interface/forms/reviewofs/view.php

   1 <?php
   2
   3 /**
   4  * Review of Systems Checks form
   5  *
   6  * @package   OpenEMR
   7  * @link      http://www.open-emr.org
   8  * @author    cfapress <cfapress>
   9  * @author    Brady Miller <brady.g.miller@gmail.com>
  10  * @author    Robert Down <robertdown@live.com>
  11  * @copyright Copyright (c) 2008 cfapress <cfapress>
  12  * @copyright Copyright (c) 2016-2019 Brady Miller <brady.g.miller@gmail.com>
  13  * @copyright Copyright (c) 2017-2023 Robert Down <robertdown@live.com>
  14  * @license   https://github.com/openemr/openemr/blob/master/LICENSE GNU General Public License 3
  15  */
  16
  17 require_once(__DIR__ . "/../../globals.php");
  18 require_once("$srcdir/api.inc.php");
  19
  20 use OpenEMR\Common\Csrf\CsrfUtils;
  21 use OpenEMR\Core\Header;
  22
  23 $returnurl = 'encounter_top.php';
  24 ?>
  25 <html>
  26 <head>
  27     <title><?php echo xlt("Review of Systems Checks"); ?></title>
  28
  29     <?php Header::setupHeader();?>
  30 </head>
  31 <?php
  32 $obj = formFetch("form_reviewofs", $_GET["id"]);
  33 ?>
  34 <body class="body_top">
  35     <div class="container">
  36         <div class="row">
  37             <div class="col-12">
  38                 <h2><?php echo xlt("Review of Systems Checks");?></h2>
  39             </div>
  40         </div>
  41         <div class="row">
  42             <form method=post action="<?php echo $rootdir; ?>/forms/reviewofs/save.php?mode=update&id=<?php echo attr_url($_GET["id"]); ?>" name="my_form" onsubmit="return top.restoreSession()">
  43                 <input type="hidden" name="csrf_token_form" value="<?php echo attr(CsrfUtils::collectCsrfToken()); ?>" />
  44                 <fieldset>
  45                     <legend><?php echo xlt('General')?></legend>
  46                     <div class="row">
  47                         <div class="col-12">
  48                             <div class="col-sm-3">
  49                                 <div class="form-group">
  50                                     <div class="checkbox">
  51                                         <label>
  52                                             <input type="checkbox" name="fever" <?php echo ($obj["fever"] == "on") ? "checked" : ""; ?>><?php echo xlt('Fever');?>
  53                                         </label>
  54                                     </div>
  55                                     <div class="checkbox">
  56                                         <label>
  57                                             <input type="checkbox" name="chills" <?php echo ($obj["chills"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chills');?>
  58                                         </label>
  59                                     </div>
  60                                     <div class="checkbox">
  61                                         <label>
  62                                             <input type="checkbox" name="night_sweats" <?php echo ($obj["night_sweats"] == "on") ? "checked" : ""; ?>><?php echo xlt('Night Sweats');?>
  63                                         </label>
  64                                     </div>
  65                                 </div>
  66                             </div>
  67                             <div class="col-sm-3">
  68                                 <div class="form-group">
  69                                     <div class="checkbox">
  70                                         <label>
  71                                             <input type="checkbox" name="weight_loss" <?php echo ($obj["weight_loss"] == "on") ? "checked" : ""; ?>><?php echo xlt('Weight Loss');?>
  72                                         </label>
  73                                     </div>
  74                                     <div class="checkbox">
  75                                         <label>
  76                                             <input type="checkbox" name="poor_appetite" <?php echo ($obj["poor_appetite"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Appetite');?>
  77                                         </label>
  78                                     </div>
  79                                     <div class="checkbox">
  80                                         <label>
  81                                             <input type="checkbox" name="insomnia" <?php echo ($obj["insomnia"] == "on") ? "checked" : ""; ?>><?php echo xlt('Insomnia');?>
  82                                         </label>
  83                                     </div>
  84                                 </div>
  85                             </div>
  86                             <div class="col-sm-3">
  87                                 <div class="form-group">
  88                                     <div class="checkbox">
  89                                         <label>
  90                                             <input type="checkbox" name="fatigued" <?php echo ($obj["fatigued"] == "on") ? "checked" : ""; ?>><?php echo xlt('Fatigued');?>
  91                                         </label>
  92                                     </div>
  93                                     <div class="checkbox">
  94                                         <label>
  95                                             <input type="checkbox" name="depressed" <?php echo ($obj["depressed"] == "on") ? "checked" : ""; ?>><?php echo xlt('Depressed');?>
  96                                         </label>
  97                                     </div>
  98                                 </div>
  99                             </div>
 100                             <div class="col-sm-3">
 101                                 <div class="form-group">
 102                                     <div class="checkbox">
 103                                         <label>
 104                                             <input type="checkbox" name="hyperactive" <?php echo ($obj["hyperactive"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hyperactive');?>
 105                                         </label>
 106                                     </div>
 107                                     <div class="checkbox">
 108                                         <label>
 109                                             <input type="checkbox" name="exposure_to_foreign_countries" <?php echo ($obj["exposure_to_foreign_countries"] == "on") ? "checked" : ""; ?>><?php echo xlt('Exposure to Foreign Countries');?>
 110                                         </label>
 111                                     </div>
 112                                 </div>
 113                             </div>
 114                         </div>
 115                     </div>
 116                 </fieldset>
 117                 <fieldset>
 118                     <legend><?php echo xlt('Skin')?></legend>
 119                     <div class="row">
 120                         <div class="col-12">
 121                             <div class="col-sm-3">
