musculoskeletal_scoliosis' VALUE='Yes' '{$data->get_musculoskeletal_scoliosis_yes()}'></td><td>Yes</td>
3641 <td><INPUT TYPE=radio NAME='musculoskeletal_scoliosis' VALUE='No' '{$data->get_musculoskeletal_scoliosis_no()}'></td><td>No</td>
3642 </tr>
3643 </table>
3644 </TD>
3645 <TD WIDTH=161px>
3646 <P>Scoliosis</P>
3647 </TD>
3648 <TD WIDTH=162px VALIGN=TOP>
3649 <P><textarea name='musculoskeletal_scoliosis_text' cols='30' rows='2'>{$data->get_musculoskeletal_scoliosis_text()}</textarea>
3650 </P>
3651 </TD>
3652 </TR>
3653
3654 <TR>
3655 <TD WIDTH=162px>
3656 <P ALIGN=CENTER>HEMATOLOGICAL
3657 </P>
3658 </TD>
3659 <TD WIDTH=100px>
3660 <table border=0 cellpadding=0 cellspacing=0>
3661 <tr>
3662 <td><INPUT TYPE=radio NAME='hematological_anemia' VALUE='Yes' '{$data->get_hematological_anemia_yes()}'></td><td>Yes</td>
3663 <td><INPUT TYPE=radio NAME='hematological_anemia' VALUE='No' '{$data->get_hematological_anemia_no()}'></td><td>No</td>
3664 </tr>
3665 </table>
3666 </TD>
3667 <TD WIDTH=161px>
3668 <P>Anemia</P>
3669 </TD>
3670 <TD WIDTH=162px VALIGN=TOP>
3671 <P><textarea name='hematological_anemia_text' cols='30' rows='2'>{$data->get_hematological_anemia_text()}</textarea>
3672 </P>
3673 </TD>
3674 </TR>
3675
3676 <TR>
3677 <TD WIDTH=162px>
3678 <P ALIGN=CENTER><BR/>
3679 </P>
3680 </TD>
3681 <TD WIDTH=100px>
3682 <table border=0 cellpadding=0 cellspacing=0>
3683 <tr>
3684 <td><INPUT TYPE=radio NAME='hematological_pallor' VALUE='Yes' '{$data->get_hematological_pallor_yes()}'></td><td>Yes</td>
3685 <td><INPUT TYPE=radio NAME='hematological_pallor' VALUE='No' '{$data->get_hematological_pallor_no()}'></td><td>No</td>
3686 </tr>
3687 </table>
3688 </TD>
3689 <TD WIDTH=161px>
3690 <P>Pallor</P>
3691 </TD>
3692 <TD WIDTH=162px VALIGN=TOP>
3693 <P><textarea name='hematological_pallor_text' cols='30' rows='2'>{$data->get_hematological_pallor_text()}</textarea>
3694 </P>
3695 </TD>
3696 </TR>
3697
3698 <TR>
3699 <TD WIDTH=162px>
3700 <P ALIGN=CENTER><BR/>
3701 </P>
3702 </TD>
3703 <TD WIDTH=100px>
3704 <table border=0 cellpadding=0 cellspacing=0>
3705 <tr>
3706 <td><INPUT TYPE=radio NAME='hematological_bleeding_tendencies' VALUE='Yes' '{$data->get_hematological_bleeding_tendencies_yes()}'></td><td>Yes</td>
3707 <td><INPUT TYPE=radio NAME='hematological_bleeding_tendencies' VALUE='No' '{$data->get_hematological_bleeding_tendencies_no()}'></td><td>No</td>
3708 </tr>
3709 </table>
3710 </TD>
3711 <TD WIDTH=161px>
3712 <P>Bleeding Tendencies</P>
3713 </TD>
3714 <TD WIDTH=162px VALIGN=TOP>
3715 <P><textarea name='hematological_bleeding_tendencies_text' cols='30' rows='2'>{$data->get_hematological_bleeding_tendencies_text()}</textarea>
3716 </P>
3717 </TD>
3718 </TR>
3719
3720 <TR>
3721 <TD WIDTH=162px>
3722 <P ALIGN=CENTER><BR/>
3723 </P>
