contrib/forms/patient_intake_history/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8 ?>
   9
  10 <html>
  11 <head>
  12 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
  13 <link rel=stylesheet href="../../acog.css" type="text/css">
  14 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  15 <script language="JavaScript" type="text/JavaScript">
  16 window.onload = initialize;
  17 </script>
  18 </head>
  19
  20 <body <?echo $top_bg_line;?>>
  21
  22 <?
  23    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  24    if ($fres){
  25      $patient = sqlFetchArray($fres);
  26    }
  27    $fres=sqlStatement("select * from form_patient_intake_history where id=$id");
  28    if ($fres){
  29      $fdata = sqlFetchArray($fres);
  30    }
  31    $fres=sqlStatement("select * from form_patient_intake_history_ros where id=".$fdata['linked_ros_id']);
  32    if ($fres){
  33      $fros = sqlFetchArray($fres);
  34    }
  35 ?>
  36 <form action="<?echo $rootdir;?>/forms/patient_intake_history/save.php?mode=update&id=<? echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
  37 <?
  38 $addmenu = <<<EOL
  39 <blockquote>
  40   <small><strong>Local sections: </strong><br>
  41   <a href="#gh">Gynecologic history</a> |
  42   <a href="#oh">Obstetric history</a> | <a href="#cm">Current medications</a> |
  43   <a href="#fh">Family history</a> | <a href="#sh">Social history</a> |
  44   <a href="#pp">Personal profile</a> |
  45   <a href="#ih">Personal past history of illnesses</a> | <a href="#op">Operations/Hospitalizations</a> |
  46   <a href="#ii">Injuries/Illnesses</a> | <a href="#im">Immunizations/Test</a> |
  47   <a href="#ros">Review of systems</a></small>
  48 </blockquote>
  49 EOL;
  50 ?>
  51 <? include("../../acog_menu.inc"); ?>
  52   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
  53     <tr>
  54       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
  55     </tr>
  56     <tr>
  57       <td align="left" valign="bottom" nowrap class="fibody3"> <input name="pih_patient" type="radio" value="0"  <? echo (($fdata{'pih_patient'} == '0')?' checked ':''); ?>>
  58       New patient </td>
  59     </tr>
  60     <tr>
  61       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_patient" type="radio" value="1" <? echo (($fdata{'pih_patient'} == '1')?' checked ':''); ?>>
  62       Established patient </td>
  63     </tr>
  64     <tr>
  65       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_consultation" type="checkbox"  value="1" <? echo (($fdata{'pih_consultation'} == '1')?' checked ':''); ?>>
  66       Consultation</td>
  67     </tr>
  68     <tr>
  69       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_report_sent" type="checkbox"  value="1" <? echo (($fdata{'pih_report_sent'} == '1')?' checked ':''); ?>>
  70       Report sent
  71       <input name="pih_report_sent_date" type="text" class="fullin"  style="width:90px"  value="<? echo $fdata{'pih_report_sent_date'}; ?>"></td>
  72     </tr>
  73 </table>
  74 <?
  75 $tip1 = <<<EOL
  76 <strong>Patient Intake History</strong> is an optional form
  77 giving practices the flexibility to have patients complete
  78 their own history at or before the visit. It uses language
  79 that a patient is likely to understand and includes ample
  80 space for physician notes. Space at the end of the form
  81 allows physicians to review the history and sign off for 4
  82 years. At year 5, the patient should be asked to complete
  83 a new Patient Intake History.
  84 EOL;
  85 $tip1 = strtr($tip1, "\n\r", "  ");
  86 ?>
  87 <div class="srvChapter">Patient Intake history <a href="#" onMouseOver="toolTip('<? echo $tip1; ?>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
  88 <div style="border: solid 2px black; background-color: white;">
  89 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  90   <tr>
  91     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  92       <tr align="left" valign="bottom" class="fibody">
  93         <td width="40%" class="bordR">Patient name <br>
  94           <input name="pname" type="text" class="fullin" id="pname" value="<?
  95           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  96           ?>"></td>
  97         <td width="20%" class="bordR">birth date
  98           <br>
  99           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?
 100           echo $patient{'DOB'};
 101           ?>" size="12"> </td>
 102         <td width="20%" class="bordR">ID No<br>
 103           <input name="pih_pid" type="text" class="fullin" id="pih_pid" size="12" value="<?
 104           echo $patient{'id'};
 105           ?>"></td>
 106         <td width="20%">date<br>
 107         <input name="pih_date" type="text" class="fullin" id="pih_date" value="<?
 108         echo date('Y-m-d');
 109         ?>" size="12"></td>
 110       </tr>
 111     </table>
 112 </td>
 113   </tr>
 114   <tr>
 115     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 116       <tr align="left" valign="bottom">
 117         <td colspan="3" class="fibody2">Address:
 118           <input name="address" type="text" class="fullin"  style="width: 90%" value="<? echo $fdata{'address'}; ?>"></td>
 119         </tr>
 120       <tr align="left" valign="bottom">
 121         <td width="50%" class="fibody2" id="bordR">City:
 122           <input name="city" type="text" class="fullin"  style="width: 250px" value="<? echo $fdata{'city'}; ?>"></td>
 123         <td width="50%" colspan="2" class="fibody2">State/ZIP:
 124           <input name="state" type="text" class="fullin"  style="width: 250px" value="<? echo $fdata{'state'}; ?>"></td>
 125       </tr>
 126       <tr align="left" valign="bottom">
 127         <td class="fibody2" id="bordR">Home telephone:
 128           <span style="width:auto">
 129           <input name="home_phone" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'home_phone'}; ?>">
 130           </span></td>
 131         <td colspan="2" class="fibody2">Work telephone:
 132           <input name="work_phone" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'work_phone'}; ?>"></td>
 133       </tr>
 134       <tr align="left" valign="bottom">
 135         <td class="fibody2" id="bordR">Employer:
 136           <input name="employer" type="text" class="fullin"  style="width: 80%" value="<? echo $fdata{'employer'}; ?>"></td>
 137         <td width="25%" class="fibody2" id="bordR">Insurance
 138           <input name="insurance" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'insurance'}; ?>"></td>
 139         <td width="25%" class="fibody2">Policy No:
 140           <input name="policy_no" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'policy_no'}; ?>"></td>
 141       </tr>
 142       <tr align="left" valign="bottom">
 143         <td class="fibody2" id="bordR">Name you would like us to use:           <input name="name_to_use" type="text" class="fullin"  style="width: 50%" value="<? echo $fdata{'name_to_use'}; ?>"> </td>
 144         <td colspan="2" class="fibody2">Primary language:
 145           <input name="primary_language" type="text" class="fullin"  style="width: 150px" value="<? echo $fdata{'primary_language'}; ?>"></td>
 146       </tr>
 147     </table></td>
 148   </tr>
 149   <tr>
 150     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 151       <tr align="left" valign="bottom">
 152         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 153         <td colspan="2" class="fibody2">Emergency contact:
 154           <input name="partner_emergency_contact" type="text" class="fullin"  style="width: 70%" value="<? echo $fdata{'partner_emergency_contact'}; ?>"></td>
 155         </tr>
 156       <tr align="left" valign="bottom">
 157         <td rowspan="2" valign="top" class="fibody2" id="bordR"><textarea name="partner_name" rows="2" wrap="VIRTUAL" class="fullin2"  style="height:100%"><? echo $fdata{'partner_name'}; ?></textarea></td>
 158         <td colspan="2" class="fibody2">Relationship:
 159           <input name="relationship" type="text" class="fullin"  style="width:80%" value="<? echo $fdata{'relationship'}; ?>"></td>
 160         </tr>
 161       <tr align="left" valign="bottom">
 162         <td width="30%" class="fibody2" id="bordR">Home telephone:
 163           <input name="partner_home_phone" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'partner_home_phone'}; ?>"></td>
 164         <td width="30%" class="fibody2">Work telephone:
 165           <input name="partner_work_phone" type="text" class="fullin"  style="width: 120px" value="<? echo $fdata{'partner_work_phone'}; ?>"></td>
 166       </tr>
 167     </table></td>
 168   </tr>
 169   <tr>
 170     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 171       <tr>
 172         <td align="left" valign="bottom" class="fibody2">Referred by:
 173           <input name="referred_by" type="text" class="fullin"  style="width: 85%;" value="<? echo $fdata{'referred_by'}; ?>"></td>
 174       </tr>
 175       <tr>
 176         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 177           <input name="why_come_to_office" type="text" class="fullin"  value="<? echo $fdata{'why_come_to_office'}; ?>"></td>
 178       </tr>
 179       <tr>
 180         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 181           <input name="primary_care_visit" type="radio" value="1"  <? echo (($fdata{'primary_care_visit'} == '1')?' checked ':''); ?>>
 182           Primary care visit or
 183           <input name="primary_care_visit" type="radio" value="0" <? echo (($fdata{'primary_care_visit'} == '0')?' checked ':''); ?>>
 184           Gynecology only </td>
 185       </tr>
 186       <tr>
 187         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 188           <input name="new_problem" type="radio" value="1"  <? echo (($fdata{'new_problem'} == '1')?' checked ':''); ?>>
 189           yes &nbsp;&nbsp;&nbsp;&nbsp;
 190           <input name="new_problem" type="radio" value="0" <? echo (($fdata{'new_problem'} == '0')?' checked ':''); ?>>
 191           no</td>
 192       </tr>
 193       <tr>
 194         <td align="left" valign="bottom" class="fibody2">Please, describe your problem, including, where it is, how severe it is, and how long it has lasted <br>
 195           <textarea name="problem_description" rows="6" class="fullin2" ><? echo $fdata{'problem_description'}; ?></textarea></td>
 196       </tr>
 197     </table></td>
 198   </tr>
 199 </table>
 200 </div>
 201 <h2 align="center"><small>If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.</small></h2>
 202 <p align="center">&nbsp;</p>
 203 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 204   </h2>
 205 <div style="border: solid 2px black; background-color: white;">
 206     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 207       <tr>
 208         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 209           <tr align="left" valign="bottom">
 210             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 211             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 212           </tr>
 213           <tr align="left" valign="bottom">
 214             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 215               <input name="last_period_date" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'last_period_date'}; ?>"></td>
 216             <td class="fibody2"><input name="gh_notes_1" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_1'}; ?>"></td>
 217           </tr>
 218           <tr align="left" valign="bottom">
 219             <td nowrap class="fibody2" id="bordR">Age periods began:
 220               <input name="periods_began" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'periods_began'}; ?>"></td>
 221             <td class="fibody2"><input name="gh_notes_2" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_2'}; ?>"></td>
 222           </tr>
 223           <tr align="left" valign="bottom">
 224             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 225               <input name="period_lenght" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'period_lenght'}; ?>"></td>
 226             <td class="fibody2"><input name="gh_notes_3" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_3'}; ?>"></td>
 227           </tr>
 228           <tr align="left" valign="bottom">
 229             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 230               <input name="period_days_between" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'period_days_between'}; ?>"></td>
 231             <td class="fibody2"><input name="gh_notes_4" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_4'}; ?>"></td>
 232           </tr>
 233           <tr align="left" valign="bottom">
 234             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 235               <input name="period_changes" type="radio" value="1" <? echo (($fdata{'period_changes'} == '1')?' checked ':''); ?>>
 236 Yes
 237 <input name="pih_gh_recent_changes_periods" type="radio" value="0"  <? echo (($fdata{'pih_gh_recent_changes_periods'} == '0')?' checked ':''); ?>>
 238 No</td>
 239             <td class="fibody2"><input name="gh_notes_5" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_5'}; ?>"></td>
 240           </tr>
 241           <tr align="left" valign="bottom">
 242             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 243               <input name="sexually_active" type="radio" value="1"  <? echo (($fdata{'sexually_active'} == '1')?' checked ':''); ?>>
 244 Yes
 245 <input name="sexually_active" type="radio" value="0" <? echo (($fdata{'sexually_active'} == '0')?' checked ':''); ?>>
 246 No</td>
 247             <td class="fibody2"><input name="gh_notes_6" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_6'}; ?>"></td>
 248           </tr>
 249           <tr align="left" valign="bottom">
 250             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 251               <input name="ever_had_sex" type="radio" value="1"  <? echo (($fdata{'ever_had_sex'} == '1')?' checked ':''); ?>>
 252 Yes
 253 <input name="ever_had_sex" type="radio" value="0" <? echo (($fdata{'ever_had_sex'} == '0')?' checked ':''); ?>>
 254 No</td>
 255             <td class="fibody2"><input name="gh_notes_7" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_7'}; ?>"></td>
 256           </tr>
 257           <tr align="left" valign="bottom">
 258             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 259               <input name="number_of_partners" type="text" class="fullin"  style="width: 90px"  value="<? echo $fdata{'number_of_partners'}; ?>"></td>
 260             <td class="fibody2"><input name="gh_notes_8" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_8'}; ?>"></td>
 261           </tr>
 262           <tr align="left" valign="bottom">
 263             <td nowrap class="fibody2" id="bordR">Sexual partners are
 264               <input name="partners" type="radio" value="men"  <? echo (($fdata{'partners'} == 'men')?' checked ':''); ?>>
 265               Men
 266               <input name="partners" type="radio" value="women" <? echo (($fdata{'partners'} == 'women')?' checked ':''); ?>>
 267               Women
 268               <input name="partners" type="radio" value="both" <? echo (($fdata{'partners'} == 'both')?' checked ':''); ?>>
 269               Both </td>
 270             <td class="fibody2"><input name="gh_notes_9" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_9'}; ?>"></td>
 271           </tr>
 272           <tr align="left" valign="bottom">
 273             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 274               <input name="present_birth_control" type="text" class="fullin"  style="width: 90px"  value="<? echo $fdata{'present_birth_control'}; ?>"></td>
 275             <td class="fibody2"><input name="gh_notes_10" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_10'}; ?>"></td>
 276           </tr>
 277           <tr align="left" valign="bottom">
 278             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 279               <input name="pills_iud" type="radio" value="1" <? echo (($fdata{'pills_iud'} == '1')?' checked ':''); ?>>
 280 Yes
 281 <input name="pills_iud" type="radio" value="0"  <? echo (($fdata{'pills_iud'} == '0')?' checked ':''); ?>>
 282 No </td>
 283             <td class="fibody2"><input name="gh_notes_11" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_11'}; ?>"></td>
 284           </tr>
 285           <tr align="left" valign="bottom">
 286             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 287               <input name="pills_how_long" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'pills_how_long'}; ?>"></td>
 288             <td class="fibody2"><input name="gh_notes_12" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_12'}; ?>"></td>
 289           </tr>
 290           <tr align="left" valign="bottom">
 291             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 292               <input name="pap_test" type="text" class="fullin"  style="width: 90px" value="<? echo $fdata{'pap_test'}; ?>"></td>
 293             <td class="fibody2"><input name="gh_notes_13" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_13'}; ?>"></td>
 294           </tr>
 295           <tr align="left" valign="bottom">
 296             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 297               <input name="breast_self_exam" type="radio" value="1" <? echo (($fdata{'breast_self_exam'} == '1')?' checked ':''); ?>>
 298               Yes
 299               <input name="breast_self_exam" type="radio" value="0"  <? echo (($fdata{'breast_self_exam'} == '0')?' checked ':''); ?>>
 300               No</td>
 301             <td class="fibody2"><input name="gh_notes_14" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_14'}; ?>"></td>
 302           </tr>
 303           <tr align="left" valign="bottom">
 304             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 305               <input name="des" type="radio" value="1" <? echo (($fdata{'des'} == '1')?' checked ':''); ?>>
 306 Yes
 307 <input name="des" type="radio" value="0" <? echo (($fdata{'des'} == '0')?' checked ':''); ?>>
 308 No </td>
 309             <td class="fibody2"><input name="gh_notes_15" type="text" class="fullin2"  value="<? echo $fdata{'gh_notes_15'}; ?>"></td>
 310           </tr>
 311         </table></td>
 312       </tr>
 313     </table>
 314   </div>
 315   <p align="center">&nbsp;</p>
 316   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 317   </h2>
 318   <div style="border: solid 2px black; background-color:#FFFFFF;">
 319     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 320       <tr>
 321         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 322             <tr align="left" valign="bottom">
 323               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 324               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 325               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 326               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 327               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 328               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 329             </tr>
 330             <tr align="left" valign="bottom">
 331               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 332               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2"   value="<? echo $fdata{'oh_pregnancies'}; ?>"></td>
 333               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 334               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2"   value="<? echo $fdata{'oh_abortions'}; ?>"></td>
 335               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 336               <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2"   value="<? echo $fdata{'oh_miscarriages'}; ?>"></td>
 337             </tr>
 338             <tr align="left" valign="bottom">
 339               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 340               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_premature_births" type="text" class="fullin2"  value="<? echo $fdata{'oh_premature_births'}; ?>"></td>
 341               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 342               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_live_births" type="text" class="fullin2"  value="<? echo $fdata{'oh_live_births'}; ?>"></td>
 343               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 344               <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2"  value="<? echo $fdata{'oh_living_children'}; ?>"></td>
 345             </tr>
 346         </table></td>
 347       </tr>
 348       <tr>
 349         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 350             <tr align="center" valign="middle">
 351               <td class="ficaption2" id="bordR">No</td>
 352               <td class="ficaption2" id="bordR">birth date </td>
 353               <td class="ficaption2" id="bordR">weight at birth </td>
 354               <td class="ficaption2" id="bordR">baby's sex </td>
 355               <td class="ficaption2" id="bordR">weeks pregnant </td>
 356               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 357               <td class="ficaption2">physician's notes</td>
 358             </tr>
 359 <?
