contrib/forms/chiro_history/print.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: chiro_history");
   5 ?>
   6 <html><head>
   7 <link rel=stylesheet href="<?echo $css_header;?>" type="text/css">
   8 </head>
   9 <body <?echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  10 <form method=post action="<?echo $rootdir;?>/forms/chiro_history/save.php?mode=new" name="my_form" onsubmit="return top.restoreSession()">
  11 <h1> Chiropractic History </h1>
  12 <hr>
  13 <input type="submit" name="submit form" value="submit form" /><br>
  14 <br>
  15 <h3> <? xl("History",'e') ?> </h3>
  16
  17 <table>
  18
  19 <tr><td>
  20 <span class='text'><?php xl('Approximate onset date (yyyy-mm-dd): ','e') ?></span>
  21 </td><td>
  22 <input type='text' size='10' name='approximate_onset_date' id='approximate_onset_date' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
  23 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
  24 id='img_approximate_onset_date' border='0' alt='[?]' style='cursor:pointer'
  25 title='Click here to choose a date'>
  26 <script>
  27 Calendar.setup({inputField:'approximate_onset_date', ifFormat:'%Y-%m-%d', button:'img_approximate_onset_date'});
  28 </script>
  29 </td></tr>
  30
  31 </table>
  32
  33 <table>
  34
  35 <tr><td> <? xl("Due to",'e') ?> </td> <td><label><input type="checkbox" name="due_to[]" value="Insidious Onset" /> <? xl("Insidious Onset",'e') ?> </label> <label><input type="checkbox" name="due_to[]" value="Trauma" /> <? xl("Trauma",'e') ?> </label> <label><input type="checkbox" name="due_to[]" value="Work Injury" /> <? xl("Work Injury",'e') ?> </label> <label><input type="checkbox" name="due_to[]" value="Personal Injury" /> <? xl("Personal Injury",'e') ?> </label> <label><input type="checkbox" name="due_to[]" value="Auto Collision" /> <? xl("Auto Collision",'e') ?> </label></td></tr>
  36
  37 </table>
  38
  39 <table>
  40
  41 <tr><td> <? xl("Areas involved",'e') ?> </td> <td><label><input type="checkbox" name="areas_involved[]" value="Right" /> <? xl("Right",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Neck" /> <? xl("Neck",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Mid Back" /> <? xl("Mid Back",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Low Back" /> <? xl("Low Back",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Shoulder" /> <? xl("Shoulder",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Elbow" /> <? xl("Elbow",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Hand" /> <? xl("Hand",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Hip" /> <? xl("Hip",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Knee" /> <? xl("Knee",'e') ?> </label> <label><input type="checkbox" name="areas_involved[]" value="Foot" /> <? xl("Foot",'e') ?> </label></td></tr>
  42
  43 </table>
  44
  45 <table>
  46
  47 <tr><td> <? xl("Radiating to",'e') ?> </td> <td><label><input type="checkbox" name="radiating_to[]" value="Right" /> <? xl("Right",'e') ?> </label> <label><input type="checkbox" name="radiating_to[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="radiating_to[]" value="Shoulder" /> <? xl("Shoulder",'e') ?> </label> <label><input type="checkbox" name="radiating_to[]" value="Arm" /> <? xl("Arm",'e') ?> </label> <label><input type="checkbox" name="radiating_to[]" value="Hip" /> <? xl("Hip",'e') ?> </label> <label><input type="checkbox" name="radiating_to[]" value="Leg" /> <? xl("Leg",'e') ?> </label></td></tr>