3724 </TD>
3725 <TD WIDTH=100px>
3726 <table border=0 cellpadding=0 cellspacing=0>
3727 <tr>
3728 <td><INPUT TYPE=radio NAME='hematological_bruising' VALUE='Yes' '{$data->get_hematological_bruising_yes()}'></td><td>Yes</td>
3729 <td><INPUT TYPE=radio NAME='hematological_bruising' VALUE='No' '{$data->get_hematological_bruising_no()}'></td><td>No</td>
3730 </tr>
3731 </table>
3732 </TD>
3733 <TD WIDTH=161px>
3734 <P>Bruising</P>
3735 </TD>
3736 <TD WIDTH=162px VALIGN=TOP>
3737 <P><textarea name='hematological_bruising_text' cols='30' rows='2'>{$data->get_hematological_bruising_text()}</textarea>
3738 </P>
3739 </TD>
3740 </TR>
3741
3742 <TR>
3743 <TD WIDTH=162px>
3744 <P ALIGN=CENTER>ENDOCRINE
3745 </P>
3746 </TD>
3747 <TD WIDTH=100px>
3748 <table border=0 cellpadding=0 cellspacing=0>
3749 <tr>
3750 <td><INPUT TYPE=radio NAME='endocrine_thyroid_problems' VALUE='Yes' '{$data->get_endocrine_thyroid_problems_yes()}'></td><td>Yes</td>
3751 <td><INPUT TYPE=radio NAME='endocrine_thyroid_problems' VALUE='No' '{$data->get_endocrine_thyroid_problems_no()}'></td><td>No</td>
3752 </tr>
3753 </table>
3754 </TD>
3755 <TD WIDTH=161px>
3756 <P>Thyroid Problems</P>
3757 </TD>
3758 <TD WIDTH=162px VALIGN=TOP>
3759 <P><textarea name='endocrine_thyroid_problems_text' cols='30' rows='2'>{$data->get_endocrine_thyroid_problems_text()}</textarea>
3760 </P>
3761 </TD>
3762 </TR>
3763
3764 <TR>
3765 <TD WIDTH=162px>
3766 <P ALIGN=CENTER><BR/>
3767 </P>
3768 </TD>
3769 <TD WIDTH=100px>
3770 <table border=0 cellpadding=0 cellspacing=0>
3771 <tr>
3772 <td><INPUT TYPE=radio NAME='endocrine_enlarged_thyroid' VALUE='Yes' '{$data->get_endocrine_enlarged_thyroid_yes()}'></td><td>Yes</td>
3773 <td><INPUT TYPE=radio NAME='endocrine_enlarged_thyroid' VALUE='No' '{$data->get_endocrine_enlarged_thyroid_no()}'></td><td>No</td>
3774 </tr>
3775 </table>
3776 </TD>
3777 <TD WIDTH=161px>
3778 <P>Enlarged Thyroid</P>
3779 </TD>
3780 <TD WIDTH=162px VALIGN=TOP>
3781 <P><textarea name='endocrine_enlarged_thyroid_text' cols='30' rows='2'>{$data->get_endocrine_enlarged_thyroid_text()}</textarea>
3782 </P>
3783 </TD>
3784 </TR>
3785
3786 <TR>
3787 <TD WIDTH=162px>
3788 <P ALIGN=CENTER><BR/>
3789 </P>
3790 </TD>
3791 <TD WIDTH=100px>
3792 <table border=0 cellpadding=0 cellspacing=0>
3793 <tr>
3794 <td><INPUT TYPE=radio NAME='endocrine_hyperglycemia' VALUE='Yes' '{$data->get_endocrine_hyperglycemia_yes()}'></td><td>Yes</td>
3795 <td><INPUT TYPE=radio NAME='endocrine_hyperglycemia' VALUE='No' '{$data->get_endocrine_hyperglycemia_no()}'></td><td>No</td>
3796 </tr>
3797 </table>
3798 </TD>
3799 <TD WIDTH=161px>
3800 <P>Hyperglycemia</P>
3801 </TD>
3802 <TD WIDTH=162px VALIGN=TOP>
3803 <P><textarea name='endocrine_hyperglycemia_text' cols='30' rows='2'>{$data->get_endocrine_hyperglycemia_text()}</textarea>