 360   $bi = 0;
 361   while ($bi<4) {
 362     $n = $bi+1;
 363     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 364     print <<<EOL
 365         <tr align="left" valign="bottom">
 366           <td nowrap class="fibody2" id="bordR">$n.</td>
 367           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" value="${oh_ch_date}" class="fullin2"></td>
 368           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" value="${oh_ch_width}"  class="fullin2"></td>
 369           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" value="${oh_ch_sex}"  class="fullin2"></td>
 370           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" value="${oh_ch_weeks}"  class="fullin2"></td>
 371           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" value="${oh_ch_delivery}"  class="fullin2"></td>
 372           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" value="${oh_ch_notes}"  class="fullin2"></td>
 373         </tr>
 374 EOL;
 375      $bi++;
 376   }
 377 ?>
 378         </table></td>
 379       </tr>
 380       <tr>
 381         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 382             <tr align="left" valign="bottom">
 383               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 384               <td class="fibody2"><input name="oh_complications" type="text" class="fullin2"   value="<? echo $fdata{'oh_complications'}; ?>"></td>
 385             </tr>
 386         </table></td>
 387       </tr>
 388       <tr>
 389         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 390             <tr align="left" valign="bottom">
 391               <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox"  value="1" <? echo (($fdata{'oh_diabetes'} == '1')?' checked ':''); ?>>
 392               diabetes
 393                 <input name="oh_hipertension" type="checkbox"  value="1" <? echo (($fdata{'oh_hipertension'} == '1')?' checked ':''); ?>>
 394               hypertension/high blood pressure
 395               <input name="oh_preemclampsia" type="checkbox"  value="1" <? echo (($fdata{'oh_preemclampsia'} == '1')?' checked ':''); ?>>
 396               preeclampsia/foxemia
 397               <input name="oh_complic_other" type="checkbox"  value="1" <? echo (($fdata{'oh_complic_other'} == '1')?' checked ':''); ?>>
 398               other </td>
 399             </tr>
 400             <tr align="left" valign="bottom">
 401               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 402                   <input name="oh_depression" type="radio" value="0"  <? echo (($fdata{'oh_depression'} == '0')?' checked ':''); ?>>
 403               no
 404               <input name="oh_depression" type="radio" value="1" <? echo (($fdata{'oh_depression'} == '1')?' checked ':''); ?>>
 405               yes, How treated </td>
 406               <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2"  value="<? echo $fdata{'oh_depression_treated'}; ?>"></td>
 407             </tr>
 408         </table></td>
 409       </tr>
 410     </table>
 411   </div>
 412   <p align="center">&nbsp;</p>
 413   <h2 align="center"><a name="cm"></a>Current medications <br>
 414     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 415   </h2>
 416   <div style="border: solid 2px black; background-color: white;">
 417     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 418       <tr align="center">
 419         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 420         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 421         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 422         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 423         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 424         <td valign="top" class="ficaption2">Who prescribed</td>
 425       </tr>
 426 <?
 427   $bi = 0;
 428   while ($bi<5) {
 429   $bi2 = $bi+5;
 430       list ($pres_drug, $pres_dosage, $pres_who) = explode('|~', $fdata["pres_drug_rec_".$bi] );
 431       list ($pres_drug1, $pres_dosage1, $pres_who1) = explode('|~', $fdata["pres_drug_rec_".$bi2] );
 432     print <<<EOL
 433       <tr>
 434         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi}" value="${pres_dosage}" type="text" class="fullin2"></td>
 435         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi}" value="${pres_drug}" type="text" class="fullin2"></td>
 436         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_who_${bi}" value="${pres_who}" type="text" class="fullin2"></td>
 437         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi2}" value="${pres_drug1}" type="text" class="fullin2"></td>
 438         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi2}" value="${pres_dosage1}" type="text" class="fullin2"></td>
 439         <td align="left" valign="top" class="fibody2"><input name="pres_who_${bi2}" type="text" value="${pres_who1}" class="fullin2"></td>
 440       </tr>
 441 EOL;
 442      $bi++;
 443   }
 444 ?>
 445     </table>
 446   </div>
 447   <p align="center">&nbsp;</p>
 448   <h2 align="center"><a name="fh"></a>Family history <br>
 449   </h2>
 450   <div style="border: solid 2px black; background-color: white;">
 451     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 452       <tr>
 453         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 454           <tr align="left" valign="bottom">
 455             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 456               <input name="fh_mother" type="radio" value="0"  <? echo (($fdata{'fh_mother'} == '0')?' checked ':''); ?>>
 457               living
 458               <input name="fh_mother" type="radio" value="1" <? echo (($fdata{'fh_mother'} == '1')?' checked ':''); ?>>
 459               deceased - cause:
 460               <input name="fh_mother_dec_cause" type="text" class="fullin"  style="width: 20%" value="<? echo $fdata{'fh_mother_dec_cause'}; ?>">
 461               Age:
 462               <input name="fh_mother_dec_age" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_mother_dec_age'}; ?>"></td>
 463             <td width="50%" nowrap class="fibody2">father:
 464               <input name="fh_father" type="radio" value="0"  <? echo (($fdata{'fh_father'} == '0')?' checked ':''); ?>>
 465 living
 466 <input name="fh_father" type="radio" value="1" <? echo (($fdata{'fh_father'} == '1')?' checked ':''); ?>>
 467 deceased - cause:
 468 <input name="fh_father_dec_cause" type="text" class="fullin"  style="width: 20%" value="<? echo $fdata{'fh_father_dec_cause'}; ?>">
 469 Age:
 470 <input name="fh_father_dec_age" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_father_dec_age'}; ?>"></td>
 471           </tr>
 472           <tr align="left" valign="bottom">
 473             <td nowrap class="fibody2">Siblings: Num.living:
 474               <input name="fh_sibl_living" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_sibl_living'}; ?>">
 475               , num.deceased:
 476               <input name="fh_sib_deceased" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_sib_deceased'}; ?>">
 477               , cause(s)/age(s): </td>
 478             <td nowrap class="fibody2"><input name="fh_sib_dec_cause" type="text" class="fullin"  value="<? echo $fdata{'fh_sib_dec_cause'}; ?>"></td>
 479           </tr>
 480           <tr align="left" valign="bottom">
 481             <td nowrap class="fibody2">Children: Num.living:
 482               <input name="fh_children_living" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_children_living'}; ?>">
 483 , num.deceased:
 484 <input name="fh_children_deceased" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'fh_children_deceased'}; ?>">
 485 , cause(s)/age(s):</td>
 486             <td nowrap class="fibody2"><input name="fh_children_dec_cause" type="text" class="fullin"  value="<? echo $fdata{'fh_children_dec_cause'}; ?>"></td>
 487           </tr>
 488         </table></td>
 489       </tr>
 490       <tr>
 491         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 492           <tr valign="bottom">
 493             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 494             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 495             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 496             <td align="center" class="ficaption2">Physician's notes </td>
 497           </tr>
 498           <tr align="left" valign="bottom">
 499             <td nowrap class="fibody2" id="bordR">diabetes</td>
 500             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_diabetes" type="checkbox"  value="1" <? echo (($fdata{'fh_diabetes'} == '1')?' checked ':''); ?>></td>
 501             <td class="fibody2" id="bordR"><input name="fh_diabetes_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_diabetes_info'}; ?>"></td>
 502             <td class="fibody2"><input name="fh_notes_1" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_1'}; ?>"></td>
 503           </tr>
 504           <tr align="left" valign="bottom">
 505             <td nowrap class="fibody2" id="bordR">Stroke</td>
 506             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_stroke" type="checkbox"  value="1" <? echo (($fdata{'fh_stroke'} == '1')?' checked ':''); ?>></td>
 507             <td class="fibody2" id="bordR"><input name="fh_stroke_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_stroke_info'}; ?>"></td>
 508             <td class="fibody2"><input name="fh_notes_2" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_2'}; ?>"></td>
 509           </tr>
 510           <tr align="left" valign="bottom">
 511             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
 512             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_heart_disease" type="checkbox"  value="1" <? echo (($fdata{'fh_heart_disease'} == '1')?' checked ':''); ?>></td>
 513             <td class="fibody2" id="bordR"> <input name="fh_heart_disease_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_heart_disease_info'}; ?>"></td>
 514             <td class="fibody2"><input name="fh_notes_3" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_3'}; ?>"></td>
 515           </tr>
 516           <tr align="left" valign="bottom">
 517             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 518             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fhbllod_clots" type="checkbox"  value="1" <? echo (($fdata{'fhbllod_clots'} == '1')?' checked ':''); ?>></td>
 519             <td class="fibody2" id="bordR"><input name="fhbllod_clots_info" type="text" class="fullin2"  value="<? echo $fdata{'fhbllod_clots_info'}; ?>"></td>
 520             <td class="fibody2"><input name="fh_notes_4" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_4'}; ?>"></td>
 521           </tr>
 522           <tr align="left" valign="bottom">
 523             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 524             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_pressure" type="checkbox"  value="1" <? echo (($fdata{'fh_high_pressure'} == '1')?' checked ':''); ?>></td>
 525             <td class="fibody2" id="bordR"><input name="fh_high_pressure_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_high_pressure_info'}; ?>"></td>
 526             <td class="fibody2"><input name="fh_notes_5" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_5'}; ?>"></td>
 527           </tr>
 528           <tr align="left" valign="bottom">
 529             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
 530             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_cholesterol" type="checkbox"  value="1" <? echo (($fdata{'fh_high_cholesterol'} == '1')?' checked ':''); ?>></td>
 531             <td class="fibody2" id="bordR"><input name="fh_high_cholesterol_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_high_cholesterol_info'}; ?>"></td>
 532             <td class="fibody2"><input name="fh_notes_6" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_6'}; ?>"></td>
 533           </tr>
 534           <tr align="left" valign="bottom">
 535             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
 536             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_osteoporosis" type="checkbox"  value="1" <? echo (($fdata{'fh_osteoporosis'} == '1')?' checked ':''); ?>></td>
 537             <td class="fibody2" id="bordR"><input name="fh_osteoporosis_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_osteoporosis_info'}; ?>"></td>
 538             <td class="fibody2"><input name="fh_notes_7" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_7'}; ?>"></td>
 539           </tr>
 540           <tr align="left" valign="bottom">
 541             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
 542             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hepatitis" type="checkbox"  value="1" <? echo (($fdata{'fh_hepatitis'} == '1')?' checked ':''); ?>></td>
 543             <td class="fibody2" id="bordR"><input name="fh_hepatitis_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_hepatitis_info'}; ?>"></td>
 544             <td class="fibody2"><input name="fh_notes_8" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_8'}; ?>"></td>
 545           </tr>
 546           <tr align="left" valign="bottom">
 547             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
 548             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hiv" type="checkbox"  value="1" <? echo (($fdata{'fh_hiv'} == '1')?' checked ':''); ?>></td>
 549             <td class="fibody2" id="bordR"><input name="fh_hiv_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_hiv_info'}; ?>"></td>
 550             <td class="fibody2"><input name="fh_notes_9" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_9'}; ?>"></td>
 551           </tr>
 552           <tr align="left" valign="bottom">
 553             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 554             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_tuberculosis" type="checkbox"  value="1" <? echo (($fdata{'fh_tuberculosis'} == '1')?' checked ':''); ?>></td>
 555             <td class="fibody2" id="bordR"><input name="fh_tuberculosis_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_tuberculosis_info'}; ?>"></td>
 556             <td class="fibody2"><input name="fh_notes_10" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_10'}; ?>"></td>
 557           </tr>
 558           <tr align="left" valign="bottom">
 559             <td nowrap class="fibody2" id="bordR">Birth defects </td>
 560             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="dh_birth_defects" type="checkbox"  value="1" <? echo (($fdata{'dh_birth_defects'} == '1')?' checked ':''); ?>></td>
 561             <td class="fibody2" id="bordR"><input name="dh_birth_defects_info" type="text" class="fullin2"  value="<? echo $fdata{'dh_birth_defects_info'}; ?>"></td>
 562             <td class="fibody2"><input name="fh_notes_11" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_11'}; ?>"></td>
 563           </tr>
 564           <tr align="left" valign="bottom">
 565             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
 566             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alcohol_drugs" type="checkbox"  value="1" <? echo (($fdata{'fh_alcohol_drugs'} == '1')?' checked ':''); ?>></td>
 567             <td class="fibody2" id="bordR"><input name="fh_alcohol_drugs_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_alcohol_drugs_info'}; ?>"></td>
 568             <td class="fibody2"><input name="fh_notes_12" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_12'}; ?>"></td>
 569           </tr>
 570           <tr align="left" valign="bottom">
 571             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
 572             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_breast_cancer" type="checkbox"  value="1" <? echo (($fdata{'fh_breast_cancer'} == '1')?' checked ':''); ?>></td>
 573             <td class="fibody2" id="bordR"><input name="fh_breast_cancer_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_breast_cancer_info'}; ?>"></td>