  48
  49 </table>
  50
  51 <table>
  52
  53 <tr><td> <? xl("Radiating to other",'e') ?> </td> <td><input type="text" name="radiating_to_other"  /></td></tr>
  54
  55 </table>
  56
  57 <table>
  58
  59 <tr><td> <? xl("Describe symtoms",'e') ?> </td> <td><label><input type="checkbox" name="describe_symtoms[]" value="Constant" /> <? xl("Constant",'e') ?> </label> <label><input type="checkbox" name="describe_symtoms[]" value="Intermittent" /> <? xl("Intermittent",'e') ?> </label> <label><input type="checkbox" name="describe_symtoms[]" value="Dull Ache" /> <? xl("Dull Ache",'e') ?> </label> <label><input type="checkbox" name="describe_symtoms[]" value="Sharp" /> <? xl("Sharp",'e') ?> </label> <label><input type="checkbox" name="describe_symtoms[]" value="Burning" /> <? xl("Burning",'e') ?> </label></td></tr>
  60
  61 </table>
  62
  63 <table>
  64
  65 <tr><td> <? xl("Pain severity",'e') ?> </td> <td><select name="pain_severity" >
  66 <option value=""></option>
  67 <option value="1">1</option>
  68 <option value="2">2</option>
  69 <option value="3">3</option>
  70 <option value="4">4</option>
  71 <option value="5">5</option>
  72 <option value="6">6</option>
  73 <option value="7">7</option>
  74 <option value="8">8</option>
  75 <option value="9">9</option>
  76 <option value="10"> <? xl("10",'e') ?> </option>
  77 </select></td></tr>
  78
  79 </table>
  80
  81 <table>
  82
  83 <tr><td> <? xl("Associated symptoms",'e') ?> </td> <td><textarea name="associated_symptoms"  rows="4" cols="40"></textarea></td></tr>
  84
  85 </table>
  86
  87 <table>
  88
  89 <tr><td> <? xl("Pain with",'e') ?> </td> <td><label><input type="checkbox" name="pain_with[]" value="Cough" /> <? xl("Cough",'e') ?> </label> <label><input type="checkbox" name="pain_with[]" value="Sneeze" /> <? xl("Sneeze",'e') ?> </label> <label><input type="checkbox" name="pain_with[]" value="Deep Breath" /> <? xl("Deep Breath",'e') ?> </label> <label><input type="checkbox" name="pain_with[]" value="Baring Down" /> <? xl("Baring Down",'e') ?> </label></td></tr>
  90
  91 </table>
  92
  93 <table>
  94
  95 <tr><td> <? xl("Describe pain",'e') ?> </td> <td><input type="text" name="describe_pain"  /></td></tr>
  96
  97 </table>
  98
  99 <table>
 100
 101 <tr><td> <? xl("Worse",'e') ?> </td> <td><label><input type="checkbox" name="worse[]" value="Bending" /> <? xl("Bending",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Sitting Rising" /> <? xl("Sitting Rising",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Turning Neck" /> <? xl("Turning Neck",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Turning Trunk" /> <? xl("Turning Trunk",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Turning Lower Back" /> <? xl("Turning Lower Back",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Standing" /> <? xl("Standing",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Lying" /> <? xl("Lying",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="Resting" /> <? xl("Resting",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="AM" /> <? xl("AM",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="PM" /> <? xl("PM",'e') ?> </label> <label><input type="checkbox" name="worse[]" value="No Effect" /> <? xl("No Effect",'e') ?> </label></td></tr>
 102
 103 </table>
 104
 105 <table>
 106