 122                                 <div class="form-group">
 123                                     <div class="checkbox">
 124                                         <label>
 125                                             <input type="checkbox" name="rashes" <?php echo ($obj["rashes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Rashes');?>
 126                                         </label>
 127                                     </div>
 128                                     <div class="checkbox">
 129                                         <label>
 130                                             <input type="checkbox" name="infections" <?php echo ($obj["infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Infections');?>
 131                                         </label>
 132                                     </div>
 133                                 </div>
 134                             </div>
 135                             <div class="col-sm-3">
 136                                 <div class="form-group">
 137                                     <div class="checkbox">
 138                                         <label>
 139                                             <input type="checkbox" name="ulcerations" <?php echo ($obj["ulcerations"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ulcerations');?>
 140                                         </label>
 141                                     </div>
 142                                 </div>
 143                             </div>
 144                             <div class="col-sm-3">
 145                                 <div class="form-group">
 146                                     <div class="checkbox">
 147                                         <label>
 148                                             <input type="checkbox" name="pemphigus" <?php echo ($obj["pemphigus"] == "on") ? "checked" : ""; ?>><?php echo xlt('Pemphigus');?>
 149                                         </label>
 150                                     </div>
 151                                 </div>
 152                             </div>
 153                             <div class="col-sm-3">
 154                                 <div class="form-group">
 155                                     <div class="checkbox">
 156                                         <label>
 157                                             <input type="checkbox" name="herpes" <?php echo ($obj["herpes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Herpes');?>
 158                                         </label>
 159                                     </div>
 160                                 </div>
 161                             </div>
 162                         </div>
 163                     </div>
 164                 </fieldset>
 165                 <fieldset>
 166                     <legend><?php echo xlt('HEENT')?></legend>
 167                     <div class="row">
 168                         <div class="col-12">
 169                             <div class="col-sm-3">
 170                                 <div class="form-group">
 171                                     <div class="checkbox">
 172                                         <label>
 173                                             <input type="checkbox" name="cataracts" <?php echo ($obj["cataracts"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cataracts');?>
 174                                         </label>
 175                                     </div>
 176                                     <div class="checkbox">
 177                                         <label>
 178                                             <input type="checkbox" name="cataract_surgery" <?php echo ($obj["cataract_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cataract Surgery');?>
 179                                         </label>
 180                                     </div>
 181                                     <div class="checkbox">
 182                                         <label>
 183                                             <input type="checkbox" name="glaucoma" <?php echo ($obj["glaucoma"] == "on") ? "checked" : ""; ?>><?php echo xlt('Glaucoma');?>
 184                                         </label>
 185                                     </div>
 186                                     <div class="checkbox">
 187                                         <label>
 188                                             <input type="checkbox" name="double_vision" <?php echo ($obj["double_vision"] == "on") ? "checked" : ""; ?>><?php echo xlt('Double Vision');?>
 189                                         </label>
 190                                     </div>
 191                                     <div class="checkbox">
 192                                         <label>
 193                                             <input type="checkbox" name="blurred_vision" <?php echo ($obj["blurred_vision"] == "on") ? "checked" : ""; ?>><?php echo xlt('Blurred Vision');?>
 194                                         </label>
 195                                     </div>
 196                                 </div>
 197                             </div>
 198                             <div class="col-sm-3">
 199                                 <div class="form-group">
 200                                     <div class="checkbox">
 201                                         <label>
 202                                             <input type="checkbox" name="poor_hearing" <?php echo ($obj["poor_hearing"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Hearing');?>
 203                                         </label>
 204                                     </div>
 205                                     <div class="checkbox">
 206                                         <label>
 207                                             <input type="checkbox" name="headaches" <?php echo ($obj["headaches"] == "on") ? "checked" : ""; ?>><?php echo xlt('Headaches');?>
 208                                         </label>
 209                                     </div>
 210                                     <div class="checkbox">
 211                                         <label>
 212                                             <input type="checkbox" name="ringing_in_ears" <?php echo ($obj["ringing_in_ears"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ringing in Ears');?>
 213                                         </label>
 214                                     </div>
 215                                     <div class="checkbox">
 216                                         <label>
 217                                             <input type="checkbox" name="bloody_nose" <?php echo ($obj["bloody_nose"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bloody Nose');?>
 218                                         </label>
 219                                     </div>
 220                                 </div>
 221                             </div>
 222                             <div class="col-sm-3">