 574             <td class="fibody2"><input name="fh_notes_13" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_13'}; ?>"></td>
 575           </tr>
 576           <tr align="left" valign="bottom">
 577             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
 578             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_colon_cancer" type="checkbox"  value="1" <? echo (($fdata{'fh_colon_cancer'} == '1')?' checked ':''); ?>></td>
 579             <td class="fibody2" id="bordR"><input name="fh_colon_cancer_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_colon_cancer_info'}; ?>"></td>
 580             <td class="fibody2"><input name="fh_notes_14" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_14'}; ?>"></td>
 581           </tr>
 582           <tr align="left" valign="bottom">
 583             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
 584             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="checkbox"  value="1" <? echo (($fdata{'fh_ovarian_cancer'} == '1')?' checked ':''); ?>></td>
 585             <td class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="text" class="fullin2"  value="<? echo $fdata{'fh_ovarian_cancer'}; ?>"></td>
 586             <td class="fibody2"><input name="fh_notes_15" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_15'}; ?>"></td>
 587           </tr>
 588           <tr align="left" valign="bottom">
 589             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
 590             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_uterine_cancer" type="checkbox"  value="1" <? echo (($fdata{'fh_uterine_cancer'} == '1')?' checked ':''); ?>></td>
 591             <td class="fibody2" id="bordR"><input name="fh_uterine_cancer_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_uterine_cancer_info'}; ?>"></td>
 592             <td class="fibody2"><input name="fh_notes_16" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_16'}; ?>"></td>
 593           </tr>
 594           <tr align="left" valign="bottom">
 595             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
 596             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_mental_illness" type="checkbox"  value="1" <? echo (($fdata{'fh_mental_illness'} == '1')?' checked ':''); ?>></td>
 597             <td class="fibody2" id="bordR"><input name="fh_mental_illness_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_mental_illness_info'}; ?>"></td>
 598             <td class="fibody2"><input name="fh_notes_17" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_17'}; ?>"></td>
 599           </tr>
 600           <tr align="left" valign="bottom">
 601             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
 602             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alzheimer" type="checkbox"  value="1" <? echo (($fdata{'fh_alzheimer'} == '1')?' checked ':''); ?>></td>
 603             <td class="fibody2" id="bordR"><input name="fh_alzheimer_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_alzheimer_info'}; ?>"></td>
 604             <td class="fibody2"><input name="fh_notes_18" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_18'}; ?>"></td>
 605           </tr>
 606           <tr align="left" valign="bottom">
 607             <td nowrap class="fibody2" id="bordR">Other</td>
 608             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_other_illness" type="checkbox"  value="1" <? echo (($fdata{'fh_other_illness'} == '1')?' checked ':''); ?>></td>
 609             <td class="fibody2" id="bordR"><input name="fh_other_illness_info" type="text" class="fullin2"  value="<? echo $fdata{'fh_other_illness_info'}; ?>"></td>
 610             <td class="fibody2"><input name="fh_notes_19" type="text" class="fullin2"  value="<? echo $fdata{'fh_notes_19'}; ?>"></td>
 611           </tr>
 612         </table></td>
 613       </tr>
 614     </table>
 615   </div>
 616   <p align="center">&nbsp;</p>
 617   <h2 align="center"><a name="sh"></a>Social history <br>
 618   </h2>
 619   <div style="border: solid 2px black; background-color: white;">
 620     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 621       <tr>
 622         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 623           <tr align="left" valign="bottom">
 624             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
 625             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 626             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 627             <td align="center" class="ficaption2">physician's notes                           </td>
 628           </tr>
 629           <tr align="left" valign="bottom">
 630             <td nowrap class="fibody2" id="bordR">Ever smoked? current smoking: packs/day:
 631               <input name="sh_smoked_packs" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_smoked_packs'}; ?>">
 632               , years:
 633               <input name="sh_smoked_years" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_smoked_years'}; ?>"></td>
 634             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="1" <? echo (($fdata{'pih_smoked'} == '1')?' checked ':''); ?>></td>
 635             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="0"  <? echo (($fdata{'pih_smoked'} == '0')?' checked ':''); ?>></td>
 636             <td class="fibody2"><input name="sh_notes_1" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_1'}; ?>"></td>
 637           </tr>
 638           <tr align="left" valign="bottom">
 639             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
 640               <input name="sh_alcohol_drinks_day" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_alcohol_drinks_day'}; ?>">
 641               ,
 642               drinks/week:
 643               <input name="sh_alcohol_drinks_week" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_alcohol_drinks_week'}; ?>">
 644               ,
 645               type of drink:
 646               <input name="sh_alcohol_drinks_type" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_alcohol_drinks_type'}; ?>"></td>
 647             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="1" <? echo (($fdata{'pih_alcohol'} == '1')?' checked ':''); ?>></td>
 648             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="0"  <? echo (($fdata{'pih_alcohol'} == '0')?' checked ':''); ?>></td>
 649             <td class="fibody2"><input name="sh_notes_2" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_2'}; ?>"></td>
 650           </tr>
 651           <tr align="left" valign="bottom">
 652             <td nowrap class="fibody2" id="bordR">Drug use </td>
 653             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="1" <? echo (($fdata{'pih_drug'} == '1')?' checked ':''); ?>></td>
 654             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="0"  <? echo (($fdata{'pih_drug'} == '0')?' checked ':''); ?>></td>
 655             <td class="fibody2"><input name="sh_notes_3" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_3'}; ?>"></td>
 656           </tr>
 657           <tr align="left" valign="bottom">
 658             <td nowrap class="fibody2" id="bordR">seat belt use </td>
 659             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="1" <? echo (($fdata{'pih_seat_belt'} == '1')?' checked ':''); ?>></td>
 660             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="0"  <? echo (($fdata{'pih_seat_belt'} == '0')?' checked ':''); ?>></td>
 661             <td class="fibody2"><input name="sh_notes_4" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_4'}; ?>"></td>
 662           </tr>
 663           <tr align="left" valign="bottom">
 664             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
 665               <input name="sh_exercise_info" type="text" class="fullin"  style="width: 150px" value="<? echo $fdata{'sh_exercise_info'}; ?>"></td>
 666             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="1" <? echo (($fdata{'pih_exercise'} == '1')?' checked ':''); ?>></td>
 667             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="0"  <? echo (($fdata{'pih_exercise'} == '0')?' checked ':''); ?>></td>
 668             <td width="400" class="fibody2"><input name="sh_notes_5" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_5'}; ?>"></td>
 669           </tr>
 670           <tr align="left" valign="bottom">
 671             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
 672               <input name="sh_dairy_daily" type="text" class="fullin"  style="width: 40px" value="<? echo $fdata{'sh_dairy_daily'}; ?>"></td>
 673             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="1" <? echo (($fdata{'pih_dairy'} == '1')?' checked ':''); ?>></td>
 674             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="0"  <? echo (($fdata{'pih_dairy'} == '0')?' checked ':''); ?>></td>
 675             <td width="400" class="fibody2"><input name="sh_notes_6" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_6'}; ?>"></td>
 676           </tr>
 677           <tr align="left" valign="bottom">
 678             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
 679             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="1" <? echo (($fdata{'pih_hazards'} == '1')?' checked ':''); ?>></td>
 680             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="0"  <? echo (($fdata{'pih_hazards'} == '0')?' checked ':''); ?>></td>
 681             <td width="400" class="fibody2"><input name="sh_notes_7" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_7'}; ?>"></td>
 682           </tr>
 683           <tr align="left" valign="bottom">
 684             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
 685             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="1" <? echo (($fdata{'pih_abuse'} == '1')?' checked ':''); ?>></td>
 686             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="0"  <? echo (($fdata{'pih_abuse'} == '0')?' checked ':''); ?>></td>
 687             <td width="400" class="fibody2"><input name="sh_notes_8" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_8'}; ?>"></td>
 688           </tr>
 689           <tr align="left" valign="bottom">
 690             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
 691             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="1" <? echo (($fdata{'pih_living_will'} == '1')?' checked ':''); ?>></td>
 692             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="0"  <? echo (($fdata{'pih_living_will'} == '0')?' checked ':''); ?>></td>
 693             <td class="fibody2"><input name="sh_notes_9" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_9'}; ?>"></td>
 694           </tr>
 695           <tr align="left" valign="bottom">
 696             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
 697             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="1" <? echo (($fdata{'pih_donor'} == '1')?' checked ':''); ?>></td>
 698             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="0"  <? echo (($fdata{'pih_donor'} == '0')?' checked ':''); ?>></td>
 699             <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2"  value="<? echo $fdata{'sh_notes_10'}; ?>"></td>
 700           </tr>
 701         </table></td>
 702       </tr>
 703     </table>
 704   </div>
 705   <p align="center">&nbsp;</p>
 706   <h2 align="center"><a name="pp"></a>Personal profile <br>
 707   </h2>
 708   <div style="border: solid 2px black; background-color: white;">
 709     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 710       <tr>
 711         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
 712           <input name="pih_pp_orientation" type="radio" value="hetero"  <? echo (($fdata{'pih_pp_orientation'} == 'hetero')?' checked ':''); ?>>
 713         heterosexual
 714         <input name="pih_pp_orientation" type="radio" value="homo" <? echo (($fdata{'pih_pp_orientation'} == 'homo')?' checked ':''); ?>>
 715         homosexual
 716         <input name="pih_pp_orientation" type="radio" value="bi" <? echo (($fdata{'pih_pp_orientation'} == 'bi')?' checked ':''); ?>>
 717         bisexual </td>
 718       </tr>
 719       <tr>
 720         <td align="left" valign="bottom" class="fibody2">Marital status:
 721           <input name="pih_pp_status" type="radio" value="married" <? echo (($fdata{'pih_pp_status'} == 'married')?' checked ':''); ?>>
 722         married
 723         &nbsp;&nbsp;
 724         <input name="pih_pp_status" type="radio" value="partner" <? echo (($fdata{'pih_pp_status'} == 'partner')?' checked ':''); ?>>
 725         living with partner&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="single"  <? echo (($fdata{'pih_pp_status'} == 'single')?' checked ':''); ?>>
 726         single
 727         &nbsp;&nbsp;
 728         <input name="pih_pp_status" type="radio" value="widowed" <? echo (($fdata{'pih_pp_status'} == 'widowed')?' checked ':''); ?>>
 729         widowed&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="divorced" <? echo (($fdata{'pih_pp_status'} == 'divorced')?' checked ':''); ?>>
 730         divorced </td>
 731       </tr>
 732       <tr>
 733         <td align="left" valign="bottom" class="fibody2">Number of living children:
 734         <input name="pp_living_children" type="text" class="fullin"  style="width: 70px"  value="<? echo $fdata{'pp_living_children'}; ?>"></td>
 735       </tr>
 736       <tr>
 737         <td align="left" valign="bottom" class="fibody2">Number of people in household:
 738         <input name="pp_number_household" type="text" class="fullin"  style="width: 70px"  value="<? echo $fdata{'pp_number_household'}; ?>"></td>
 739       </tr>
 740       <tr>
 741         <td align="left" valign="bottom" class="fibody2">School completed:
 742           <input name="pih_pp_education" type="radio"  value="highschool" <? echo (($fdata{'pih_pp_education'} == 'highschool')?' checked ':''); ?>>
 743         high school
 744         <input name="pih_pp_education" type="radio"  value="aadegree" <? echo (($fdata{'pih_pp_education'} == 'aadegree')?' checked ':''); ?>>
 745         some college/AA degree
 746         <input name="pih_pp_education" type="radio"  value="college" <? echo (($fdata{'pih_pp_education'} == 'college')?' checked ':''); ?>>
 747         college
 748         <input name="pih_pp_education" type="radio"  value="gdegree" <? echo (($fdata{'pih_pp_education'} == 'gdegree')?' checked ':''); ?>>
 749         graduate degree
 750         <input name="pih_pp_education" type="radio"  value="other"  <? echo (($fdata{'pih_pp_education'} == 'other')?' checked ':''); ?>>
 751         other </td>
 752       </tr>
 753       <tr>
 754         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
 755         <input name="pp_current_job" type="text" class="fullin"  style="width: 77%"  value="<? echo $fdata{'pp_current_job'}; ?>"></td>
 756       </tr>
 757       <tr>
 758         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
 759           <input name="pp_travel_outside_us" type="radio" value="1" <? echo (($fdata{'pp_travel_outside_us'} == '1')?' checked ':''); ?>>
 760           yes
 761           <input name="pp_travel_outside_us" type="radio" value="0"  <? echo (($fdata{'pp_travel_outside_us'} == '0')?' checked ':''); ?>>
 762           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
 763           <input name="pp_travel_outside_locations" type="text" class="fullin"  style="width:50%" value="<? echo $fdata{'pp_travel_outside_locations'}; ?>">
 764         </span></td>
 765       </tr>
 766     </table>
 767   </div>
 768   <p align="center">&nbsp;</p>
 769   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
 770   </h2>
 771   <div style="border: solid 2px black; background-color: white;">
 772     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 773       <tr>
 774         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 775             <tr align="left" valign="bottom">
 776               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
 777               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
 778               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