 107 <tr><td> <? xl("Worse other",'e') ?> </td> <td><input type="text" name="worse_other"  /></td></tr>
 108
 109 </table>
 110
 111 <table>
 112
 113 <tr><td> <? xl("Better",'e') ?> </td> <td><label><input type="checkbox" name="better[]" value="Bending" /> <? xl("Bending",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Sitting Rising" /> <? xl("Sitting Rising",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Turning Neck" /> <? xl("Turning Neck",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Turning Trunk" /> <? xl("Turning Trunk",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Turning Lower Back" /> <? xl("Turning Lower Back",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Standing" /> <? xl("Standing",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Lying" /> <? xl("Lying",'e') ?> </label> <label><input type="checkbox" name="better[]" value="Resting" /> <? xl("Resting",'e') ?> </label> <label><input type="checkbox" name="better[]" value="AM" /> <? xl("AM",'e') ?> </label> <label><input type="checkbox" name="better[]" value="PM" /> <? xl("PM",'e') ?> </label> <label><input type="checkbox" name="better[]" value="No Effect" /> <? xl("No Effect",'e') ?> </label></td></tr>
 114
 115 </table>
 116
 117 <table>
 118
 119 <tr><td> <? xl("Better other",'e') ?> </td> <td><input type="text" name="better_other"  /></td></tr>
 120
 121 </table>
 122
 123 <table>
 124
 125 <tr><td> <? xl("Pain effected",'e') ?> </td> <td><label><input type="checkbox" name="pain_effected[]" value="NA" /> <? xl("NA",'e') ?> </label> <label><input type="checkbox" name="pain_effected[]" value="Job" /> <? xl("Job",'e') ?> </label> <label><input type="checkbox" name="pain_effected[]" value="Home" /> <? xl("Home",'e') ?> </label> <label><input type="checkbox" name="pain_effected[]" value="Recreational Activities" /> <? xl("Recreational Activities",'e') ?> </label></td></tr>
 126
 127 </table>
 128
 129 <table>
 130
 131 <tr><td> <? xl("Effected other",'e') ?> </td> <td><input type="text" name="effected_other"  /></td></tr>
 132
 133 </table>
 134
 135 <table>
 136
 137 <tr><td> <? xl("Previous history",'e') ?> </td> <td><label><input type="checkbox" name="previous_history[]" value="No" /> <? xl("No",'e') ?> </label> <label><input type="checkbox" name="previous_history[]" value="Yes" /> <? xl("Yes",'e') ?> </label></td></tr>
 138
 139 </table>
 140
 141 <table>
 142
 143 <tr><td> <? xl("Previous history explain",'e') ?> </td> <td><input type="text" name="previous_history_explain"  /></td></tr>
 144
 145 </table>
 146
 147 <table>
 148
 149 <tr><td> <? xl("Previous treatment",'e') ?> </td> <td><label><input type="checkbox" name="previous_treatment[]" value="DC" /> <? xl("DC",'e') ?> </label> <label><input type="checkbox" name="previous_treatment[]" value="MD" /> <? xl("MD",'e') ?> </label> <label><input type="checkbox" name="previous_treatment[]" value="PT" /> <? xl("PT",'e') ?> </label></td></tr>
 150
 151 </table>
 152
 153 <table>
 154
 155 <tr><td> <? xl("Previous treatment other",'e') ?> </td> <td><input type="text" name="previous_treatment_other"  /></td></tr>
 156
 157 </table>
 158
 159 <table>
 160
 161 <tr><td> <? xl("Current treatment",'e') ?> </td> <td><label><input type="checkbox" name="current_treatment[]" value="DC" /> <? xl("DC",'e') ?> </label> <label><input type="checkbox" name="current_treatment[]" value="MD" /> <? xl("MD",'e') ?> </label> <label><input type="checkbox" name="current_treatment[]" value="PT" /> <? xl("PT",'e') ?> </label></td></tr>