 223                                 <div class="form-group">
 224                                     <div class="checkbox">
 225                                         <label>
 226                                             <input type="checkbox" name="sinusitis" <?php echo ($obj["sinusitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sinusitis');?>
 227                                         </label>
 228                                     </div>
 229                                     <div class="checkbox">
 230                                         <label>
 231                                             <input type="checkbox" name="sinus_surgery" <?php echo ($obj["sinus_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sinus Surgery');?>
 232                                         </label>
 233                                     </div>
 234                                     <div class="checkbox">
 235                                         <label>
 236                                             <input type="checkbox" name="dry_mouth" <?php echo ($obj["dry_mouth"] == "on") ? "checked" : ""; ?>><?php echo xlt('Dry Mouth');?>
 237                                         </label>
 238                                     </div>
 239                                     <div class="checkbox">
 240                                         <label>
 241                                             <input type="checkbox" name="strep_throat" <?php echo ($obj["strep_throat"] == "on") ? "checked" : ""; ?>><?php echo xlt('Strep Throat');?>
 242                                         </label>
 243                                     </div>
 244                                 </div>
 245                             </div>
 246                             <div class="col-sm-3">
 247                                 <div class="form-group">
 248                                     <div class="checkbox">
 249                                         <label>
 250                                             <input type="checkbox" name="tonsillectomy" <?php echo ($obj["tonsillectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Tonsillectomy');?>
 251                                         </label>
 252                                     </div>
 253                                     <div class="checkbox">
 254                                         <label>
 255                                             <input type="checkbox" name="swollen_lymph_nodes" <?php echo ($obj["swollen_lymph_nodes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Swollen Lymph Nodes');?>
 256                                         </label>
 257                                     </div>
 258                                     <div class="checkbox">
 259                                         <label>
 260                                             <input type="checkbox" name="throat_cancer" <?php echo ($obj["throat_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Throat Cancer');?>
 261                                         </label>
 262                                     </div>
 263                                     <div class="checkbox">
 264                                         <label>
 265                                             <input type="checkbox" name="throat_cancer_surgery" <?php echo ($obj["throat_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Throat Cancer Surgery');?>
 266                                         </label>
 267                                     </div>
 268                                 </div>
 269                             </div>
 270                         </div>
 271                     </div>
 272                 </fieldset>
 273                 <fieldset>
 274                     <legend><?php echo xlt('Pulmonary')?></legend>
 275                     <div class="row">
 276                         <div class="col-12">
 277                             <div class="col-sm-3">
 278                                 <div class="form-group">
 279                                     <div class="checkbox">
 280                                         <label>
 281                                             <input type="checkbox" name="emphysema" <?php echo ($obj["emphysema"] == "on") ? "checked" : ""; ?>><?php echo xlt('Emphysema');?>
 282                                         </label>
 283                                     </div>
 284                                     <div class="checkbox">
 285                                         <label>
 286                                             <input type="checkbox" name="chronic_bronchitis" <?php echo ($obj["chronic_bronchitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chronic Bronchitis');?>
 287                                         </label>
 288                                     </div>
 289                                 </div>
 290                             </div>
 291                             <div class="col-sm-3">
 292                                 <div class="form-group">
 293                                     <div class="checkbox">
 294                                         <label>
 295                                             <input type="checkbox" name="interstitial_lung_disease" <?php echo ($obj["interstitial_lung_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Interstitial Lung Disease');?>
 296                                         </label>
 297                                     </div>
 298                                     <div class="checkbox">
 299                                         <label>
 300                                             <input type="checkbox" name="shortness_of_breath_2" <?php echo ($obj["shortness_of_breath_2"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shortness of Breath');?>
 301                                         </label>
 302                                     </div>
 303                                 </div>
 304                             </div>
 305                             <div class="col-sm-3">
 306                                 <div class="form-group">
 307                                     <div class="checkbox">
 308                                         <label>
 309                                             <input type="checkbox" name="lung_cancer" <?php echo ($obj["lung_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lung Cancer');?>
 310                                         </label>
 311                                     </div>
 312                                     <div class="checkbox">
 313                                         <label>
 314                                             <input type="checkbox" name="lung_cancer_surgery" <?php echo ($obj["lung_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lung Cancer Surgery');?>
 315                                         </label>
 316                                     </div>
 317                                 </div>
 318                             </div>
 319                             <div class="col-sm-3">
 320                                 <div class="form-group">