 779               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
 780               <td align="center" class="ficaption2">Physician's notes </td>
 781             </tr>
 782             <tr align="left" valign="bottom">
 783               <td nowrap class="fibody2" id="bordR">Asthma</td>
 784               <td class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="1" <? echo (($fdata{'pih_ih_asthma'} == '1')?' checked ':''); ?>>
 785                   <input name="pih_ih_asthma_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_asthma_date'}; ?>"></td>
 786               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="0"  <? echo (($fdata{'pih_ih_asthma'} == '0')?' checked ':''); ?>></td>
 787               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="2" <? echo (($fdata{'pih_ih_asthma'} == '2')?' checked ':''); ?>></td>
 788               <td class="fibody2"><input name="ih_notes_1" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_1'}; ?>"></td>
 789             </tr>
 790             <tr align="left" valign="bottom">
 791               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
 792               <td class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="1" <? echo (($fdata{'pih_ih_pneumonia'} == '1')?' checked ':''); ?>>
 793                   <input name="pih_ih_pneumonia_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_pneumonia_date'}; ?>"></td>
 794               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="0"  <? echo (($fdata{'pih_ih_pneumonia'} == '0')?' checked ':''); ?>></td>
 795               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="2" <? echo (($fdata{'pih_ih_pneumonia'} == '2')?' checked ':''); ?>></td>
 796               <td class="fibody2"><input name="ih_notes_2" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_2'}; ?>"></td>
 797             </tr>
 798             <tr align="left" valign="bottom">
 799               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
 800               <td class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="1" <? echo (($fdata{'pih_ih_kidney'} == '1')?' checked ':''); ?>>
 801                   <input name="pih_ih_kidney_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_kidney_date'}; ?>"></td>
 802               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="0"  <? echo (($fdata{'pih_ih_kidney'} == '0')?' checked ':''); ?>></td>
 803               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="2" <? echo (($fdata{'pih_ih_kidney'} == '2')?' checked ':''); ?>></td>
 804               <td class="fibody2"><input name="ih_notes_3" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_3'}; ?>"></td>
 805             </tr>
 806             <tr align="left" valign="bottom">
 807               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
 808               <td class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="1" <? echo (($fdata{'pih_ih_tuber'} == '1')?' checked ':''); ?>>
 809                   <input name="pih_ih_tuber_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_tuber_date'}; ?>"></td>
 810               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="0"  <? echo (($fdata{'pih_ih_tuber'} == '0')?' checked ':''); ?>></td>
 811               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="2" <? echo (($fdata{'pih_ih_tuber'} == '2')?' checked ':''); ?>></td>
 812               <td class="fibody2"><input name="ih_notes_4" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_4'}; ?>"></td>
 813             </tr>
 814             <tr align="left" valign="bottom">
 815               <td nowrap class="fibody2" id="bordR">Fibroids</td>
 816               <td class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="1" <? echo (($fdata{'pih_ih_fibroids'} == '1')?' checked ':''); ?>>
 817                   <input name="pih_ih_fibroids_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_fibroids_date'}; ?>"></td>
 818               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="0"  <? echo (($fdata{'pih_ih_fibroids'} == '0')?' checked ':''); ?>></td>
 819               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="2" <? echo (($fdata{'pih_ih_fibroids'} == '2')?' checked ':''); ?>></td>
 820               <td class="fibody2"><input name="ih_notes_5" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_5'}; ?>"></td>
 821             </tr>
 822             <tr align="left" valign="bottom">
 823               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
 824               <td class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="1" <? echo (($fdata{'pih_ih_sexually'} == '1')?' checked ':''); ?>>
 825                   <input name="pih_ih_sexually_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_sexually_date'}; ?>"></td>
 826               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="0"  <? echo (($fdata{'pih_ih_sexually'} == '0')?' checked ':''); ?>></td>
 827               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="2" <? echo (($fdata{'pih_ih_sexually'} == '2')?' checked ':''); ?>></td>
 828               <td class="fibody2"><input name="ih_notes_6" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_6'}; ?>"></td>
 829             </tr>
 830             <tr align="left" valign="bottom">
 831               <td nowrap class="fibody2" id="bordR">Infertility</td>
 832               <td class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="1" <? echo (($fdata{'pih_ih_infertil'} == '1')?' checked ':''); ?>>
 833                   <input name="pih_ih_infertil_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_infertil_date'}; ?>"></td>
 834               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="0"  <? echo (($fdata{'pih_ih_infertil'} == '0')?' checked ':''); ?>></td>
 835               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="2" <? echo (($fdata{'pih_ih_infertil'} == '2')?' checked ':''); ?>></td>
 836               <td class="fibody2"><input name="ih_notes_7" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_7'}; ?>"></td>
 837             </tr>
 838             <tr align="left" valign="bottom">
 839               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
 840               <td class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="1" <? echo (($fdata{'pih_ih_hiv'} == '1')?' checked ':''); ?>>
 841                   <input name="pih_ih_hiv_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_hiv_date'}; ?>"></td>
 842               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="0"  <? echo (($fdata{'pih_ih_hiv'} == '0')?' checked ':''); ?>></td>
 843               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="2" <? echo (($fdata{'pih_ih_hiv'} == '2')?' checked ':''); ?>></td>
 844               <td class="fibody2"><input name="ih_notes_8" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_8'}; ?>"></td>
 845             </tr>
 846             <tr align="left" valign="bottom">
 847               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
 848               <td class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="1" <? echo (($fdata{'pih_ih_heart'} == '1')?' checked ':''); ?>>
 849                   <input name="pih_ih_heart_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_heart_date'}; ?>"></td>
 850               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="0"  <? echo (($fdata{'pih_ih_heart'} == '0')?' checked ':''); ?>></td>
 851               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="2" <? echo (($fdata{'pih_ih_heart'} == '2')?' checked ':''); ?>></td>
 852               <td class="fibody2"><input name="ih_notes_9" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_9'}; ?>"></td>
 853             </tr>
 854             <tr align="left" valign="bottom">
 855               <td nowrap class="fibody2" id="bordR">Diabetes</td>
 856               <td class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="1" <? echo (($fdata{'pih_ih_diabetes'} == '1')?' checked ':''); ?>>
 857                   <input name="pih_ih_diabetes_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_diabetes_date'}; ?>"></td>
 858               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="0"  <? echo (($fdata{'pih_ih_diabetes'} == '0')?' checked ':''); ?>></td>
 859               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="2" <? echo (($fdata{'pih_ih_diabetes'} == '2')?' checked ':''); ?>></td>
 860               <td class="fibody2"><input name="ih_notes_10" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_10'}; ?>"></td>
 861             </tr>
 862             <tr align="left" valign="bottom">
 863               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
 864               <td class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="1" <? echo (($fdata{'pih_ih_high_pressure'} == '1')?' checked ':''); ?>>
 865                   <input name="pih_ih_high_pressure_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_high_pressure_date'}; ?>"></td>
 866               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="0"  <? echo (($fdata{'pih_ih_high_pressure'} == '0')?' checked ':''); ?>></td>
 867               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="2" <? echo (($fdata{'pih_ih_high_pressure'} == '2')?' checked ':''); ?>></td>
 868               <td class="fibody2"><input name="ih_notes_11" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_11'}; ?>"></td>
 869             </tr>
 870             <tr align="left" valign="bottom">
 871               <td nowrap class="fibody2" id="bordR">Stroke</td>
 872               <td class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="1" <? echo (($fdata{'pih_ih_stroke'} == '1')?' checked ':''); ?>>
 873                   <input name="pih_ih_stroke_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_stroke_date'}; ?>"></td>
 874               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="0"  <? echo (($fdata{'pih_ih_stroke'} == '0')?' checked ':''); ?>></td>
 875               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="2" <? echo (($fdata{'pih_ih_stroke'} == '2')?' checked ':''); ?>></td>
 876               <td class="fibody2"><input name="ih_notes_12" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_12'}; ?>"></td>
 877             </tr>
 878             <tr align="left" valign="bottom">
 879               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
 880               <td class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="1" <? echo (($fdata{'pih_ih_rheumatic'} == '1')?' checked ':''); ?>>
 881                   <input name="pih_ih_rheumatic_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_rheumatic_date'}; ?>"></td>
 882               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="0"  <? echo (($fdata{'pih_ih_rheumatic'} == '0')?' checked ':''); ?>></td>
 883               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="2" <? echo (($fdata{'pih_ih_rheumatic'} == '2')?' checked ':''); ?>></td>
 884               <td class="fibody2"><input name="ih_notes_13" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_13'}; ?>"></td>
 885             </tr>
 886             <tr align="left" valign="bottom">
 887               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
 888               <td class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="1" <? echo (($fdata{'pih_ih_blood_clots'} == '1')?' checked ':''); ?>>
 889                   <input name="pih_ih_blood_clots_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_blood_clots_date'}; ?>"></td>
 890               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="0"  <? echo (($fdata{'pih_ih_blood_clots'} == '0')?' checked ':''); ?>></td>
 891               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="2" <? echo (($fdata{'pih_ih_blood_clots'} == '2')?' checked ':''); ?>></td>
 892               <td class="fibody2"><input name="ih_notes_14" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_14'}; ?>"></td>
 893             </tr>
 894             <tr align="left" valign="bottom">
 895               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
 896               <td class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="1" <? echo (($fdata{'pih_ih_eating_disorder'} == '1')?' checked ':''); ?>>
 897                   <input name="pih_ih_eating_disorder_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_eating_disorder_date'}; ?>"></td>
 898               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="0"  <? echo (($fdata{'pih_ih_eating_disorder'} == '0')?' checked ':''); ?>></td>
 899               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="2" <? echo (($fdata{'pih_ih_eating_disorder'} == '2')?' checked ':''); ?>></td>
 900               <td class="fibody2"><input name="ih_notes_15" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_15'}; ?>"></td>
 901             </tr>
 902             <tr align="left" valign="bottom">
 903               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
 904               <td class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="1" <? echo (($fdata{'pih_ih_autoimmune'} == '1')?' checked ':''); ?>>
 905                   <input name="pih_ih_autoimmune_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_autoimmune_date'}; ?>"></td>
 906               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="0"  <? echo (($fdata{'pih_ih_autoimmune'} == '0')?' checked ':''); ?>></td>
 907               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="2" <? echo (($fdata{'pih_ih_autoimmune'} == '2')?' checked ':''); ?>></td>
 908               <td class="fibody2"><input name="ih_notes_16" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_16'}; ?>"></td>
 909             </tr>
 910             <tr align="left" valign="bottom">
 911               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
 912               <td class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="1" <? echo (($fdata{'pih_ih_chickenpox'} == '1')?' checked ':''); ?>>
 913                   <input name="pih_ih_chickenpox_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_chickenpox_date'}; ?>"></td>
 914               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="0"  <? echo (($fdata{'pih_ih_chickenpox'} == '0')?' checked ':''); ?>></td>
 915               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="2" <? echo (($fdata{'pih_ih_chickenpox'} == '2')?' checked ':''); ?>></td>
 916               <td class="fibody2"><input name="ih_notes_17" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_17'}; ?>"></td>
 917             </tr>
 918             <tr align="left" valign="bottom">
 919               <td nowrap class="fibody2" id="bordR">Cancer</td>
 920               <td class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="1" <? echo (($fdata{'pih_ih_cancer'} == '1')?' checked ':''); ?>>
 921                   <input name="pih_ih_cancer_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_cancer_date'}; ?>"></td>
 922               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="0"  <? echo (($fdata{'pih_ih_cancer'} == '0')?' checked ':''); ?>></td>
 923               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="2" <? echo (($fdata{'pih_ih_cancer'} == '2')?' checked ':''); ?>></td>
 924               <td class="fibody2"><input name="ih_notes_18" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_18'}; ?>"></td>
 925             </tr>
 926             <tr align="left" valign="bottom">
 927               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
 928               <td class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="1" <? echo (($fdata{'pih_ih_reflux'} == '1')?' checked ':''); ?>>
 929                   <input name="pih_ih_reflux_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_reflux_date'}; ?>"></td>
 930               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="0"  <? echo (($fdata{'pih_ih_reflux'} == '0')?' checked ':''); ?>></td>