 162
 163 </table>
 164
 165 <table>
 166
 167 <tr><td> <? xl("Current treatment other",'e') ?> </td> <td><input type="text" name="current_treatment_other"  /></td></tr>
 168
 169 </table>
 170
 171 <table>
 172
 173 <tr><td> <? xl("Recent scans",'e') ?> </td> <td><label><input type="checkbox" name="recent_scans[]" value="X-Rays" /> <? xl("X-Rays",'e') ?> </label> <label><input type="checkbox" name="recent_scans[]" value="MRI" /> <? xl("MRI",'e') ?> </label> <label><input type="checkbox" name="recent_scans[]" value="CT" /> <? xl("CT",'e') ?> </label></td></tr>
 174
 175 </table>
 176
 177 <table>
 178
 179 <tr><td>
 180 <span class='text'><?php xl('Scan date (yyyy-mm-dd): ','e') ?></span>
 181 </td><td>
 182 <input type='text' size='10' name='scan_date' id='scan_date' onkeyup='datekeyup(this,mypcc)' onblur='dateblur(this,mypcc)' title='yyyy-mm-dd last date of this event' />
 183 <img src='../../../interface/pic/show_calendar.gif' align='absbottom' width='24' height='22'
 184 id='img_scan_date' border='0' alt='[?]' style='cursor:pointer'
 185 title='Click here to choose a date'>
 186 <script>
 187 Calendar.setup({inputField:'scan_date', ifFormat:'%Y-%m-%d', button:'img_scan_date'});
 188 </script>
 189 </td></tr>
 190
 191 </table>
 192
 193 <table>
 194
 195 <tr><td> <? xl("Scan location",'e') ?> </td> <td><input type="text" name="scan_location"  /></td></tr>
 196
 197 </table>
 198
 199 <table>
 200
 201 <tr><td> <? xl("Medications",'e') ?> </td> <td><label><input type="checkbox" name="medications[]" value="NSAIDS" /> <? xl("NSAIDS",'e') ?> </label> <label><input type="checkbox" name="medications[]" value="Muscle Relaxer" /> <? xl("Muscle Relaxer",'e') ?> </label></td></tr>
 202
 203 </table>
 204
 205 <table>
 206
 207 <tr><td> <? xl("Medications other",'e') ?> </td> <td><input type="text" name="medications_other"  /></td></tr>
 208
 209 </table>
 210
 211 <table>
 212
 213 <tr><td> <? xl("Vitamins supplements",'e') ?> </td> <td><label><input type="checkbox" name="vitamins_supplements[]" value="Mulivitamin" /> <? xl("Mulivitamin",'e') ?> </label> <label><input type="checkbox" name="vitamins_supplements[]" value="Calcium" /> <? xl("Calcium",'e') ?> </label> <label><input type="checkbox" name="vitamins_supplements[]" value="Fish Oil" /> <? xl("Fish Oil",'e') ?> </label></td></tr>
 214
 215 </table>
 216
 217 <table>
 218
 219 <tr><td> <? xl("Vitamins supplements other",'e') ?> </td> <td><input type="text" name="vitamins_supplements_other"  /></td></tr>
 220
 221 </table>
 222
 223 <table>
 224
 225 <tr><td> <? xl("Recent or major surgeries",'e') ?> </td> <td><input type="text" name="recent_or_major_surgeries"  /></td></tr>
 226
 227 </table>
 228
 229 <table>
 230
 231 <tr><td> <? xl("Current or past health problems",'e') ?> </td> <td><input type="text" name="current_or_past_health_problems"  /></td></tr>
 232
 233 </table>
 234
 235 <table>
 236
 237 <tr><td> <? xl("Family history of major illness",'e') ?> </td> <td><input type="text" name="family_history_of_major_illness"  /></td></tr>
 238
 239 </table>
 240 <br>
 241 <h3> <? xl("Musculosketal Exam",'e') ?> </h3>
 242 <br>
 243 <h3> <? xl("Constitutional",'e') ?> </h3>
 244
 245 <table>
 246
 247 <tr><td> <? xl("Ht",'e') ?> </td> <td><input type="text" name="ht"  /></td></tr>