 321                                     <div class="checkbox">
 322                                         <label>
 323                                             <input type="checkbox" name="pheumothorax" <?php echo ($obj["pheumothorax"] == "on") ? "checked" : ""; ?>><?php echo xlt('Pheumothorax');?>
 324                                         </label>
 325                                     </div>
 326                                 </div>
 327                             </div>
 328                         </div>
 329                     </div>
 330                 </fieldset>
 331                 <fieldset>
 332                     <legend><?php echo xlt('Cardiovascular')?></legend>
 333                     <div class="row">
 334                         <div class="col-12">
 335                             <div class="col-sm-3">
 336                                 <div class="form-group">
 337                                     <div class="checkbox">
 338                                         <label>
 339                                             <input type="checkbox" name="heart_attack" <?php echo ($obj["heart_attack"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Attack');?>
 340                                         </label>
 341                                     </div>
 342                                     <div class="checkbox">
 343                                         <label>
 344                                             <input type="checkbox" name="irregular_heart_beat" <?php echo ($obj["irregular_heart_beat"] == "on") ? "checked" : ""; ?>><?php echo xlt('Irregular Heart Beat');?>
 345                                         </label>
 346                                     </div>
 347                                     <div class="checkbox">
 348                                         <label>
 349                                             <input type="checkbox" name="chest_pains" <?php echo ($obj["chest_pains"] == "on") ? "checked" : ""; ?>><?php echo xlt('Chest Pains');?>
 350                                         </label>
 351                                     </div>
 352                                 </div>
 353                             </div>
 354                             <div class="col-sm-3">
 355                                 <div class="form-group">
 356                                     <div class="checkbox">
 357                                         <label>
 358                                             <input type="checkbox" name="shortness_of_breath" <?php echo ($obj["shortness_of_breath"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shortness of Breath');?>
 359                                         </label>
 360                                     </div>
 361                                     <div class="checkbox">
 362                                         <label>
 363                                             <input type="checkbox" name="high_blood_pressure" <?php echo ($obj["high_blood_pressure"] == "on") ? "checked" : ""; ?>><?php echo xlt('High Blood Pressure');?>
 364                                         </label>
 365                                     </div>
 366                                     <div class="checkbox">
 367                                         <label>
 368                                             <input type="checkbox" name="heart_failure" <?php echo ($obj["heart_failure"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Failure');?>
 369                                         </label>
 370                                     </div>
 371                                 </div>
 372                             </div>
 373                             <div class="col-sm-3">
 374                                 <div class="form-group">
 375                                     <div class="checkbox">
 376                                         <label>
 377                                             <input type="checkbox" name="poor_circulation" <?php echo ($obj["poor_circulation"] == "on") ? "checked" : ""; ?>><?php echo xlt('Poor Circulation');?>
 378                                         </label>
 379                                     </div>
 380                                     <div class="checkbox">
 381                                         <label>
 382                                             <input type="checkbox" name="vascular_surgery" <?php echo ($obj["vascular_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Vascular Surgery');?>
 383                                         </label>
 384                                     </div>
 385                                     <div class="checkbox">
 386                                         <label>
 387                                             <input type="checkbox" name="cardiac_catheterization" <?php echo ($obj["cardiac_catheterization"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cardiac Catheterization');?>
 388                                         </label>
 389                                     </div>
 390                                 </div>
 391                             </div>
 392                             <div class="col-sm-3">
 393                                 <div class="form-group">
 394                                     <div class="checkbox">
 395                                         <label>
 396                                             <input type="checkbox" name="heart_transplant" <?php echo ($obj["heart_transplant"] == "on") ? "checked" : ""; ?>><?php echo xlt('Heart Transplant');?>
 397                                         </label>
 398                                     </div>
 399                                     <div class="checkbox">
 400                                         <label>
 401                                             <input type="checkbox" name="stress_test" <?php echo ($obj["stress_test"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stress Test');?>
 402                                         </label>
 403                                     </div>
 404                                     <div class="checkbox">
 405                                         <label>
 406                                             <input type="checkbox" name="stress_test" <?php echo ($obj["stress_test"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stress Test');?>
 407                                         </label>
 408                                     </div>
 409                                 </div>
 410                             </div>
 411                         </div>
 412                     </div>
 413                 </fieldset>
 414                 <fieldset>
 415                     <legend><?php echo xlt('Gastrointestinal')?></legend>
 416                     <div class="row">
 417                         <div class="col-12">
 418                             <div class="col-sm-3">
 419                                 <div class="form-group">
 420                                     <div class="checkbox">