 931               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="2" <? echo (($fdata{'pih_ih_reflux'} == '2')?' checked ':''); ?>></td>
 932               <td class="fibody2"><input name="ih_notes_19" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_19'}; ?>"></td>
 933             </tr>
 934             <tr align="left" valign="bottom">
 935               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
 936               <td class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="1" <? echo (($fdata{'pih_ih_depression'} == '1')?' checked ':''); ?>>
 937                   <input name="pih_ih_depression_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_depression_date'}; ?>"></td>
 938               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="0"  <? echo (($fdata{'pih_ih_depression'} == '0')?' checked ':''); ?>></td>
 939               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="2" <? echo (($fdata{'pih_ih_depression'} == '2')?' checked ':''); ?>></td>
 940               <td class="fibody2"><input name="ih_notes_20" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_20'}; ?>"></td>
 941             </tr>
 942             <tr align="left" valign="bottom">
 943               <td nowrap class="fibody2" id="bordR">Anemia</td>
 944               <td class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="1" <? echo (($fdata{'pih_ih_anemia'} == '1')?' checked ':''); ?>>
 945                   <input name="pih_ih_anemia_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_anemia_date'}; ?>"></td>
 946               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="0"  <? echo (($fdata{'pih_ih_anemia'} == '0')?' checked ':''); ?>></td>
 947               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="2" <? echo (($fdata{'pih_ih_anemia'} == '2')?' checked ':''); ?>></td>
 948               <td class="fibody2"><input name="ih_notes_21" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_21'}; ?>"></td>
 949             </tr>
 950             <tr align="left" valign="bottom">
 951               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
 952               <td class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="1" <? echo (($fdata{'pih_ih_blood_transf'} == '1')?' checked ':''); ?>>
 953                   <input name="pih_ih_blood_transf_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_blood_transf_date'}; ?>"></td>
 954               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="0"  <? echo (($fdata{'pih_ih_blood_transf'} == '0')?' checked ':''); ?>></td>
 955               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="2" <? echo (($fdata{'pih_ih_blood_transf'} == '2')?' checked ':''); ?>></td>
 956               <td class="fibody2"><input name="ih_notes_22" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_22'}; ?>"></td>
 957             </tr>
 958             <tr align="left" valign="bottom">
 959               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
 960               <td class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="1" <? echo (($fdata{'pih_ih_seizures'} == '1')?' checked ':''); ?>>
 961                   <input name="pih_ih_seizures_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_seizures_date'}; ?>"></td>
 962               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="0"  <? echo (($fdata{'pih_ih_seizures'} == '0')?' checked ':''); ?>></td>
 963               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="2" <? echo (($fdata{'pih_ih_seizures'} == '2')?' checked ':''); ?>></td>
 964               <td class="fibody2"><input name="ih_notes_23" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_23'}; ?>"></td>
 965             </tr>
 966             <tr align="left" valign="bottom">
 967               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
 968               <td class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="1" <? echo (($fdata{'pih_ih_bowel_problems'} == '1')?' checked ':''); ?>>
 969                   <input name="pih_ih_bowel_problems_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_bowel_problems_date'}; ?>"></td>
 970               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="0"  <? echo (($fdata{'pih_ih_bowel_problems'} == '0')?' checked ':''); ?>></td>
 971               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="2" <? echo (($fdata{'pih_ih_bowel_problems'} == '2')?' checked ':''); ?>></td>
 972               <td class="fibody2"><input name="ih_notes_24" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_24'}; ?>"></td>
 973             </tr>
 974             <tr align="left" valign="bottom">
 975               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
 976               <td class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="1" <? echo (($fdata{'pih_ih_glaucoma'} == '1')?' checked ':''); ?>>
 977                   <input name="pih_ih_glaucoma_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_glaucoma_date'}; ?>"></td>
 978               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="0"  <? echo (($fdata{'pih_ih_glaucoma'} == '0')?' checked ':''); ?>></td>
 979               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="2" <? echo (($fdata{'pih_ih_glaucoma'} == '2')?' checked ':''); ?>></td>
 980               <td class="fibody2"><input name="ih_notes_25" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_25'}; ?>"></td>
 981             </tr>
 982             <tr align="left" valign="bottom">
 983               <td nowrap class="fibody2" id="bordR">Cataracts</td>
 984               <td class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="1" <? echo (($fdata{'pih_ih_cataracts'} == '1')?' checked ':''); ?>>
 985                   <input name="pih_ih_cataracts_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_cataracts_date'}; ?>"></td>
 986               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="0"  <? echo (($fdata{'pih_ih_cataracts'} == '0')?' checked ':''); ?>></td>
 987               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="2" <? echo (($fdata{'pih_ih_cataracts'} == '2')?' checked ':''); ?>></td>
 988               <td class="fibody2"><input name="ih_notes_26" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_26'}; ?>"></td>
 989             </tr>
 990             <tr align="left" valign="bottom">
 991               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
 992               <td class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="1" <? echo (($fdata{'pih_ih_joint_pain'} == '1')?' checked ':''); ?>>
 993                   <input name="pih_ih_joint_pain_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_joint_pain_date'}; ?>"></td>
 994               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="0"  <? echo (($fdata{'pih_ih_joint_pain'} == '0')?' checked ':''); ?>></td>
 995               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="2" <? echo (($fdata{'pih_ih_joint_pain'} == '2')?' checked ':''); ?>></td>
 996               <td class="fibody2"><input name="ih_notes_27" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_27'}; ?>"></td>
 997             </tr>
 998             <tr align="left" valign="bottom">
 999               <td nowrap class="fibody2" id="bordR">Broken bones </td>
1000               <td class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="1" <? echo (($fdata{'pih_ih_broken_bones'} == '1')?' checked ':''); ?>>
1001                   <input name="pih_ih_broken_bones_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_broken_bones_date'}; ?>"></td>
1002               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="0"  <? echo (($fdata{'pih_ih_broken_bones'} == '0')?' checked ':''); ?>></td>
1003               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="2" <? echo (($fdata{'pih_ih_broken_bones'} == '2')?' checked ':''); ?>></td>
1004               <td class="fibody2"><input name="ih_notes_28" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_28'}; ?>"></td>
1005             </tr>
1006             <tr align="left" valign="bottom">
1007               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
1008               <td class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="1" <? echo (($fdata{'pih_ih_hepatitis'} == '1')?' checked ':''); ?>>
1009                   <input name="pih_ih_hepatitis_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_hepatitis_date'}; ?>"></td>
1010               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="0"  <? echo (($fdata{'pih_ih_hepatitis'} == '0')?' checked ':''); ?>></td>
1011               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="2" <? echo (($fdata{'pih_ih_hepatitis'} == '2')?' checked ':''); ?>></td>
1012               <td class="fibody2"><input name="ih_notes_29" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_29'}; ?>"></td>
1013             </tr>
1014             <tr align="left" valign="bottom">
1015               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
1016               <td class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="1" <? echo (($fdata{'pih_ih_thyroid'} == '1')?' checked ':''); ?>>
1017                   <input name="pih_ih_thyroid_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_thyroid_date'}; ?>"></td>
1018               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="0"  <? echo (($fdata{'pih_ih_thyroid'} == '0')?' checked ':''); ?>></td>
1019               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="2" <? echo (($fdata{'pih_ih_thyroid'} == '2')?' checked ':''); ?>></td>
1020               <td class="fibody2"><input name="ih_notes_30" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_30'}; ?>"></td>
1021             </tr>
1022             <tr align="left" valign="bottom">
1023               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
1024               <td class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="1" <? echo (($fdata{'pih_ih_galibladder'} == '1')?' checked ':''); ?>>
1025                   <input name="pih_ih_galibladder_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_galibladder_date'}; ?>"></td>
1026               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="0"  <? echo (($fdata{'pih_ih_galibladder'} == '0')?' checked ':''); ?>></td>
1027               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="2" <? echo (($fdata{'pih_ih_galibladder'} == '2')?' checked ':''); ?>></td>
1028               <td class="fibody2"><input name="ih_notes_31" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_31'}; ?>"></td>
1029             </tr>
1030             <tr align="left" valign="bottom">
1031               <td nowrap class="fibody2" id="bordR">Headaches</td>
1032               <td class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="1" <? echo (($fdata{'pih_ih_headaches'} == '1')?' checked ':''); ?>>
1033                   <input name="pih_ih_headaches_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_headaches_date'}; ?>"></td>
1034               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="0"  <? echo (($fdata{'pih_ih_headaches'} == '0')?' checked ':''); ?>></td>
1035               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="2" <? echo (($fdata{'pih_ih_headaches'} == '2')?' checked ':''); ?>></td>
1036               <td class="fibody2"><input name="ih_notes_32" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_32'}; ?>"></td>
1037             </tr>
1038             <tr align="left" valign="bottom">
1039               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
1040               <td class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="1" <? echo (($fdata{'pih_ih_des'} == '1')?' checked ':''); ?>>
1041                   <input name="pih_ih_des_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_des_date'}; ?>"></td>
1042               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="0"  <? echo (($fdata{'pih_ih_des'} == '0')?' checked ':''); ?>></td>
1043               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="2" <? echo (($fdata{'pih_ih_des'} == '2')?' checked ':''); ?>></td>
1044               <td class="fibody2"><input name="ih_notes_33" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_33'}; ?>"></td>
1045             </tr>
1046             <tr align="left" valign="bottom">
1047               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
1048               <td class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="1" <? echo (($fdata{'pih_ih_bleeding_disorders'} == '1')?' checked ':''); ?>>
1049                   <input name="pih_ih_bleeding_disorders_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_bleeding_disorders_date'}; ?>"></td>
1050               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="0"  <? echo (($fdata{'pih_ih_bleeding_disorders'} == '0')?' checked ':''); ?>></td>
1051               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="2" <? echo (($fdata{'pih_ih_bleeding_disorders'} == '2')?' checked ':''); ?>></td>
1052               <td class="fibody2"><input name="ih_notes_34" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_34'}; ?>"></td>
1053             </tr>
1054             <tr align="left" valign="bottom">
1055               <td nowrap class="fibody2" id="bordR">other</td>
1056               <td class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="1" <? echo (($fdata{'pih_ih_other'} == '1')?' checked ':''); ?>>
1057                   <input name="pih_ih_other_date" type="text" class="fullin"  style="width: 70px" value="<? echo $fdata{'pih_ih_other_date'}; ?>"></td>
1058               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="0"  <? echo (($fdata{'pih_ih_other'} == '0')?' checked ':''); ?>></td>
1059               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="2" <? echo (($fdata{'pih_ih_other'} == '2')?' checked ':''); ?>></td>
1060               <td class="fibody2"><input name="ih_notes_35" type="text" class="fullin2"  value="<? echo $fdata{'ih_notes_35'}; ?>"></td>
1061             </tr>
1062             <tr align="left" valign="bottom">
1063               <td colspan="5" nowrap class="fibody3"><textarea name="pih_ih_extended_info" rows="4" wrap="VIRTUAL" class="fullin2" ><? echo $fdata{'pih_ih_extended_info'}; ?></textarea></td>
1064             </tr>
1065         </table></td>
1066       </tr>
1067     </table>
1068   </div>
1069   <p align="center">&nbsp;</p>
1070   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
1071   </h2>
1072   <div style="border: solid 2px black; background-color: white;">
1073     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1074       <tr>
1075         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
1076         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
1077         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
1078       </tr>
1079 <?
1080 $ii = 0;
1081 while ($ii<6){
1082 list ($op_reason, $op_date, $op_hospital)= explode('|~', $fdata["op_rec_".$ii] );
1083 print <<<EOL
1084       <tr>
1085         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_reason_${ii}" value="${op_reason}" type="text" class="fullin2"></td>
1086         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_date_${ii}" value="${op_date}" type="text" class="fullin2"></td>
1087         <td align="left" valign="bottom" class="fibody2"><input name="op_hospital_${ii}" value="${op_hospital}" type="text" class="fullin2"></td>
1088       </tr>
1089 EOL;
1090 $ii++;
1091 }
1092 ?>
1093     </table>
1094   </div>
1095   <p align="center">&nbsp;</p>
1096   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
1097   </h2>
1098   <div style="border: solid 2px black; background-color: white;">
1099     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1100       <tr valign="bottom">
1101         <td align="left" class="ficaption2" id="bordR">Type</td>
1102         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
1103         <td align="left" class="ficaption2" id="bordR">Type</td>
1104         <td width="90" align="center" nowrap class="ficaption2">date</td>
1105       </tr>
1106 <?