 248
 249 </table>
 250
 251 <table>
 252
 253 <tr><td> <? xl("Wt",'e') ?> </td> <td><input type="text" name="wt"  /></td></tr>
 254
 255 </table>
 256
 257 <table>
 258
 259 <tr><td> <? xl("Bp",'e') ?> </td> <td><input type="text" name="bp"  /></td></tr>
 260
 261 </table>
 262
 263 <table>
 264
 265 <tr><td> <? xl("General appearance",'e') ?> </td> <td><label><input type="checkbox" name="general_appearance[]" value="Normal" /> <? xl("Normal",'e') ?> </label> <label><input type="checkbox" name="general_appearance[]" value="Other" /> <? xl("Other",'e') ?> </label></td></tr>
 266
 267 </table>
 268
 269 <table>
 270
 271 <tr><td> <? xl("General appearance other",'e') ?> </td> <td><input type="text" name="general_appearance_other"  /></td></tr>
 272
 273 </table>
 274
 275 <table>
 276
 277 <tr><td> <? xl("Current symptoms",'e') ?> </td> <td><label><input type="checkbox" name="current_symptoms[]" value="Cervical" /> <? xl("Cervical",'e') ?> </label> <label><input type="checkbox" name="current_symptoms[]" value="Thoracic" /> <? xl("Thoracic",'e') ?> </label> <label><input type="checkbox" name="current_symptoms[]" value="Lumbar" /> <? xl("Lumbar",'e') ?> </label> <label><input type="checkbox" name="current_symptoms[]" value="SI" /> <? xl("SI",'e') ?> </label> <label><input type="checkbox" name="current_symptoms[]" value="Other" /> <? xl("Other",'e') ?> </label></td></tr>
 278
 279 </table>
 280
 281 <table>
 282
 283 <tr><td> <? xl("Symptoms other",'e') ?> </td> <td><input type="text" name="symptoms_other"  /></td></tr>
 284
 285 </table>
 286 <br>
 287 <h3> <? xl("Mechanical MecKenzie Exam",'e') ?> </h3>
 288
 289 <table>
 290
 291 <tr><td> <? xl("Cervical",'e') ?> </td> <td><label><input type="checkbox" name="cervical" value="yes" /></label></td></tr>
 292
 293 </table>
 294
 295 <table>
 296
 297 <tr><td> <? xl("Cervical wnl",'e') ?> </td> <td><input type="text" name="cervical_wnl"  /></td></tr>
 298
 299 </table>
 300
 301 <table>
 302
 303 <tr><td> <? xl("Thoracic",'e') ?> </td> <td><label><input type="checkbox" name="thoracic" value="yes" /></label></td></tr>
 304
 305 </table>
 306
 307 <table>
 308
 309 <tr><td> <? xl("Thoracic wnl",'e') ?> </td> <td><input type="text" name="thoracic_wnl"  /></td></tr>
 310
 311 </table>
 312
 313 <table>
 314
 315 <tr><td> <? xl("Lumbar",'e') ?> </td> <td><label><input type="checkbox" name="lumbar" value="yes" /></label></td></tr>
 316
 317 </table>
 318
 319 <table>
 320
 321 <tr><td> <? xl("Lumbar wnl",'e') ?> </td> <td><input type="text" name="lumbar_wnl"  /></td></tr>
 322
 323 </table>
 324
 325 <table>
 326
 327 <tr><td> <? xl("Cerv rom",'e') ?> </td> <td><label><input type="checkbox" name="cerv_rom[]" value="Subject" /> <? xl("Subject",'e') ?> </label> <label><input type="checkbox" name="cerv_rom[]" value="Object" /> <? xl("Object",'e') ?> </label> <label><input type="checkbox" name="cerv_rom[]" value="WNL" /> <? xl("WNL",'e') ?> </label></td></tr>
 328
 329 </table>
 330
 331 <table>
 332
 333 <tr><td> <? xl("Cerv flexion rom",'e') ?> </td> <td><input type="text" name="cerv_flexion_rom"  /></td></tr>
 334
 335 </table>
 336
 337 <table>
 338
 339 <tr><td> <? xl("Cerv flexion pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_flexion_pain" value="yes" /></label></td></tr>
 340
 341 </table>
 342
 343 <table>
 344
 345 <tr><td> <? xl("Cerv flexion response",'e') ?> </td> <td><input type="text" name="cerv_flexion_response"  /></td></tr>