 421                                         <label>
 422                                             <input type="checkbox" name="stomach_pains" <?php echo ($obj["stomach_pains"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stomach Pains');?>
 423                                         </label>
 424                                     </div>
 425                                     <div class="checkbox">
 426                                         <label>
 427                                             <input type="checkbox" name="peptic_ulcer_disease" <?php echo ($obj["peptic_ulcer_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Peptic Ulcer Disease');?>
 428                                         </label>
 429                                     </div>
 430                                     <div class="checkbox">
 431                                         <label>
 432                                             <input type="checkbox" name="gastritis" <?php echo ($obj["gastritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Gastritis');?>
 433                                         </label>
 434                                     </div>
 435                                     <div class="checkbox">
 436                                         <label>
 437                                             <input type="checkbox" name="endoscopy" <?php echo ($obj["endoscopy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Endoscopy');?>
 438                                         </label>
 439                                     </div>
 440                                     <div class="checkbox">
 441                                         <label>
 442                                             <input type="checkbox" name="polyps" <?php echo ($obj["polyps"] == "on") ? "checked" : ""; ?>><?php echo xlt('Polyps');?>
 443                                         </label>
 444                                     </div>
 445                                 </div>
 446                             </div>
 447                             <div class="col-sm-3">
 448                                 <div class="form-group">
 449                                     <div class="checkbox">
 450                                         <label>
 451                                             <input type="checkbox" name="colonoscopy" <?php echo ($obj["colonoscopy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colonoscopy');?>
 452                                         </label>
 453                                     </div>
 454                                     <div class="checkbox">
 455                                         <label>
 456                                             <input type="checkbox" name="colon_cancer" <?php echo ($obj["colon_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colon Cancer');?>
 457                                         </label>
 458                                     </div>
 459                                     <div class="checkbox">
 460                                         <label>
 461                                             <input type="checkbox" name="colon_cancer_surgery" <?php echo ($obj["colon_cancer_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Colon Cancer Surgery');?>
 462                                         </label>
 463                                     </div>
 464                                     <div class="checkbox">
 465                                         <label>
 466                                             <input type="checkbox" name="ulcerative_colitis" <?php echo ($obj["ulcerative_colitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ulcerative Colitis');?>
 467                                         </label>
 468                                     </div>
 469                                     <div class="checkbox">
 470                                         <label>
 471                                             <input type="checkbox" name="crohns_disease" <?php echo ($obj["crohns_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Crohn\'s Disease');?>
 472                                         </label>
 473                                     </div>
 474                                 </div>
 475                             </div>
 476                             <div class="col-sm-3">
 477                                 <div class="form-group">
 478                                     <div class="checkbox">
 479                                         <label>
 480                                             <input type="checkbox" name="appendectomy" <?php echo ($obj["appendectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Appendectomy');?>
 481                                         </label>
 482                                     </div>
 483                                     <div class="checkbox">
 484                                         <label>
 485                                             <input type="checkbox" name="divirticulitis" <?php echo ($obj["divirticulitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Divirticulitis');?>
 486                                         </label>
 487                                     </div>
 488                                     <div class="checkbox">
 489                                         <label>
 490                                             <input type="checkbox" name="divirticulitis_surgery" <?php echo ($obj["divirticulitis_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Diverticulitis Surgery');?>
 491                                         </label>
 492                                     </div>
 493                                     <div class="checkbox">
 494                                         <label>
 495                                             <input type="checkbox" name="gall_stones" <?php echo ($obj["gall_stones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Gall Stones');?>
 496                                         </label>
 497                                     </div>
 498                                 </div>
 499                             </div>
 500                             <div class="col-sm-3">
 501                                 <div class="form-group">
 502                                     <div class="checkbox">
 503                                         <label>
 504                                             <input type="checkbox" name="cholecystectomy" <?php echo ($obj["cholecystectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cholecystectomy');?>
 505                                         </label>
 506                                     </div>
 507                                     <div class="checkbox">
 508                                         <label>
 509                                             <input type="checkbox" name="hepatitis" <?php echo ($obj["hepatitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hepatitis');?>
 510                                         </label>
 511                                     </div>