3804 </P>
3805 </TD>
3806 </TR>
3807
3808 <TR>
3809 <TD WIDTH=162px>
3810 <P ALIGN=CENTER><BR/>
3811 </P>
3812 </TD>
3813 <TD WIDTH=100px>
3814 <table border=0 cellpadding=0 cellspacing=0>
3815 <tr>
3816 <td><INPUT TYPE=radio NAME='endocrine_hypoglycemia' VALUE='Yes' '{$data->get_endocrine_hypoglycemia_yes()}'></td><td>Yes</td>
3817 <td><INPUT TYPE=radio NAME='endocrine_hypoglycemia' VALUE='No' '{$data->get_endocrine_hypoglycemia_no()}'></td><td>No</td>
3818 </tr>
3819 </table>
3820 </TD>
3821 <TD WIDTH=161px>
3822 <P>Hypoglycemia</P>
3823 </TD>
3824 <TD WIDTH=162px VALIGN=TOP>
3825 <P><textarea name='endocrine_hypoglycemia_text' cols='30' rows='2'>{$data->get_endocrine_hypoglycemia_text()}</textarea>
3826 </P>
3827 </TD>
3828 </TR>
3829
3830 <TR>
3831 <TD WIDTH=162px>
3832 <P ALIGN=CENTER><BR/>
3833 </P>
3834 </TD>
3835 <TD WIDTH=100px>
3836 <table border=0 cellpadding=0 cellspacing=0>
3837 <tr>
3838 <td><INPUT TYPE=radio NAME='endocrine_cold_intolerance' VALUE='Yes' '{$data->get_endocrine_cold_intolerance_yes()}'></td><td>Yes</td>
3839 <td><INPUT TYPE=radio NAME='endocrine_cold_intolerance' VALUE='No' '{$data->get_endocrine_cold_intolerance_no()}'></td><td>No</td>
3840 </tr>
3841 </table>
3842 </TD>
3843 <TD WIDTH=161px>
3844 <P>Cold Intolerance</P>
3845 </TD>
3846 <TD WIDTH=162px VALIGN=TOP>
3847 <P><textarea name='endocrine_cold_intolerance_text' cols='30' rows='2'>{$data->get_endocrine_cold_intolerance_text()}</textarea>
3848 </P>
3849 </TD>
3850 </TR>
3851
3852 <TR>
3853 <TD WIDTH=162px>
3854 <P ALIGN=CENTER><BR/>
3855 </P>
3856 </TD>
3857 <TD WIDTH=100px>
3858 <table border=0 cellpadding=0 cellspacing=0>
3859 <tr>
3860 <td><INPUT TYPE=radio NAME='endocrine_heat_intolerance' VALUE='Yes' '{$data->get_endocrine_heat_intolerance_yes()}'></td><td>Yes</td>
3861 <td><INPUT TYPE=radio NAME='endocrine_heat_intolerance' VALUE='No' '{$data->get_endocrine_heat_intolerance_no()}'></td><td>No</td>
3862 </tr>
3863 </table>
3864 </TD>
3865 <TD WIDTH=161px>
3866 <P>Heat Intolerance</P>
3867 </TD>
3868 <TD WIDTH=162px VALIGN=TOP>
3869 <P><textarea name='endocrine_heat_intolerance_text' cols='30' rows='2'>{$data->get_endocrine_heat_intolerance_text()}</textarea>
3870 </P>
3871 </TD>
3872 </TR>
3873
3874 <TR>
3875 <TD WIDTH=162px>
3876 <P ALIGN=CENTER><BR/>
3877 </P>
3878 </TD>
3879 <TD WIDTH=100px>
3880 <table border=0 cellpadding=0 cellspacing=0>
3881 <tr>
3882 <td><INPUT TYPE=radio NAME='endocrine_early_awakening' VALUE='Yes' '{$data->get_endocrine_early_awakening_yes()}'></td><td>Yes</td>
3883 <td><INPUT TYPE=radio NAME='endocrine_early_awakening' VALUE='No' '{$data->get_endocrine_early_awakening_no()}'></td><td>No</td>
3884 </tr>
3885 </table>
3886 </TD>
3887 <TD WIDTH=161px>
3888 <P>Early Awakening</P>