1107 $ii = 0;
1108 while ($ii<6){
1109 $ij = $ii+6;
1110 list ($ii_type, $ii_date)= explode('|~', $fdata["ii_rec_".$ii] );
1111 list ($ii_type1, $ii_date1)= explode('|~', $fdata["ii_rec_".$ij] );
1112
1113 print <<<EOL
1114    <tr valign="bottom">
1115      <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ii}" value="${ii_type}" type="text" class="fullin2"></td>
1116      <td align="left" nowrap class="fibody2" id="bordR"><input name="ii_date_${ii}" value="${ii_date}" type="text" class="fullin2"></td>
1117      <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ij}" value="${ii_type1}" type="text" class="fullin2"></td>
1118      <td align="left" nowrap class="fibody2"><input name="ii_date_${ij}" value="${ii_date1}" type="text" class="fullin2"></td>
1119    </tr>
1120 EOL;
1121 $ii++;
1122 }
1123 ?>
1124     </table>
1125   </div>
1126   <p align="center">&nbsp;</p>
1127   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
1128   </h2>
1129   <div style="border: solid 2px black; background-color: white;">
1130     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1131       <tr valign="bottom">
1132         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
1133         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
1134         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
1135         <td width="90" align="center" class="ficaption2">date</td>
1136       </tr>
1137       <tr valign="bottom">
1138         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
1139         <td align="left" nowrap class="fibody2" id="bordR">
1140           <input name="imm_tetanus" type="text" class="fullin2"  value="<? echo $fdata{'imm_tetanus'}; ?>">
1141         </td>
1142         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
1143         <td align="left" valign="bottom" nowrap class="fibody2">
1144           <input name="imm_influenza" type="text" class="fullin2"  value="<? echo $fdata{'imm_influenza'}; ?>">
1145         </td>
1146       </tr>
1147       <tr valign="bottom">
1148         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
1149         <td align="left" nowrap class="fibody2" id="bordR">
1150           <input name="imm_hepatitis_a" type="text" class="fullin2"  value="<? echo $fdata{'imm_hepatitis_a'}; ?>">
1151         </td>
1152         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
1153         <td align="left" valign="bottom" nowrap class="fibody2">
1154           <input name="imm_hepatitis_b" type="text" class="fullin2"  value="<? echo $fdata{'imm_hepatitis_b'}; ?>">
1155         </td>
1156       </tr>
1157       <tr valign="bottom">
1158         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
1159         <td align="left" nowrap class="fibody2" id="bordR">
1160           <input name="imm_varicella" type="text" class="fullin2"  value="<? echo $fdata{'imm_varicella'}; ?>">
1161         </td>
1162         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
1163         <td align="left" valign="bottom" nowrap class="fibody2">
1164           <input name="imm_pneumococcal" type="text" class="fullin2"  value="<? echo $fdata{'imm_pneumococcal'}; ?>">
1165         </td>
1166       </tr>
1167       <tr valign="bottom">
1168         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
1169         <td align="left" nowrap class="fibody2" id="bordR">
1170           <input name="imm_mmr" type="text" class="fullin2"  value="<? echo $fdata{'imm_mmr'}; ?>">
1171         </td>
1172         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
1173         <input name="imm_tuberculosis_skin" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'imm_tuberculosis_skin'}; ?>">
1174         , result:
1175         <input name="imm_tuberculosis_result" type="text" class="fullin"  style="width:40px" value="<? echo $fdata{'imm_tuberculosis_result'}; ?>"></td>
1176         <td align="left" valign="bottom" nowrap class="fibody2">
1177           <input name="imm_tuberculosis" type="text" class="fullin2"  value="<? echo $fdata{'imm_tuberculosis'}; ?>">
1178         </td>
1179       </tr>
1180     </table>
1181   </div>
1182   <p align="center">&nbsp;</p>
1183   <div style="border: solid 2px black; background-color: white;">
1184     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1185       <tr>
1186         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
1187         <textarea name="imm_extended_info" rows="6" wrap="VIRTUAL" class="fullin2" ><? echo $fdata{'imm_extended_info'}; ?></textarea></td>
1188       </tr>
1189     </table>
1190   </div>
1191   <p align="center">&nbsp;</p>
1192   <a name="ros">
1193   <h2 align="center"><a ></a>Review of systems<br>
1194     <small>Please check (x), if any of the following symptoms
1195 apply to you now or since adulthood</small> </h2>
1196   <div style="border: solid 2px black; background-color: white;">
1197     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1198       <tr>
1199         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
1200         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
1201         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
1202         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
1203         <td align="center" valign="top" class="ficaption2">physician's notes </td>
1204       </tr>
1205       <tr valign="bottom">
1206         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
1207         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1208         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1209         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1210         <td align="left" class="fibody2">&nbsp;</td>
1211       </tr>
1212       <tr valign="bottom">
1213         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
1214         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="1" <? echo (($fros{'ros_weight_loss_now'} == '1')?' checked ':''); ?>></td>
1215         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="2" <? echo (($fros{'ros_weight_loss_now'} == '2')?' checked ':''); ?>></td>
1216         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="3" <? echo (($fros{'ros_weight_loss_now'} == '3')?' checked ':''); ?>></td>
1217         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_1"   value="<? echo $fros{'ros_notes_1'}; ?>"></td>
1218       </tr>
1219       <tr valign="bottom">
1220         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
1221         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="1" <? echo (($fros{'ros_weight_gain_now'} == '1')?' checked ':''); ?>></td>
1222         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="2" <? echo (($fros{'ros_weight_gain_now'} == '2')?' checked ':''); ?>></td>
1223         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="3" <? echo (($fros{'ros_weight_gain_now'} == '3')?' checked ':''); ?>></td>
1224         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_2"   value="<? echo $fros{'ros_notes_2'}; ?>"></td>
1225       </tr>
1226       <tr valign="bottom">
1227         <td align="left" class="fibody4"  id="bordR" >Fever</td>
1228         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="1" <? echo (($fros{'ros_fever_now'} == '1')?' checked ':''); ?>></td>
1229         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="2" <? echo (($fros{'ros_fever_now'} == '2')?' checked ':''); ?>></td>
1230         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="3" <? echo (($fros{'ros_fever_now'} == '3')?' checked ':''); ?>></td>
1231         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_3"   value="<? echo $fros{'ros_notes_3'}; ?>"></td>
1232       </tr>
1233       <tr valign="bottom">
1234         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
1235         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="1" <? echo (($fros{'ros_fatigue_now'} == '1')?' checked ':''); ?>></td>
1236         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="2" <? echo (($fros{'ros_fatigue_now'} == '2')?' checked ':''); ?>></td>
1237         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="3" <? echo (($fros{'ros_fatigue_now'} == '3')?' checked ':''); ?>></td>
1238         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_4"   value="<? echo $fros{'ros_notes_4'}; ?>"></td>
1239       </tr>
1240       <tr valign="bottom">
1241         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
1242         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="1" <? echo (($fros{'ros_height_change_now'} == '1')?' checked ':''); ?>></td>
1243         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="2" <? echo (($fros{'ros_height_change_now'} == '2')?' checked ':''); ?>></td>
1244         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="3" <? echo (($fros{'ros_height_change_now'} == '3')?' checked ':''); ?>></td>
1245         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_5"   value="<? echo $fros{'ros_notes_5'}; ?>"></td>
1246       </tr>
1247       <tr valign="bottom">
1248         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
1249         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1250         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1251         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1252         <td align="left" class="fibody2">&nbsp;</td>
1253       </tr>
1254       <tr valign="bottom">
1255         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
1256         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="1" <? echo (($fros{'ros_dvision_now'} == '1')?' checked ':''); ?>></td>
1257         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="2" <? echo (($fros{'ros_dvision_now'} == '2')?' checked ':''); ?>></td>
1258         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="3" <? echo (($fros{'ros_dvision_now'} == '3')?' checked ':''); ?>></td>
1259         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_6"   value="<? echo $fros{'ros_notes_6'}; ?>"></td>
1260       </tr>
1261       <tr valign="bottom">
1262         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
1263         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="1" <? echo (($fros{'ros_spots_eyes_now'} == '1')?' checked ':''); ?>></td>
1264         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="2" <? echo (($fros{'ros_spots_eyes_now'} == '2')?' checked ':''); ?>></td>
1265         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="3" <? echo (($fros{'ros_spots_eyes_now'} == '3')?' checked ':''); ?>></td>
1266         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_7"   value="<? echo $fros{'ros_notes_7'}; ?>"></td>
1267       </tr>
1268       <tr valign="bottom">
1269         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
1270         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="1" <? echo (($fros{'ros_vis_changes_now'} == '1')?' checked ':''); ?>></td>
1271         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="2" <? echo (($fros{'ros_vis_changes_now'} == '2')?' checked ':''); ?>></td>
1272         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="3" <? echo (($fros{'ros_vis_changes_now'} == '3')?' checked ':''); ?>></td>
1273         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_8"   value="<? echo $fros{'ros_notes_8'}; ?>"></td>
1274       </tr>
1275       <tr valign="bottom">
1276         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
1277         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="1" <? echo (($fros{'ros_glasses_now'} == '1')?' checked ':''); ?>></td>
1278         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="2" <? echo (($fros{'ros_glasses_now'} == '2')?' checked ':''); ?>></td>
1279         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="3" <? echo (($fros{'ros_glasses_now'} == '3')?' checked ':''); ?>></td>
1280         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_9"   value="<? echo $fros{'ros_notes_9'}; ?>"></td>
1281       </tr>
1282       <tr valign="bottom">
1283         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
1284         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1285         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1286         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1287         <td align="left" class="fibody2">&nbsp;</td>
1288       </tr>
1289       <tr valign="bottom">
1290         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
1291         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="1" <? echo (($fros{'ros_earaches_now'} == '1')?' checked ':''); ?>></td>
1292         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="2" <? echo (($fros{'ros_earaches_now'} == '2')?' checked ':''); ?>></td>
1293         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="3" <? echo (($fros{'ros_earaches_now'} == '3')?' checked ':''); ?>></td>
1294         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_10"   value="<? echo $fros{'ros_notes_10'}; ?>"></td>
1295       </tr>
1296       <tr valign="bottom">
1297         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
1298         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="1" <? echo (($fros{'ros_ringing_now'} == '1')?' checked ':''); ?>></td>
1299         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="2" <? echo (($fros{'ros_ringing_now'} == '2')?' checked ':''); ?>></td>
1300         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="3" <? echo (($fros{'ros_ringing_now'} == '3')?' checked ':''); ?>></td>
1301         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_11"   value="<? echo $fros{'ros_notes_11'}; ?>"></td>
1302       </tr>
1303       <tr valign="bottom">
1304         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
1305         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="1" <? echo (($fros{'ros_hearing_problems_now'} == '1')?' checked ':''); ?>></td>
1306         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="2" <? echo (($fros{'ros_hearing_problems_now'} == '2')?' checked ':''); ?>></td>
1307         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="3" <? echo (($fros{'ros_hearing_problems_now'} == '3')?' checked ':''); ?>></td>
1308         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_12"   value="<? echo $fros{'ros_notes_12'}; ?>"></td>
1309       </tr>
1310       <tr valign="bottom">
1311         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
1312         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="1" <? echo (($fros{'ros_sinus_problems_now'} == '1')?' checked ':''); ?>></td>
1313         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="2" <? echo (($fros{'ros_sinus_problems_now'} == '2')?' checked ':''); ?>></td>
1314         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="3" <? echo (($fros{'ros_sinus_problems_now'} == '3')?' checked ':''); ?>></td>
1315         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_13"   value="<? echo $fros{'ros_notes_13'}; ?>"></td>
1316       </tr>
1317       <tr valign="bottom">
1318         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
1319         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="1" <? echo (($fros{'ros_sore_throat_now'} == '1')?' checked ':''); ?>></td>
1320         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="2" <? echo (($fros{'ros_sore_throat_now'} == '2')?' checked ':''); ?>></td>
1321         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="3" <? echo (($fros{'ros_sore_throat_now'} == '3')?' checked ':''); ?>></td>
1322         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_14"   value="<? echo $fros{'ros_notes_14'}; ?>"></td>
1323       </tr>
1324       <tr valign="bottom">
1325         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
1326         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="1" <? echo (($fros{'ros_mouth_sores_now'} == '1')?' checked ':''); ?>></td>
1327         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="2" <? echo (($fros{'ros_mouth_sores_now'} == '2')?' checked ':''); ?>></td>
1328         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="3" <? echo (($fros{'ros_mouth_sores_now'} == '3')?' checked ':''); ?>></td>
1329         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_15"   value="<? echo $fros{'ros_notes_15'}; ?>"></td>
1330       </tr>
1331       <tr valign="bottom">
1332         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
1333         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="1" <? echo (($fros{'ros_dental_problems_now'} == '1')?' checked ':''); ?>></td>
1334         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="2" <? echo (($fros{'ros_dental_problems_now'} == '2')?' checked ':''); ?>></td>
1335         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="3" <? echo (($fros{'ros_dental_problems_now'} == '3')?' checked ':''); ?>></td>
1336         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_16"   value="<? echo $fros{'ros_notes_16'}; ?>"></td>
1337       </tr>
1338       <tr valign="bottom">
1339         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
1340         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1341         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1342         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1343         <td align="left" class="fibody2">&nbsp;</td>
1344       </tr>
1345       <tr valign="bottom">
1346         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
1347         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="1" <? echo (($fros{'ros_chest_pain_now'} == '1')?' checked ':''); ?>></td>
1348         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="2" <? echo (($fros{'ros_chest_pain_now'} == '2')?' checked ':''); ?>></td>
1349         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="3" <? echo (($fros{'ros_chest_pain_now'} == '3')?' checked ':''); ?>></td>
1350         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_17"   value="<? echo $fros{'ros_notes_17'}; ?>"></td>
1351       </tr>
1352       <tr valign="bottom">
1353         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
1354         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="1" <? echo (($fros{'ros_difficulty_breathing_now'} == '1')?' checked ':''); ?>></td>
1355         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="2" <? echo (($fros{'ros_difficulty_breathing_now'} == '2')?' checked ':''); ?>></td>
1356         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="3" <? echo (($fros{'ros_difficulty_breathing_now'} == '3')?' checked ':''); ?>></td>
1357         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_18"   value="<? echo $fros{'ros_notes_18'}; ?>"></td>
1358       </tr>
1359       <tr valign="bottom">
1360         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
1361         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="1" <? echo (($fros{'ros_swelling_legs_now'} == '1')?' checked ':''); ?>></td>
1362         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="2" <? echo (($fros{'ros_swelling_legs_now'} == '2')?' checked ':''); ?>></td>
1363         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="3" <? echo (($fros{'ros_swelling_legs_now'} == '3')?' checked ':''); ?>></td>
1364         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_19"   value="<? echo $fros{'ros_notes_19'}; ?>"></td>
1365       </tr>
1366       <tr valign="bottom">
1367         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
1368         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="1" <? echo (($fros{'ros_rapid_heartbeat_now'} == '1')?' checked ':''); ?>></td>
1369         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="2" <? echo (($fros{'ros_rapid_heartbeat_now'} == '2')?' checked ':''); ?>></td>
1370         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="3" <? echo (($fros{'ros_rapid_heartbeat_now'} == '3')?' checked ':''); ?>></td>
1371         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_20"   value="<? echo $fros{'ros_notes_20'}; ?>"></td>
1372       </tr>
1373       <tr valign="bottom">
1374         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
1375         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1376         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1377         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1378         <td align="left" class="fibody2">&nbsp;</td>
1379       </tr>
1380       <tr valign="bottom">
1381         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