 512                                     <div class="checkbox">
 513                                         <label>
 514                                             <input type="checkbox" name="cirrhosis_of_the_liver" <?php echo ($obj["cirrhosis_of_the_liver"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cirrhosis of the Liver');?>
 515                                         </label>
 516                                     </div>
 517                                     <div class="checkbox">
 518                                         <label>
 519                                             <input type="checkbox" name="splenectomy" <?php echo ($obj["splenectomy"] == "on") ? "checked" : ""; ?>><?php echo xlt('Splenectomy');?>
 520                                         </label>
 521                                     </div>
 522                                 </div>
 523                             </div>
 524                         </div>
 525                     </div>
 526                 </fieldset>
 527                 <fieldset>
 528                     <legend><?php echo xlt('Genitourinary')?></legend>
 529                     <div class="row">
 530                         <div class="col-12">
 531                             <div class="col-sm-3">
 532                                 <div class="form-group">
 533                                     <div class="checkbox">
 534                                         <label>
 535                                             <input type="checkbox" name="kidney_failure" <?php echo ($obj["kidney_failure"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Failure');?>
 536                                         </label>
 537                                     </div>
 538                                     <div class="checkbox">
 539                                         <label>
 540                                             <input type="checkbox" name="kidney_stones" <?php echo ($obj["kidney_stones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Stones');?>
 541                                         </label>
 542                                     </div>
 543                                     <div class="checkbox">
 544                                         <label>
 545                                             <input type="checkbox" name="kidney_cancer" <?php echo ($obj["kidney_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Cancer');?>
 546                                         </label>
 547                                     </div>
 548                                 </div>
 549                             </div>
 550                             <div class="col-sm-3">
 551                                 <div class="form-group">
 552                                     <div class="checkbox">
 553                                         <label>
 554                                             <input type="checkbox" name="kidney_infections" <?php echo ($obj["kidney_infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Infections');?>
 555                                         </label>
 556                                     </div>
 557                                     <div class="checkbox">
 558                                         <label>
 559                                             <input type="checkbox" name="bladder_infections" <?php echo ($obj["bladder_infections"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bladder Infections');?>
 560                                         </label>
 561                                     </div>
 562                                     <div class="checkbox">
 563                                         <label>
 564                                             <input type="checkbox" name="bladder_cancer" <?php echo ($obj["bladder_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Bladder Cancer');?>
 565                                         </label>
 566                                     </div>
 567                                 </div>
 568                             </div>
 569                             <div class="col-sm-3">
 570                                 <div class="form-group">
 571                                     <div class="checkbox">
 572                                         <label>
 573                                             <input type="checkbox" name="prostate_problems" <?php echo ($obj["prostate_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Prostate Problems');?>
 574                                         </label>
 575                                     </div>
 576                                     <div class="checkbox">
 577                                         <label>
 578                                             <input type="checkbox" name="prostate_cancer" <?php echo ($obj["prostate_cancer"] == "on") ? "checked" : ""; ?>><?php echo xlt('Prostate Cancer');?>
 579                                         </label>
 580                                     </div>
 581                                     <div class="checkbox">
 582                                         <label>
 583                                             <input type="checkbox" name="kidney_transplant" <?php echo ($obj["kidney_transplant"] == "on") ? "checked" : ""; ?>><?php echo xlt('Kidney Transplant');?>
 584                                         </label>
 585                                     </div>
 586                                 </div>
 587                             </div>
 588                             <div class="col-sm-3">
 589                                 <div class="form-group">
 590                                     <div class="checkbox">
 591                                         <label>
 592                                             <input type="checkbox" name="sexually_transmitted_disease" <?php echo ($obj["sexually_transmitted_disease"] == "on") ? "checked" : ""; ?>><?php echo xlt('Sexually Transmitted Disease');?>
 593                                         </label>
 594                                     </div>
 595                                     <div class="checkbox">
 596                                         <label>
 597                                             <input type="checkbox" name="burning_with_urination" <?php echo ($obj["burning_with_urination"] == "on") ? "checked" : ""; ?>><?php echo xlt('Burning with Urination');?>
 598                                         </label>
 599                                     </div>
 600                                     <div class="checkbox">
 601                                         <label>
 602                                             <input type="checkbox" name="discharge_from_urethra" <?php echo ($obj["discharge_from_urethra"] == "on") ? "checked" : ""; ?>><?php echo xlt('Discharge From Urethra');?>
 603                                         </label>
 604                                     </div>
 605                                 </div>
 606                             </div>
 607                         </div>
 608                     </div>
 609                 </fieldset>