3889 </TD>
3890 <TD WIDTH=162px VALIGN=TOP>
3891 <P><textarea name='endocrine_early_awakening_text' cols='30' rows='2'>{$data->get_endocrine_early_awakening_text()}</textarea>
3892 </P>
3893 </TD>
3894 </TR>
3895
3896 <TR>
3897 <TD WIDTH=162px>
3898 <P ALIGN=CENTER><BR/>
3899 </P>
3900 </TD>
3901 <TD WIDTH=100px>
3902 <table border=0 cellpadding=0 cellspacing=0>
3903 <tr>
3904 <td><INPUT TYPE=radio NAME='endocrine_fatigue_unexplained' VALUE='Yes' '{$data->get_endocrine_fatigue_unexplained_yes()}'></td><td>Yes</td>
3905 <td><INPUT TYPE=radio NAME='endocrine_fatigue_unexplained' VALUE='No' '{$data->get_endocrine_fatigue_unexplained_no()}'></td><td>No</td>
3906 </tr>
3907 </table>
3908 </TD>
3909 <TD WIDTH=161px>
3910 <P>Fatigue unexplained</P>
3911 </TD>
3912 <TD WIDTH=162px VALIGN=TOP>
3913 <P><textarea name='endocrine_fatigue_unexplained_text' cols='30' rows='2'>{$data->get_endocrine_fatigue_unexplained_text()}</textarea>
3914 </P>
3915 </TD>
3916 </TR>
3917
3918 <TR>
3919 <TD WIDTH=162px>
3920 <P ALIGN=CENTER><BR/>
3921 </P>
3922 </TD>
3923 <TD WIDTH=100px>
3924 <table border=0 cellpadding=0 cellspacing=0>
3925 <tr>
3926 <td><INPUT TYPE=radio NAME='endocrine_weight_gain' VALUE='Yes' '{$data->get_endocrine_weight_gain_yes()}'></td><td>Yes</td>
3927 <td><INPUT TYPE=radio NAME='endocrine_weight_gain' VALUE='No' '{$data->get_endocrine_weight_gain_no()}'></td><td>No</td>
3928 </tr>
3929 </table>
3930 </TD>
3931 <TD WIDTH=161px>
3932 <P>Weight Gain</P>
3933 </TD>
3934 <TD WIDTH=162px VALIGN=TOP>
3935 <P><textarea name='endocrine_weight_gain_text' cols='30' rows='2'>{$data->get_endocrine_weight_gain_text()}</textarea>
3936 </P>
3937 </TD>
3938 </TR>
3939
3940 <TR>
3941 <TD WIDTH=162px>
3942 <P ALIGN=CENTER><BR/>
3943 </P>
3944 </TD>
3945 <TD WIDTH=100px>
3946 <table border=0 cellpadding=0 cellspacing=0>
3947 <tr>
3948 <td><INPUT TYPE=radio NAME='endocrine_weight_loss' VALUE='Yes' '{$data->get_endocrine_weight_loss_yes()}'></td><td>Yes</td>
3949 <td><INPUT TYPE=radio NAME='endocrine_weight_loss' VALUE='No' '{$data->get_endocrine_weight_loss_no()}'></td><td>No</td>
3950 </tr>
3951 </table>
3952 </TD>
3953 <TD WIDTH=161px>
3954 <P>Weight Loss</P>
3955 </TD>
3956 <TD WIDTH=162px VALIGN=TOP>
3957 <P><textarea name='endocrine_weight_loss_text' cols='30' rows='2'>{$data->get_endocrine_weight_loss_text()}</textarea>
3958 </P>
3959 </TD>
3960 </TR>
3961
3962 <TR>
3963 <TD WIDTH=162px>
3964 <P ALIGN=CENTER><BR/>
3965 </P>
3966 </TD>
3967 <TD WIDTH=100px>
3968 <table border=0 cellpadding=0 cellspacing=0>
3969 <tr>
3970 <td><INPUT TYPE=radio NAME='endocrine_premenstrual_symptoms' VALUE='Yes' '{$data->get_endocrine_premenstrual_symptoms_yes()}'></td><td>Yes</td>
3971 <td><INPUT TYPE=radio NAME='endocrine_premenstrual_symptoms' VALUE='No' '{$data->get_endocrine_premenstrual_symptoms_no()}'></td><td>No</td>