 346
 347 </table>
 348
 349 <table>
 350
 351 <tr><td> <? xl("Cerv extension rom",'e') ?> </td> <td><input type="text" name="cerv_extension_rom"  /></td></tr>
 352
 353 </table>
 354
 355 <table>
 356
 357 <tr><td> <? xl("Cerv extension pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_extension_pain" value="yes" /></label></td></tr>
 358
 359 </table>
 360
 361 <table>
 362
 363 <tr><td> <? xl("Cerv extension response",'e') ?> </td> <td><input type="text" name="cerv_extension_response"  /></td></tr>
 364
 365 </table>
 366
 367 <table>
 368
 369 <tr><td> <? xl("Cerv lt lat flex rom",'e') ?> </td> <td><input type="text" name="cerv_lt_lat_flex_rom"  /></td></tr>
 370
 371 </table>
 372
 373 <table>
 374
 375 <tr><td> <? xl("Cerv lt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_lt_lat_flex_pain" value="yes" /></label></td></tr>
 376
 377 </table>
 378
 379 <table>
 380
 381 <tr><td> <? xl("Cerv lt lat flex response",'e') ?> </td> <td><input type="text" name="cerv_lt_lat_flex_response"  /></td></tr>
 382
 383 </table>
 384
 385 <table>
 386
 387 <tr><td> <? xl("Cerv rt lat flex rom",'e') ?> </td> <td><input type="text" name="cerv_rt_lat_flex_rom"  /></td></tr>
 388
 389 </table>
 390
 391 <table>
 392
 393 <tr><td> <? xl("Cerv rt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_rt_lat_flex_pain" value="yes" /></label></td></tr>
 394
 395 </table>
 396
 397 <table>
 398
 399 <tr><td> <? xl("Cerv rt lat flex response",'e') ?> </td> <td><input type="text" name="cerv_rt_lat_flex_response"  /></td></tr>
 400
 401 </table>
 402
 403 <table>
 404
 405 <tr><td> <? xl("Cerv lt rotation rom",'e') ?> </td> <td><input type="text" name="cerv_lt_rotation_rom"  /></td></tr>
 406
 407 </table>
 408
 409 <table>
 410
 411 <tr><td> <? xl("Cerv lt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_lt_rotation_pain" value="yes" /></label></td></tr>
 412
 413 </table>
 414
 415 <table>
 416
 417 <tr><td> <? xl("Cerv lt rotation response",'e') ?> </td> <td><input type="text" name="cerv_lt_rotation_response"  /></td></tr>
 418
 419 </table>
 420
 421 <table>
 422
 423 <tr><td> <? xl("Cerv rt rotation rom",'e') ?> </td> <td><input type="text" name="cerv_rt_rotation_rom"  /></td></tr>
 424
 425 </table>
 426
 427 <table>
 428
 429 <tr><td> <? xl("Cerv rt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="cerv_rt_rotation_pain" value="yes" /></label></td></tr>
 430
 431 </table>
 432
 433 <table>
 434
 435 <tr><td> <? xl("Cerv rt rotation response",'e') ?> </td> <td><input type="text" name="cerv_rt_rotation_response"  /></td></tr>
 436
 437 </table>
 438
 439 <table>
 440
 441 <tr><td> <? xl("Thor rom",'e') ?> </td> <td><label><input type="checkbox" name="thor_rom[]" value="Subject" /> <? xl("Subject",'e') ?> </label> <label><input type="checkbox" name="thor_rom[]" value="Object" /> <? xl("Object",'e') ?> </label> <label><input type="checkbox" name="thor_rom[]" value="WNL" /> <? xl("WNL",'e') ?> </label></td></tr>
 442
 443 </table>
 444
 445 <table>
 446
 447 <tr><td> <? xl("Thor flexion rom",'e') ?> </td> <td><input type="text" name="thor_flexion_rom"  /></td></tr>
 448
 449 </table>
 450
 451 <table>
 452
 453 <tr><td> <? xl("Thor flexion pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_flexion_pain" value="yes" /></label></td></tr>
 454
 455 </table>
 456
 457 <table>
 458