 610                 <fieldset>
 611                     <legend><?php echo xlt('Musculoskeletal')?></legend>
 612                     <div class="row">
 613                         <div class="col-12">
 614                             <div class="col-sm-3">
 615                                 <div class="form-group">
 616                                     <div class="checkbox">
 617                                         <label>
 618                                             <input type="checkbox" name="osetoarthritis" <?php echo ($obj["osetoarthritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Osetoarthritis');?>
 619                                         </label>
 620                                     </div>
 621                                     <div class="checkbox">
 622                                         <label>
 623                                             <input type="checkbox" name="rheumotoid_arthritis" <?php echo ($obj["rheumotoid_arthritis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Rheumatoid Arthritis');?>
 624                                         </label>
 625                                     </div>
 626                                     <div class="checkbox">
 627                                         <label>
 628                                             <input type="checkbox" name="lupus" <?php echo ($obj["lupus"] == "on") ? "checked" : ""; ?>><?php echo xlt('Lupus');?>
 629                                         </label>
 630                                     </div>
 631                                     <div class="checkbox">
 632                                         <label>
 633                                             <input type="checkbox" name="ankylosing_sondlilitis" <?php echo ($obj["ankylosing_sondlilitis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ankylosing Sondlilitis');?>
 634                                         </label>
 635                                     </div>
 636                                     <div class="checkbox">
 637                                         <label>
 638                                             <input type="checkbox" name="swollen_joints" <?php echo ($obj["swollen_joints"] == "on") ? "checked" : ""; ?>><?php echo xlt('Swollen Joints');?>
 639                                         </label>
 640                                     </div>
 641                                 </div>
 642                             </div>
 643                             <div class="col-sm-3">
 644                                 <div class="form-group">
 645                                     <div class="checkbox">
 646                                         <label>
 647                                             <input type="checkbox" name="stiff_joints" <?php echo ($obj["stiff_joints"] == "on") ? "checked" : ""; ?>><?php echo xlt('Stiff Joints');?>
 648                                         </label>
 649                                     </div>
 650                                     <div class="checkbox">
 651                                         <label>
 652                                             <input type="checkbox" name="broken_bones" <?php echo ($obj["broken_bones"] == "on") ? "checked" : ""; ?>><?php echo xlt('Broken Bones');?>
 653                                         </label>
 654                                     </div>
 655                                     <div class="checkbox">
 656                                         <label>
 657                                             <input type="checkbox" name="neck_problems" <?php echo ($obj["neck_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Neck Problems');?>
 658                                         </label>
 659                                     </div>
 660                                     <div class="checkbox">
 661                                         <label>
 662                                             <input type="checkbox" name="back_problems" <?php echo ($obj["back_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Back Problems');?>
 663                                         </label>
 664                                     </div>
 665                                     <div class="checkbox">
 666                                         <label>
 667                                             <input type="checkbox" name="back_surgery" <?php echo ($obj["back_surgery"] == "on") ? "checked" : ""; ?>><?php echo xlt('Back Surgery');?>
 668                                         </label>
 669                                     </div>
 670                                 </div>
 671                             </div>
 672                             <div class="col-sm-3">
 673                                 <div class="form-group">
 674                                     <div class="checkbox">
 675                                         <label>
 676                                             <input type="checkbox" name="scoliosis" <?php echo ($obj["scoliosis"] == "on") ? "checked" : ""; ?>><?php echo xlt('Scoliosis');?>
 677                                         </label>
 678                                     </div>
 679                                     <div class="checkbox">
 680                                         <label>
 681                                             <input type="checkbox" name="herniated_disc" <?php echo ($obj["herniated_disc"] == "on") ? "checked" : ""; ?>><?php echo xlt('Herniated Disc');?>
 682                                         </label>
 683                                     </div>
 684                                     <div class="checkbox">
 685                                         <label>
 686                                             <input type="checkbox" name="shoulder_problems" <?php echo ($obj["shoulder_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Shoulder Problems');?>
 687                                         </label>
 688                                     </div>
 689                                     <div class="checkbox">
 690                                         <label>
 691                                             <input type="checkbox" name="elbow_problems" <?php echo ($obj["elbow_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Elbow Problems');?>
 692                                         </label>
 693                                     </div>
 694                                     <div class="checkbox">
 695                                         <label>
 696                                             <input type="checkbox" name="wrist_problems" <?php echo ($obj["wrist_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Wrist Problems');?>
 697                                         </label>
 698                                     </div>
 699                                 </div>
 700                             </div>
 701                             <div class="col-sm-3">
 702                                 <div class="form-group">
 703                                     <div class="checkbox">