3972 </tr>
3973 </table>
3974 </TD>
3975 <TD WIDTH=161px>
3976 <P>Premenstrual symptoms</P>
3977 </TD>
3978 <TD WIDTH=162px VALIGN=TOP>
3979 <P><textarea name='endocrine_premenstrual_symptoms_text' cols='30' rows='2'>{$data->get_endocrine_premenstrual_symptoms_text()}</textarea>
3980 </P>
3981 </TD>
3982 </TR>
3983
3984 <TR>
3985 <TD WIDTH=162px>
3986 <P ALIGN=CENTER><BR/>
3987 </P>
3988 </TD>
3989 <TD WIDTH=100px>
3990 <table border=0 cellpadding=0 cellspacing=0>
3991 <tr>
3992 <td><INPUT TYPE=radio NAME='endocrine_hair_no_change_or_no_loss' VALUE='Yes' '{$data->get_endocrine_hair_no_change_or_no_loss_yes()}'></td><td>Yes</td>
3993 <td><INPUT TYPE=radio NAME='endocrine_hair_no_change_or_no_loss' VALUE='No' '{$data->get_endocrine_hair_no_change_or_no_loss_no()}'></td><td>No</td>
3994 </tr>
3995 </table>
3996 </TD>
3997 <TD WIDTH=161px>
3998 <P>Hair (no change or no loss)</P>
3999 </TD>
4000 <TD WIDTH=162px VALIGN=TOP>
4001 <P><textarea name='endocrine_hair_no_change_or_no_loss_text' cols='30' rows='2'>{$data->get_endocrine_hair_no_change_or_no_loss_text()}</textarea>
4002 </P>
4003 </TD>
4004 </TR>
4005
4006 <TR>
4007 <TD WIDTH=162px>
4008 <P ALIGN=CENTER><BR/>
4009 </P>
4010 </TD>
4011 <TD WIDTH=100px>
4012 <table border=0 cellpadding=0 cellspacing=0>
4013 <tr>
4014 <td><INPUT TYPE=radio NAME='endocrine_hot_flashes' VALUE='Yes' '{$data->get_endocrine_hot_flashes_yes()}'></td><td>Yes</td>
4015 <td><INPUT TYPE=radio NAME='endocrine_hot_flashes' VALUE='No' '{$data->get_endocrine_hot_flashes_no()}'></td><td>No</td>
4016 </tr>
4017 </table>
4018 </TD>
4019 <TD WIDTH=161px>
4020 <P>Hot flashes</P>
4021 </TD>
4022 <TD WIDTH=162px VALIGN=TOP>
4023 <P><textarea name='endocrine_hot_flashes_text' cols='30' rows='2'>{$data->get_endocrine_hot_flashes_text()}</textarea>
4024 </P>
4025 </TD>
4026 </TR>
4027
4028 <TR>
4029 <TD WIDTH=162px>
4030 <P ALIGN=CENTER>LYMPHATIC
4031 </P>
4032 </TD>
4033 <TD WIDTH=100px>
4034 <table border=0 cellpadding=0 cellspacing=0>
4035 <tr>
4036 <td><INPUT TYPE=radio NAME='lymphatic_swollen_lymph_nodes' VALUE='Yes' '{$data->get_lymphatic_swollen_lymph_nodes_yes()}'></td><td>Yes</td>
4037 <td><INPUT TYPE=radio NAME='lymphatic_swollen_lymph_nodes' VALUE='No' '{$data->get_lymphatic_swollen_lymph_nodes_no()}'></td><td>No</td>
4038 </tr>
4039 </table>
4040 </TD>
4041 <TD WIDTH=161px>
4042 <P>Swollen lymph nodes</P>
4043 </TD>
4044 <TD WIDTH=162px VALIGN=TOP>
4045 <P><textarea name='lymphatic_swollen_lymph_nodes_text' cols='30' rows='2'>{$data->get_lymphatic_swollen_lymph_nodes_text()}</textarea>
4046 </P>
4047 </TD>
4048 </TR>
4049
4050 <TR>
4051 <TD WIDTH=162px>
4052 <P ALIGN=CENTER><BR/>
4053 </P>
4054 </TD>
4055 <TD WIDTH=100px>
4056 <table border=0 cellpadding=0 cellspacing=0>