1382         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="1" <? echo (($fros{'ros_painful_breathing_now'} == '1')?' checked ':''); ?>></td>
1383         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="2" <? echo (($fros{'ros_painful_breathing_now'} == '2')?' checked ':''); ?>></td>
1384         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="3" <? echo (($fros{'ros_painful_breathing_now'} == '3')?' checked ':''); ?>></td>
1385         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_21"   value="<? echo $fros{'ros_notes_21'}; ?>"></td>
1386       </tr>
1387       <tr valign="bottom">
1388         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
1389         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="1" <? echo (($fros{'ros_wheezing_now'} == '1')?' checked ':''); ?>></td>
1390         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="2" <? echo (($fros{'ros_wheezing_now'} == '2')?' checked ':''); ?>></td>
1391         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="3" <? echo (($fros{'ros_wheezing_now'} == '3')?' checked ':''); ?>></td>
1392         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_22"   value="<? echo $fros{'ros_notes_22'}; ?>"></td>
1393       </tr>
1394       <tr valign="bottom">
1395         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
1396         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="1" <? echo (($fros{'ros_spitting_blood_now'} == '1')?' checked ':''); ?>></td>
1397         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="2" <? echo (($fros{'ros_spitting_blood_now'} == '2')?' checked ':''); ?>></td>
1398         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="3" <? echo (($fros{'ros_spitting_blood_now'} == '3')?' checked ':''); ?>></td>
1399         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_23"   value="<? echo $fros{'ros_notes_23'}; ?>"></td>
1400       </tr>
1401       <tr valign="bottom">
1402         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
1403         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="1" <? echo (($fros{'ros_breath_shortness_now'} == '1')?' checked ':''); ?>></td>
1404         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="2" <? echo (($fros{'ros_breath_shortness_now'} == '2')?' checked ':''); ?>></td>
1405         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="3" <? echo (($fros{'ros_breath_shortness_now'} == '3')?' checked ':''); ?>></td>
1406         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_24"   value="<? echo $fros{'ros_notes_24'}; ?>"></td>
1407       </tr>
1408       <tr valign="bottom">
1409         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
1410         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="1" <? echo (($fros{'ros_chronic_cough_now'} == '1')?' checked ':''); ?>></td>
1411         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="2" <? echo (($fros{'ros_chronic_cough_now'} == '2')?' checked ':''); ?>></td>
1412         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="3" <? echo (($fros{'ros_chronic_cough_now'} == '3')?' checked ':''); ?>></td>
1413         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_25"   value="<? echo $fros{'ros_notes_25'}; ?>"></td>
1414       </tr>
1415       <tr valign="bottom">
1416         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
1417         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1418         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1419         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1420         <td align="left" class="fibody2">&nbsp;</td>
1421       </tr>
1422       <tr valign="bottom">
1423         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
1424         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="1" <? echo (($fros{'ros_diarrhea_now'} == '1')?' checked ':''); ?>></td>
1425         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="2" <? echo (($fros{'ros_diarrhea_now'} == '2')?' checked ':''); ?>></td>
1426         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="3" <? echo (($fros{'ros_diarrhea_now'} == '3')?' checked ':''); ?>></td>
1427         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_26"   value="<? echo $fros{'ros_notes_26'}; ?>"></td>
1428       </tr>
1429       <tr valign="bottom">
1430         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
1431         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="1" <? echo (($fros{'ros_bloody_stool_now'} == '1')?' checked ':''); ?>></td>
1432         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="2" <? echo (($fros{'ros_bloody_stool_now'} == '2')?' checked ':''); ?>></td>
1433         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="3" <? echo (($fros{'ros_bloody_stool_now'} == '3')?' checked ':''); ?>></td>
1434         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_27"   value="<? echo $fros{'ros_notes_27'}; ?>"></td>
1435       </tr>
1436       <tr valign="bottom">
1437         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
1438         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="1" <? echo (($fros{'ros_nausea_now'} == '1')?' checked ':''); ?>></td>
1439         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="2" <? echo (($fros{'ros_nausea_now'} == '2')?' checked ':''); ?>></td>
1440         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="3" <? echo (($fros{'ros_nausea_now'} == '3')?' checked ':''); ?>></td>
1441         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_28"   value="<? echo $fros{'ros_notes_28'}; ?>"></td>
1442       </tr>
1443       <tr valign="bottom">
1444         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
1445         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="1" <? echo (($fros{'ros_constipation_now'} == '1')?' checked ':''); ?>></td>
1446         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="2" <? echo (($fros{'ros_constipation_now'} == '2')?' checked ':''); ?>></td>
1447         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="3" <? echo (($fros{'ros_constipation_now'} == '3')?' checked ':''); ?>></td>
1448         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_29"   value="<? echo $fros{'ros_notes_29'}; ?>"></td>
1449       </tr>
1450       <tr valign="bottom">
1451         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
1452         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="1" <? echo (($fros{'ros_gas_loss_now'} == '1')?' checked ':''); ?>></td>
1453         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="2" <? echo (($fros{'ros_gas_loss_now'} == '2')?' checked ':''); ?>></td>
1454         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="3" <? echo (($fros{'ros_gas_loss_now'} == '3')?' checked ':''); ?>></td>
1455         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_30"   value="<? echo $fros{'ros_notes_30'}; ?>"></td>
1456       </tr>
1457       <tr valign="bottom">
1458         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
1459         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1460         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1461         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1462         <td align="left" class="fibody2">&nbsp;</td>
1463       </tr>
1464       <tr valign="bottom">
1465         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
1466         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="1" <? echo (($fros{'ros_blood_urine_now'} == '1')?' checked ':''); ?>></td>
1467         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="2" <? echo (($fros{'ros_blood_urine_now'} == '2')?' checked ':''); ?>></td>
1468         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="3" <? echo (($fros{'ros_blood_urine_now'} == '3')?' checked ':''); ?>></td>
1469         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_31"   value="<? echo $fros{'ros_notes_31'}; ?>"></td>
1470       </tr>
1471       <tr valign="bottom">
1472         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
1473         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="1" <? echo (($fros{'ros_pain_urination_now'} == '1')?' checked ':''); ?>></td>
1474         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="2" <? echo (($fros{'ros_pain_urination_now'} == '2')?' checked ':''); ?>></td>
1475         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="3" <? echo (($fros{'ros_pain_urination_now'} == '3')?' checked ':''); ?>></td>
1476         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_32"   value="<? echo $fros{'ros_notes_32'}; ?>"></td>
1477       </tr>
1478       <tr valign="bottom">
1479         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
1480         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="1" <? echo (($fros{'ros_urgency_urinate_now'} == '1')?' checked ':''); ?>></td>
1481         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="2" <? echo (($fros{'ros_urgency_urinate_now'} == '2')?' checked ':''); ?>></td>
1482         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="3" <? echo (($fros{'ros_urgency_urinate_now'} == '3')?' checked ':''); ?>></td>
1483         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_33"   value="<? echo $fros{'ros_notes_33'}; ?>"></td>
1484       </tr>
1485       <tr valign="bottom">
1486         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
1487         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="1" <? echo (($fros{'ros_frequent_urination_now'} == '1')?' checked ':''); ?>></td>
1488         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="2" <? echo (($fros{'ros_frequent_urination_now'} == '2')?' checked ':''); ?>></td>
1489         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="3" <? echo (($fros{'ros_frequent_urination_now'} == '3')?' checked ':''); ?>></td>
1490         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_34"   value="<? echo $fros{'ros_notes_34'}; ?>"></td>
1491       </tr>
1492       <tr valign="bottom">
1493         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
1494         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="1" <? echo (($fros{'ros_incomplete_emptying_now'} == '1')?' checked ':''); ?>></td>
1495         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="2" <? echo (($fros{'ros_incomplete_emptying_now'} == '2')?' checked ':''); ?>></td>
1496         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="3" <? echo (($fros{'ros_incomplete_emptying_now'} == '3')?' checked ':''); ?>></td>
1497         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_35"   value="<? echo $fros{'ros_notes_35'}; ?>"></td>
1498       </tr>
1499       <tr valign="bottom">
1500         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
1501         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="1" <? echo (($fros{'ros_unint_urine_loss_now'} == '1')?' checked ':''); ?>></td>
1502         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="2" <? echo (($fros{'ros_unint_urine_loss_now'} == '2')?' checked ':''); ?>></td>
1503         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="3" <? echo (($fros{'ros_unint_urine_loss_now'} == '3')?' checked ':''); ?>></td>
1504         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_36"   value="<? echo $fros{'ros_notes_36'}; ?>"></td>
1505       </tr>
1506       <tr valign="bottom">
1507         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
1508         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="1" <? echo (($fros{'ros_lifting_urine_loss_now'} == '1')?' checked ':''); ?>></td>
1509         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="2" <? echo (($fros{'ros_lifting_urine_loss_now'} == '2')?' checked ':''); ?>></td>
1510         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="3" <? echo (($fros{'ros_lifting_urine_loss_now'} == '3')?' checked ':''); ?>></td>
1511         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_37"   value="<? echo $fros{'ros_notes_37'}; ?>"></td>
1512       </tr>
1513       <tr valign="bottom">
1514         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
1515         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="1" <? echo (($fros{'ros_abnormal_bleeding_now'} == '1')?' checked ':''); ?>></td>
1516         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="2" <? echo (($fros{'ros_abnormal_bleeding_now'} == '2')?' checked ':''); ?>></td>
1517         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="3" <? echo (($fros{'ros_abnormal_bleeding_now'} == '3')?' checked ':''); ?>></td>
1518         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_38"   value="<? echo $fros{'ros_notes_38'}; ?>"></td>
1519       </tr>
1520       <tr valign="bottom">
1521         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
1522         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="1" <? echo (($fros{'ros_painful_periods_now'} == '1')?' checked ':''); ?>></td>
1523         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="2" <? echo (($fros{'ros_painful_periods_now'} == '2')?' checked ':''); ?>></td>
1524         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="3" <? echo (($fros{'ros_painful_periods_now'} == '3')?' checked ':''); ?>></td>
1525         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_39"   value="<? echo $fros{'ros_notes_39'}; ?>"></td>
1526       </tr>
1527       <tr valign="bottom">
1528         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
1529         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="1" <? echo (($fros{'ros_pms_now'} == '1')?' checked ':''); ?>></td>
1530         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="2" <? echo (($fros{'ros_pms_now'} == '2')?' checked ':''); ?>></td>
1531         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="3" <? echo (($fros{'ros_pms_now'} == '3')?' checked ':''); ?>></td>
1532         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_40"   value="<? echo $fros{'ros_notes_40'}; ?>"></td>
1533       </tr>
1534       <tr valign="bottom">
1535         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
1536         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="1" <? echo (($fros{'ros_painful_intercourse_now'} == '1')?' checked ':''); ?>></td>
1537         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="2" <? echo (($fros{'ros_painful_intercourse_now'} == '2')?' checked ':''); ?>></td>
1538         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="3" <? echo (($fros{'ros_painful_intercourse_now'} == '3')?' checked ':''); ?>></td>
1539         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_41"   value="<? echo $fros{'ros_notes_41'}; ?>"></td>
1540       </tr>
1541       <tr valign="bottom">
1542         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
1543         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="1" <? echo (($fros{'ros_vaginal_discharge_now'} == '1')?' checked ':''); ?>></td>
1544         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="2" <? echo (($fros{'ros_vaginal_discharge_now'} == '2')?' checked ':''); ?>></td>
1545         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="3" <? echo (($fros{'ros_vaginal_discharge_now'} == '3')?' checked ':''); ?>></td>
1546         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_42"   value="<? echo $fros{'ros_notes_42'}; ?>"></td>
1547       </tr>
1548       <tr valign="bottom">
1549         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
1550         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1551         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1552         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1553         <td align="left" class="fibody2">&nbsp;</td>
1554       </tr>
1555       <tr valign="bottom">
1556         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
1557         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="1" <? echo (($fros{'ros_muscle_weakness_now'} == '1')?' checked ':''); ?>></td>
1558         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="2" <? echo (($fros{'ros_muscle_weakness_now'} == '2')?' checked ':''); ?>></td>
1559         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="3" <? echo (($fros{'ros_muscle_weakness_now'} == '3')?' checked ':''); ?>></td>
1560         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_43"   value="<? echo $fros{'ros_notes_43'}; ?>"></td>
1561       </tr>
1562       <tr valign="bottom">
1563         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
1564         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="1" <? echo (($fros{'ros_muscle_pain_now'} == '1')?' checked ':''); ?>></td>
1565         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="2" <? echo (($fros{'ros_muscle_pain_now'} == '2')?' checked ':''); ?>></td>
1566         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="3" <? echo (($fros{'ros_muscle_pain_now'} == '3')?' checked ':''); ?>></td>
1567         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_44"   value="<? echo $fros{'ros_notes_44'}; ?>"></td>
1568       </tr>
1569       <tr valign="bottom">
1570         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
1571         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1572         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1573         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1574         <td align="left" class="fibody2">&nbsp;</td>
1575       </tr>
1576       <tr valign="bottom">
1577         <td align="left" class="fibody4"  id="bordR" >Rash</td>
1578         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="1" <? echo (($fros{'ros_rash_now'} == '1')?' checked ':''); ?>></td>
1579         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="2" <? echo (($fros{'ros_rash_now'} == '2')?' checked ':''); ?>></td>
1580         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="3" <? echo (($fros{'ros_rash_now'} == '3')?' checked ':''); ?>></td>
1581         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_45"   value="<? echo $fros{'ros_notes_45'}; ?>"></td>
1582       </tr>
1583       <tr valign="bottom">
1584         <td align="left" class="fibody4"  id="bordR" >Sores</td>
1585         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="1" <? echo (($fros{'ros_sores_now'} == '1')?' checked ':''); ?>></td>
1586         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="2" <? echo (($fros{'ros_sores_now'} == '2')?' checked ':''); ?>></td>
1587         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="3" <? echo (($fros{'ros_sores_now'} == '3')?' checked ':''); ?>></td>
1588         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_46"   value="<? echo $fros{'ros_notes_46'}; ?>"></td>
1589       </tr>
1590       <tr valign="bottom">
1591         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
1592         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="1" <? echo (($fros{'ros_dry_skin_now'} == '1')?' checked ':''); ?>></td>
1593         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="2" <? echo (($fros{'ros_dry_skin_now'} == '2')?' checked ':''); ?>></td>
1594         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="3" <? echo (($fros{'ros_dry_skin_now'} == '3')?' checked ':''); ?>></td>
1595         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_47"   value="<? echo $fros{'ros_notes_47'}; ?>"></td>
1596       </tr>
1597       <tr valign="bottom">
1598         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
1599         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="1" <? echo (($fros{'ros_moles_now'} == '1')?' checked ':''); ?>></td>
1600         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="2" <? echo (($fros{'ros_moles_now'} == '2')?' checked ':''); ?>></td>
1601         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="3" <? echo (($fros{'ros_moles_now'} == '3')?' checked ':''); ?>></td>
1602         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_48"   value="<? echo $fros{'ros_notes_48'}; ?>"></td>
1603       </tr>
1604       <tr valign="bottom">
1605         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
1606         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1607         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1608         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1609         <td align="left" class="fibody2">&nbsp;</td>