 704                                         <label>
 705                                             <input type="checkbox" name="hand_problems" <?php echo ($obj["hand_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hand Problems');?>
 706                                         </label>
 707                                     </div>
 708                                     <div class="checkbox">
 709                                         <label>
 710                                             <input type="checkbox" name="hip_problems" <?php echo ($obj["hip_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hip Problems');?>
 711                                         </label>
 712                                     </div>
 713                                     <div class="checkbox">
 714                                         <label>
 715                                             <input type="checkbox" name="knee_problems" <?php echo ($obj["knee_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Knee Problems');?>
 716                                         </label>
 717                                     </div>
 718                                     <div class="checkbox">
 719                                         <label>
 720                                             <input type="checkbox" name="ankle_problems" <?php echo ($obj["ankle_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Ankle Problems');?>
 721                                         </label>
 722                                     </div>
 723                                     <div class="checkbox">
 724                                         <label>
 725                                             <input type="checkbox" name="foot_problems" <?php echo ($obj["foot_problems"] == "on") ? "checked" : ""; ?>><?php echo xlt('Foot Problems');?>
 726                                         </label>
 727                                     </div>
 728                                 </div>
 729                             </div>
 730                         </div>
 731                     </div>
 732                 </fieldset>
 733                 <fieldset>
 734                     <legend><?php echo xlt('Endocrine')?></legend>
 735                     <div class="row">
 736                         <div class="col-12">
 737                             <div class="col-sm-3">
 738                                 <div class="form-group">
 739                                     <div class="checkbox">
 740                                         <label>
 741                                             <input type="checkbox" name="insulin_dependent_diabetes" <?php echo ($obj["insulin_dependent_diabetes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Insulin Dependent Diabetes');?>
 742                                         </label>
 743                                     </div>
 744                                     <div class="checkbox">
 745                                         <label>
 746                                             <input type="checkbox" name="noninsulin_dependent_diabetes" <?php echo ($obj["noninsulin_dependent_diabetes"] == "on") ? "checked" : ""; ?>><?php echo xlt('Non-Insulin Dependent Diabetes');?>
 747                                         </label>
 748                                     </div>
 749                                 </div>
 750                             </div>
 751                             <div class="col-sm-3">
 752                                 <div class="form-group">
 753                                     <div class="checkbox">
 754                                         <label>
 755                                             <input type="checkbox" name="hypothyroidism" <?php echo ($obj["hypothyroidism"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hypothyroidism');?>
 756                                         </label>
 757                                     </div>
 758                                     <div class="checkbox">
 759                                         <label>
 760                                             <input type="checkbox" name="hyperthyroidism" <?php echo ($obj["hyperthyroidism"] == "on") ? "checked" : ""; ?>><?php echo xlt('Hyperthyroidism');?>
 761                                         </label>
 762                                     </div>
 763                                 </div>
 764                             </div>
 765                             <div class="col-sm-3">
 766                                 <div class="form-group">
 767                                     <div class="checkbox">
 768                                         <label>
 769                                             <input type="checkbox" name="cushing_syndrom" <?php echo ($obj["cushing_syndrom"] == "on") ? "checked" : ""; ?>><?php echo xlt('Cushing Syndrome');?>
 770                                         </label>
 771                                     </div>
 772                                 </div>
 773                             </div>
 774                             <div class="col-sm-3">
 775                                 <div class="form-group">
 776                                     <div class="checkbox">
 777                                         <label>
 778                                             <input type="checkbox" name="addison_syndrom" <?php echo ($obj["addison_syndrom"] == "on") ? "checked" : ""; ?>><?php echo xlt('Addison Syndrome');?>
 779                                         </label>
 780                                     </div>
 781                                 </div>
 782                             </div>
 783                         </div>
 784                     </div>
 785                 </fieldset>
 786                 <fieldset>
 787                         <legend class=""><?php echo xlt('Additional Notes');?></legend>
 788                             <div class="form-group">
 789                                 <div class="col-sm-10 offset-sm-1">
 790                                     <textarea name="additional_notes" class="form-control" cols="80" rows="5" ><?php echo text($obj["additional_notes"]); ?></textarea>
 791                                 </div>
 792                             </div>
 793                 </fieldset>
 794                     <div class="form-group clearfix">
 795                         <div class="col-sm-12 offset-sm-1 position-override">
 796                             <div class="btn-group" role="group">
 797                             <button type="submit" onclick="top.restoreSession()" class="btn btn-secondary btn-save"><?php echo xlt('Save'); ?></button>
 798                             <button type="button" class="btn btn-link btn-cancel" onclick="top.restoreSession(); parent.closeTab(window.name, false);"><?php echo xlt('Cancel');?></button>
 799                         </div>
 800                     </div>
 801                 </div>
 802             </form>
 803         </div>
 804     </div>
 805 </body>
 806 </html>