4057 <tr>
4058 <td><INPUT TYPE=radio NAME='lymphatic_swollen_extremities' VALUE='Yes' '{$data->get_lymphatic_swollen_extremities_yes()}'></td><td>Yes</td>
4059 <td><INPUT TYPE=radio NAME='lymphatic_swollen_extremities' VALUE='No' '{$data->get_lymphatic_swollen_extremities_no()}'></td><td>No</td>
4060 </tr>
4061 </table>
4062 </TD>
4063 <TD WIDTH=161px>
4064 <P>Swollen extremities</P>
4065 </TD>
4066 <TD WIDTH=162px VALIGN=TOP>
4067 <P><textarea name='lymphatic_swollen_extremities_text' cols='30' rows='2'>{$data->get_lymphatic_swollen_extremities_text()}</textarea>
4068 </P>
4069 </TD>
4070 </TR>
4071
4072 <TR>
4073 <TD WIDTH=162px>
4074 <P ALIGN=CENTER>PSYCHIATRIC
4075 </P>
4076 </TD>
4077 <TD WIDTH=100px>
4078 <table border=0 cellpadding=0 cellspacing=0>
4079 <tr>
4080 <td><INPUT TYPE=radio NAME='psychiatric_compulsions' VALUE='Yes' '{$data->get_psychiatric_compulsions_yes()}'></td><td>Yes</td>
4081 <td><INPUT TYPE=radio NAME='psychiatric_compulsions' VALUE='No' '{$data->get_psychiatric_compulsions_no()}'></td><td>No</td>
4082 </tr>
4083 </table>
4084 </TD>
4085 <TD WIDTH=161px>
4086 <P>Compulsions</P>
4087 </TD>
4088 <TD WIDTH=162px VALIGN=TOP>
4089 <P><textarea name='psychiatric_compulsions_text' cols='30' rows='2'>{$data->get_psychiatric_compulsions_text()}</textarea>
4090 </P>
4091 </TD>
4092 </TR>
4093
4094 <TR>
4095 <TD WIDTH=162px>
4096 <P ALIGN=CENTER><BR/>
4097 </P>
4098 </TD>
4099 <TD WIDTH=100px>
4100 <table border=0 cellpadding=0 cellspacing=0>
4101 <tr>
4102 <td><INPUT TYPE=radio NAME='psychiatric_depression' VALUE='Yes' '{$data->get_psychiatric_depression_yes()}'></td><td>Yes</td>
4103 <td><INPUT TYPE=radio NAME='psychiatric_depression' VALUE='No' '{$data->get_psychiatric_depression_no()}'></td><td>No</td>
4104 </tr>
4105 </table>
4106 </TD>
4107 <TD WIDTH=161px>
4108 <P>Depression</P>
4109 </TD>
4110 <TD WIDTH=162px VALIGN=TOP>
4111 <P><textarea name='psychiatric_depression_text' cols='30' rows='2'>{$data->get_psychiatric_depression_text()}</textarea>
4112 </P>
4113 </TD>
4114 </TR>
4115
4116 <TR>
4117 <TD WIDTH=162px>
4118 <P ALIGN=CENTER><BR/>
4119 </P>
4120 </TD>
4121 <TD WIDTH=100px>
4122 <table border=0 cellpadding=0 cellspacing=0>
4123 <tr>
4124 <td><INPUT TYPE=radio NAME='psychiatric_fear' VALUE='Yes' '{$data->get_psychiatric_fear_yes()}'></td><td>Yes</td>
4125 <td><INPUT TYPE=radio NAME='psychiatric_fear' VALUE='No' '{$data->get_psychiatric_fear_no()}'></td><td>No</td>
4126 </tr>
4127 </table>
4128 </TD>
4129 <TD WIDTH=161px>
4130 <P>Fear</P>
4131 </TD>
4132 <TD WIDTH=162px VALIGN=TOP>
4133 <P><textarea name='psychiatric_fear_text' cols='30' rows='2'>{$data->get_psychiatric_fear_text()}</textarea>
4134 </P>
4135 </TD>
4136 </TR>
4137
4138 <TR>
4139 <TD WIDTH=162px>
4140 <P ALIGN=CENTER><BR/>