1610       </tr>
1611       <tr valign="bottom">
1612         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
1613         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="1" <? echo (($fros{'ros_pain_breast_now'} == '1')?' checked ':''); ?>></td>
1614         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="2" <? echo (($fros{'ros_pain_breast_now'} == '2')?' checked ':''); ?>></td>
1615         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="3" <? echo (($fros{'ros_pain_breast_now'} == '3')?' checked ':''); ?>></td>
1616         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_49"   value="<? echo $fros{'ros_notes_49'}; ?>"></td>
1617       </tr>
1618       <tr valign="bottom">
1619         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
1620         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="1" <? echo (($fros{'ros_nipple_discharge_now'} == '1')?' checked ':''); ?>></td>
1621         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="2" <? echo (($fros{'ros_nipple_discharge_now'} == '2')?' checked ':''); ?>></td>
1622         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="3" <? echo (($fros{'ros_nipple_discharge_now'} == '3')?' checked ':''); ?>></td>
1623         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_50"   value="<? echo $fros{'ros_notes_50'}; ?>"></td>
1624       </tr>
1625       <tr valign="bottom">
1626         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
1627         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="1" <? echo (($fros{'ros_lumps_now'} == '1')?' checked ':''); ?>></td>
1628         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="2" <? echo (($fros{'ros_lumps_now'} == '2')?' checked ':''); ?>></td>
1629         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="3" <? echo (($fros{'ros_lumps_now'} == '3')?' checked ':''); ?>></td>
1630         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_51"   value="<? echo $fros{'ros_notes_51'}; ?>"></td>
1631       </tr>
1632       <tr valign="bottom">
1633         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
1634         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1635         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1636         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1637         <td align="left" class="fibody2">&nbsp;</td>
1638       </tr>
1639       <tr valign="bottom">
1640         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
1641         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="1" <? echo (($fros{'ros_dizziness_now'} == '1')?' checked ':''); ?>></td>
1642         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="2" <? echo (($fros{'ros_dizziness_now'} == '2')?' checked ':''); ?>></td>
1643         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="3" <? echo (($fros{'ros_dizziness_now'} == '3')?' checked ':''); ?>></td>
1644         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_52"   value="<? echo $fros{'ros_notes_52'}; ?>"></td>
1645       </tr>
1646       <tr valign="bottom">
1647         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
1648         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="1" <? echo (($fros{'ros_seizures_now'} == '1')?' checked ':''); ?>></td>
1649         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="2" <? echo (($fros{'ros_seizures_now'} == '2')?' checked ':''); ?>></td>
1650         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="3" <? echo (($fros{'ros_seizures_now'} == '3')?' checked ':''); ?>></td>
1651         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_53"   value="<? echo $fros{'ros_notes_53'}; ?>"></td>
1652       </tr>
1653       <tr valign="bottom">
1654         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
1655         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="1" <? echo (($fros{'ros_numbness_now'} == '1')?' checked ':''); ?>></td>
1656         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="2" <? echo (($fros{'ros_numbness_now'} == '2')?' checked ':''); ?>></td>
1657         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="3" <? echo (($fros{'ros_numbness_now'} == '3')?' checked ':''); ?>></td>
1658         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_54"   value="<? echo $fros{'ros_notes_54'}; ?>"></td>
1659       </tr>
1660       <tr valign="bottom">
1661         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
1662         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="1" <? echo (($fros{'ros_trouble_walking_now'} == '1')?' checked ':''); ?>></td>
1663         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="2" <? echo (($fros{'ros_trouble_walking_now'} == '2')?' checked ':''); ?>></td>
1664         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="3" <? echo (($fros{'ros_trouble_walking_now'} == '3')?' checked ':''); ?>></td>
1665         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_55"   value="<? echo $fros{'ros_notes_55'}; ?>"></td>
1666       </tr>
1667       <tr valign="bottom">
1668         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
1669         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="1" <? echo (($fros{'ros_memory_problems_now'} == '1')?' checked ':''); ?>></td>
1670         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="2" <? echo (($fros{'ros_memory_problems_now'} == '2')?' checked ':''); ?>></td>
1671         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="3" <? echo (($fros{'ros_memory_problems_now'} == '3')?' checked ':''); ?>></td>
1672         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_56"   value="<? echo $fros{'ros_notes_56'}; ?>"></td>
1673       </tr>
1674       <tr valign="bottom">
1675         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
1676         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="1" <? echo (($fros{'ros_freq_headaches_now'} == '1')?' checked ':''); ?>></td>
1677         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="2" <? echo (($fros{'ros_freq_headaches_now'} == '2')?' checked ':''); ?>></td>
1678         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="3" <? echo (($fros{'ros_freq_headaches_now'} == '3')?' checked ':''); ?>></td>
1679         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_57"   value="<? echo $fros{'ros_notes_57'}; ?>"></td>
1680       </tr>
1681       <tr valign="bottom">
1682         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
1683         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1684         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1685         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1686         <td align="left" class="fibody2">&nbsp;</td>
1687       </tr>
1688       <tr valign="bottom">
1689         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
1690         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="1" <? echo (($fros{'ros_depression_now'} == '1')?' checked ':''); ?>></td>
1691         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="2" <? echo (($fros{'ros_depression_now'} == '2')?' checked ':''); ?>></td>
1692         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="3" <? echo (($fros{'ros_depression_now'} == '3')?' checked ':''); ?>></td>
1693         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_58"   value="<? echo $fros{'ros_notes_58'}; ?>"></td>
1694       </tr>
1695       <tr valign="bottom">
1696         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
1697         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="1" <? echo (($fros{'ros_anxiety_now'} == '1')?' checked ':''); ?>></td>
1698         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="2" <? echo (($fros{'ros_anxiety_now'} == '2')?' checked ':''); ?>></td>
1699         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="3" <? echo (($fros{'ros_anxiety_now'} == '3')?' checked ':''); ?>></td>
1700         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_59"   value="<? echo $fros{'ros_notes_59'}; ?>"></td>
1701       </tr>
1702       <tr valign="bottom">
1703         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
1704         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1705         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1706         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1707         <td align="left" class="fibody2">&nbsp;</td>
1708       </tr>
1709       <tr valign="bottom">
1710         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
1711         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="1" <? echo (($fros{'ros_hair_loss_now'} == '1')?' checked ':''); ?>></td>
1712         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="2" <? echo (($fros{'ros_hair_loss_now'} == '2')?' checked ':''); ?>></td>
1713         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="3" <? echo (($fros{'ros_hair_loss_now'} == '3')?' checked ':''); ?>></td>
1714         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_60"   value="<? echo $fros{'ros_notes_60'}; ?>"></td>
1715       </tr>
1716       <tr valign="bottom">
1717         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
1718         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="1" <? echo (($fros{'ros_heat_cold_intolerance_now'} == '1')?' checked ':''); ?>></td>
1719         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="2" <? echo (($fros{'ros_heat_cold_intolerance_now'} == '2')?' checked ':''); ?>></td>
1720         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="3" <? echo (($fros{'ros_heat_cold_intolerance_now'} == '3')?' checked ':''); ?>></td>
1721         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_61"   value="<? echo $fros{'ros_notes_61'}; ?>"></td>
1722       </tr>
1723       <tr valign="bottom">
1724         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
1725         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="1" <? echo (($fros{'ros_abnormal_thirst_now'} == '1')?' checked ':''); ?>></td>
1726         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="2" <? echo (($fros{'ros_abnormal_thirst_now'} == '2')?' checked ':''); ?>></td>
1727         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="3" <? echo (($fros{'ros_abnormal_thirst_now'} == '3')?' checked ':''); ?>></td>
1728         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_62"   value="<? echo $fros{'ros_notes_62'}; ?>"></td>
1729       </tr>
1730       <tr valign="bottom">
1731         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
1732         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="1" <? echo (($fros{'ros_hot_flashes_now'} == '1')?' checked ':''); ?>></td>
1733         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="2" <? echo (($fros{'ros_hot_flashes_now'} == '2')?' checked ':''); ?>></td>
1734         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="3" <? echo (($fros{'ros_hot_flashes_now'} == '3')?' checked ':''); ?>></td>
1735         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_63"   value="<? echo $fros{'ros_notes_63'}; ?>"></td>
1736       </tr>
1737       <tr valign="bottom">
1738         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
1739         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1740         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1741         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1742         <td align="left" class="fibody2">&nbsp;</td>
1743       </tr>
1744       <tr valign="bottom">
1745         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
1746         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="1" <? echo (($fros{'ros_frequent_bruises_now'} == '1')?' checked ':''); ?>></td>
1747         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="2" <? echo (($fros{'ros_frequent_bruises_now'} == '2')?' checked ':''); ?>></td>
1748         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="3" <? echo (($fros{'ros_frequent_bruises_now'} == '3')?' checked ':''); ?>></td>
1749         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_64"   value="<? echo $fros{'ros_notes_64'}; ?>"></td>
1750       </tr>
1751       <tr valign="bottom">
1752         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
1753         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="1" <? echo (($fros{'ros_cuts_bleeding_now'} == '1')?' checked ':''); ?>></td>
1754         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="2" <? echo (($fros{'ros_cuts_bleeding_now'} == '2')?' checked ':''); ?>></td>
1755         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="3" <? echo (($fros{'ros_cuts_bleeding_now'} == '3')?' checked ':''); ?>></td>
1756         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_65"   value="<? echo $fros{'ros_notes_65'}; ?>"></td>
1757       </tr>
1758       <tr valign="bottom">
1759         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
1760         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="1" <? echo (($fros{'ros_enlarged_nodes_now'} == '1')?' checked ':''); ?>></td>
1761         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="2" <? echo (($fros{'ros_enlarged_nodes_now'} == '2')?' checked ':''); ?>></td>
1762         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="3" <? echo (($fros{'ros_enlarged_nodes_now'} == '3')?' checked ':''); ?>></td>
1763         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_66"   value="<? echo $fros{'ros_notes_66'}; ?>"></td>
1764       </tr>
1765       <tr valign="bottom">
1766         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
1767         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1768         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1769         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
1770         <td align="left" class="fibody2">&nbsp;</td>
1771       </tr>
1772       <tr valign="bottom">
1773         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
1774         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="1" <? echo (($fros{'ros_med_allergy_now'} == '1')?' checked ':''); ?>></td>
1775         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="2" <? echo (($fros{'ros_med_allergy_now'} == '2')?' checked ':''); ?>></td>
1776         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="3" <? echo (($fros{'ros_med_allergy_now'} == '3')?' checked ':''); ?>></td>
1777         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_68"   value="<? echo $fros{'ros_notes_68'}; ?>"></td>
1778       </tr>
1779       <tr valign="bottom">
1780         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
1781         <td colspan="4" align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_med_allergy_reaction"   value="<? echo $fros{'ros_med_allergy_reaction'}; ?>"></td>
1782       </tr>
1783       <tr valign="bottom">
1784         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
1785         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="1" <? echo (($fros{'ros_latex_allergy_now'} == '1')?' checked ':''); ?>></td>
1786         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="2" <? echo (($fros{'ros_latex_allergy_now'} == '2')?' checked ':''); ?>></td>
1787         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="3" <? echo (($fros{'ros_latex_allergy_now'} == '3')?' checked ':''); ?>></td>
1788         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_69"   value="<? echo $fros{'ros_notes_69'}; ?>"></td>
1789       </tr>
1790       <tr valign="bottom">
1791         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
1792         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="1" <? echo (($fros{'ros_other_allergy_now'} == '1')?' checked ':''); ?>></td>
1793         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="2" <? echo (($fros{'ros_other_allergy_now'} == '2')?' checked ':''); ?>></td>
1794         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="3" <? echo (($fros{'ros_other_allergy_now'} == '3')?' checked ':''); ?>></td>
1795         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_70"   value="<? echo $fros{'ros_notes_70'}; ?>"></td>
1796       </tr>
1797       <tr valign="bottom">
1798         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
1799         <td colspan="4" align="left" class="fibody2"><input type="text" class="fullin2"   name="ros_other_allergy_reaction_"   value="<? echo $fros{'ros_other_allergy_reaction_'}; ?>"></td>
1800       </tr>
1801     </table>
1802   </div>
1803   <p align="center">&nbsp;</p>
1804   <div style="border: solid 2px black; background-color: white;">
1805     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1806       <tr valign="bottom">
1807         <td colspan="2" align="left" class="fibody2">Form completed by
1808           <input name="pih_completed_by" type="radio" value="patient"  <? echo (($fdata{'pih_completed_by'} == 'patient')?' checked ':''); ?>>
1809         patient
1810         <input name="pih_completed_by" type="radio" value="nurse" <? echo (($fdata{'pih_completed_by'} == 'nurse')?' checked ':''); ?>>
1811         office nurse
1812        <input name="pih_completed_by" type="radio" value="physician" <? echo (($fdata{'pih_completed_by'} == 'physician')?' checked ':''); ?>>
1813         physician
1814         <input name="pih_completed_by" type="radio" value="other" <? echo (($fdata{'pih_completed_by'} == 'other')?' checked ':''); ?>>
1815         other:
1816         <input name="pih_completed_by_other" type="text" class="fullin"  style="width: 40%" value="<? echo $fdata{'pih_completed_by_other'}; ?>"></td>
1817       </tr>
1818       <tr valign="bottom">
1819         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
1820       </tr>
1821       <tr valign="bottom">
1822         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
1823         <input name="pih_date_reviewed_1" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_1'}; ?>"></td>
1824         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
1825       </tr>
1826       <tr valign="bottom">
1827         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
1828       </tr>
1829       <tr valign="bottom">
1830         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1831           <input name="pih_date_reviewed_2" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_2'}; ?>">
1832         </span></td>
1833         <td height="46" align="left" class="fibody2">Physician signature: </td>
1834       </tr>
1835       <tr valign="bottom">
1836         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1837           <input name="pih_date_reviewed_3" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_3'}; ?>">
1838         </span> </td>
1839         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1840       </tr>
1841       <tr valign="bottom">
1842         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1843           <input name="pih_date_reviewed_4" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_4'}; ?>">
1844         </span> </td>
1845         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1846       </tr>
1847       <tr valign="bottom">
1848         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1849           <input name="pih_date_reviewed_5" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_5'}; ?>">
1850         </span> </td>
1851         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1852       </tr>
1853       <tr valign="bottom">
1854         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
1855           <input name="pih_date_reviewed_6" type="text" class="fullin"  style="width:70px" value="<? echo $fdata{'pih_date_reviewed_6'}; ?>">
1856         </span> </td>
1857         <td height="46" align="left" class="fibody2">Physician signature:  </td>
1858       </tr>
1859     </table>
1860   </div>
1861   <p align="center">&nbsp;</p>
1862 <table width="100%" border="0">
1863   <tr><td align="left" width="120"> <a href="javascript:document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
1864   <td align="left" nowrap> <a href="<? echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<? echo $id; ?>&formname=<? echo $formname; ?>" target="_blank" class="link_submit">[Printable form]</a> </td>
1865   <td align="right"> <a href="<?echo "$rootdir/patient_file/encounter/patient_encounter.php";?>" class="link_submit">[Don't Save]</a> </td></tr>
1866 </table>
1867 </form>
1868 <?php
1869 formFooter();
1870 ?>
1871 </body>
1872 </html>