4141 </P>
4142 </TD>
4143 <TD WIDTH=100px>
4144 <table border=0 cellpadding=0 cellspacing=0>
4145 <tr>
4146 <td><INPUT TYPE=radio NAME='psychiatric_anxiety' VALUE='Yes' '{$data->get_psychiatric_anxiety_yes()}'></td><td>Yes</td>
4147 <td><INPUT TYPE=radio NAME='psychiatric_anxiety' VALUE='No' '{$data->get_psychiatric_anxiety_no()}'></td><td>No</td>
4148 </tr>
4149 </table>
4150 </TD>
4151 <TD WIDTH=161px>
4152 <P>Anxiety</P>
4153 </TD>
4154 <TD WIDTH=162px VALIGN=TOP>
4155 <P><textarea name='psychiatric_anxiety_text' cols='30' rows='2'>{$data->get_psychiatric_anxiety_text()}</textarea>
4156 </P>
4157 </TD>
4158 </TR>
4159
4160 <TR>
4161 <TD WIDTH=162px>
4162 <P ALIGN=CENTER><BR/>
4163 </P>
4164 </TD>
4165 <TD WIDTH=100px>
4166 <table border=0 cellpadding=0 cellspacing=0>
4167 <tr>
4168 <td><INPUT TYPE=radio NAME='psychiatric_hallucinations' VALUE='Yes' '{$data->get_psychiatric_hallucinations_yes()}'></td><td>Yes</td>
4169 <td><INPUT TYPE=radio NAME='psychiatric_hallucinations' VALUE='No' '{$data->get_psychiatric_hallucinations_no()}'></td><td>No</td>
4170 </tr>
4171 </table>
4172 </TD>
4173 <TD WIDTH=161px>
4174 <P>Hallucinations</P>
4175 </TD>
4176 <TD WIDTH=162px VALIGN=TOP>
4177 <P><textarea name='psychiatric_hallucinations_text' cols='30' rows='2'>{$data->get_psychiatric_hallucinations_text()}</textarea>
4178 </P>
4179 </TD>
4180 </TR>
4181
4182 <TR>
4183 <TD WIDTH=162px>
4184 <P ALIGN=CENTER><BR/>
4185 </P>
4186 </TD>
4187 <TD WIDTH=100px>
4188 <table border=0 cellpadding=0 cellspacing=0>
4189 <tr>
4190 <td><INPUT TYPE=radio NAME='psychiatric_loss_of_interest' VALUE='Yes' '{$data->get_psychiatric_loss_of_interest_yes()}'></td><td>Yes</td>
4191 <td><INPUT TYPE=radio NAME='psychiatric_loss_of_interest' VALUE='No' '{$data->get_psychiatric_loss_of_interest_no()}'></td><td>No</td>
4192 </tr>
4193 </table>
4194 </TD>
4195 <TD WIDTH=161px>
4196 <P>Loss of Interest</P>
4197 </TD>
4198 <TD WIDTH=162px VALIGN=TOP>
4199 <P><textarea name='psychiatric_loss_of_interest_text' cols='30' rows='2'>{$data->get_psychiatric_loss_of_interest_text()}</textarea>
4200 </P>
4201 </TD>
4202 </TR>
4203
4204 <TR>
4205 <TD WIDTH=162px>
4206 <P ALIGN=CENTER><BR/>
4207 </P>
4208 </TD>
4209 <TD WIDTH=100px>
4210 <table border=0 cellpadding=0 cellspacing=0>
4211 <tr>
4212 <td><INPUT TYPE=radio NAME='psychiatric_memory_loss' VALUE='Yes' '{$data->get_psychiatric_memory_loss_yes()}'></td><td>Yes</td>
4213 <td><INPUT TYPE=radio NAME='psychiatric_memory_loss' VALUE='No' '{$data->get_psychiatric_memory_loss_no()}'></td><td>No</td>
4214 </tr>
4215 </table>
4216 </TD>
4217 <TD WIDTH=161px>
4218 <P>Memory Loss</P>
4219 </TD>
4220 <TD WIDTH=162px VALIGN=TOP>
4221 <P><textarea name='psychiatric_memory_loss_text' cols='30' rows='2'>{$data->get_psychiatric_memory_loss_text()}</textarea>
4222 </P>
4223 </TD>
4224 </TR>
4225
4226 <TR>
4227 <TD WIDTH=162px>
4228 <P ALIGN=CENTER><BR/>
4229 </P>
4230 </TD>
4231 <TD WIDTH=100px>
4232 <table border=0 cellpadding=0 cellspacing=0>
4233 <tr>
4234 <td><INPUT TYPE=radio NAME='psychiatric_mood_swings' VALUE='Yes' '{$data->get_psychiatric_mood_swings_yes()}'></td><td>Yes</td>
4235 <td><INPUT TYPE=radio NAME='psychiatric_mood_swings' VALUE='No' '{$data->get_psychiatric_mood_swings_no()}'></td><td>No</td>
4236 </tr>
4237 </table>
4238 </TD>
4239 <TD WIDTH=161px>
4240 <P>Mood Swings</P>
4241 </TD>
4242 <TD WIDTH=162px VALIGN=TOP>
4243 <P><textarea name='psychiatric_mood_swings_text' cols='30' rows='2'>{$data->get_psychiatric_mood_swings_text()}</textarea>
4244 </P>
4245 </TD>
4246 </TR>
4247
4248 <TR>
4249 <TD WIDTH=162px>
4250 <P ALIGN=CENTER><BR/>
4251 </P>
4252 </TD>
4253 <TD WIDTH=100px>
4254 <table border=0 cellpadding=0 cellspacing=0>
4255 <tr>
4256 <td><INPUT TYPE=radio NAME='psychiatric_pananoia' VALUE='Yes' '{$data->get_psychiatric_pananoia_yes()}'></td><td>Yes</td>
4257 <td><INPUT TYPE=radio NAME='psychiatric_pananoia' VALUE='No' '{$data->get_psychiatric_pananoia_no()}'></td><td>No</td>
4258 </tr>
4259 </table>
4260 </TD>
4261 <TD WIDTH=161px>
4262 <P>Pananoia</P>
4263 </TD>
4264 <TD WIDTH=162px VALIGN=TOP>
4265 <P><textarea name='psychiatric_pananoia_text' cols='30' rows='2'>{$data->get_psychiatric_pananoia_text()}</textarea>
4266 </P>
4267 </TD>
4268 </TR>
4269
4270 <TR>
4271 <TD WIDTH=162px>
4272 <P ALIGN=CENTER><BR/>
4273 </P>
4274 </TD>
4275 <TD WIDTH=100px>
4276 <table border=0 cellpadding=0 cellspacing=0>
4277 <tr>
4278 <td><INPUT TYPE=radio NAME='psychiatric_insomnia' VALUE='Yes' '{$data->get_psychiatric_insomnia_yes()}'></td><td>Yes</td>
4279 <td><INPUT TYPE=radio NAME='psychiatric_insomnia' VALUE='No' '{$data->get_psychiatric_insomnia_no()}'></td><td>No</td>
4280 </tr>
4281 </table>
4282 </TD>
4283 <TD WIDTH=161px>
4284 <P>Insomnia</P>
4285 </TD>
4286 <TD WIDTH=162px VALIGN=TOP>
4287 <P><textarea name='psychiatric_insomnia_text' cols='30' rows='2'>{$data->get_psychiatric_insomnia_text()}</textarea>
4288 </P>
4289 </TD>
4290 </TR>
4291
4292 </table>
4293
4294 <table border=0 cellpadding=0 cellspacing=20px>
4295 <tr>
4296 <td><input type="submit" name="Submit" value="Save Form"></td>
4297 <td><a href="{$DONT_SAVE_LINK}" class="link">[Don't Save]</a></td>
4298 </tr>
4299 </table>
4300
4301 <input type="hidden" name="id" value="{$data->get_id()}" />
4302 <input type="hidden" name="activity" value="{$data->get_activity()}">
4303 <input type="hidden" name="pid" value="{$data->get_pid()}">
4304 <input type="hidden" name="process" value="true">
4305 </form>
4306 </body>
4307 </html>
Mirror of official OpenEMR Sourceforge repository