 459 <tr><td> <? xl("Thor flexion response",'e') ?> </td> <td><input type="text" name="thor_flexion_response"  /></td></tr>
 460
 461 </table>
 462
 463 <table>
 464
 465 <tr><td> <? xl("Thor extension rom",'e') ?> </td> <td><input type="text" name="thor_extension_rom"  /></td></tr>
 466
 467 </table>
 468
 469 <table>
 470
 471 <tr><td> <? xl("Thor extension pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_extension_pain" value="yes" /></label></td></tr>
 472
 473 </table>
 474
 475 <table>
 476
 477 <tr><td> <? xl("Thor extension response",'e') ?> </td> <td><input type="text" name="thor_extension_response"  /></td></tr>
 478
 479 </table>
 480
 481 <table>
 482
 483 <tr><td> <? xl("Thor lt lat flex rom",'e') ?> </td> <td><input type="text" name="thor_lt_lat_flex_rom"  /></td></tr>
 484
 485 </table>
 486
 487 <table>
 488
 489 <tr><td> <? xl("Thor lt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_lt_lat_flex_pain" value="yes" /></label></td></tr>
 490
 491 </table>
 492
 493 <table>
 494
 495 <tr><td> <? xl("Thor lt lat flex response",'e') ?> </td> <td><input type="text" name="thor_lt_lat_flex_response"  /></td></tr>
 496
 497 </table>
 498
 499 <table>
 500
 501 <tr><td> <? xl("Thor rt lat flex rom",'e') ?> </td> <td><input type="text" name="thor_rt_lat_flex_rom"  /></td></tr>
 502
 503 </table>
 504
 505 <table>
 506
 507 <tr><td> <? xl("Thor rt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_rt_lat_flex_pain" value="yes" /></label></td></tr>
 508
 509 </table>
 510
 511 <table>
 512
 513 <tr><td> <? xl("Thor rt lat flex response",'e') ?> </td> <td><input type="text" name="thor_rt_lat_flex_response"  /></td></tr>
 514
 515 </table>
 516
 517 <table>
 518
 519 <tr><td> <? xl("Thor lt rotation rom",'e') ?> </td> <td><input type="text" name="thor_lt_rotation_rom"  /></td></tr>
 520
 521 </table>
 522
 523 <table>
 524
 525 <tr><td> <? xl("Thor lt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_lt_rotation_pain" value="yes" /></label></td></tr>
 526
 527 </table>
 528
 529 <table>
 530
 531 <tr><td> <? xl("Thor lt rotation response",'e') ?> </td> <td><input type="text" name="thor_lt_rotation_response"  /></td></tr>
 532
 533 </table>
 534
 535 <table>
 536
 537 <tr><td> <? xl("Thor rt rotation rom",'e') ?> </td> <td><input type="text" name="thor_rt_rotation_rom"  /></td></tr>
 538
 539 </table>
 540
 541 <table>
 542
 543 <tr><td> <? xl("Thor rt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="thor_rt_rotation_pain" value="yes" /></label></td></tr>
 544
 545 </table>
 546
 547 <table>
 548
 549 <tr><td> <? xl("Thor rt rotation response",'e') ?> </td> <td><input type="text" name="thor_rt_rotation_response"  /></td></tr>
 550
 551 </table>
 552
 553 <table>
 554
 555 <tr><td> <? xl("Lumb rom",'e') ?> </td> <td><label><input type="checkbox" name="lumb_rom[]" value="Subject" /> <? xl("Subject",'e') ?> </label> <label><input type="checkbox" name="lumb_rom[]" value="Object" /> <? xl("Object",'e') ?> </label> <label><input type="checkbox" name="lumb_rom[]" value="WNL" /> <? xl("WNL",'e') ?> </label></td></tr>
 556
 557 </table>
 558
 559 <table>
 560
 561 <tr><td> <? xl("Lumb flexion rom",'e') ?> </td> <td><input type="text" name="lumb_flexion_rom"  /></td></tr>
 562
 563 </table>
 564
 565 <table>
 566
 567 <tr><td> <? xl("Lumb flexion pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_flexion_pain" value="yes" /></label></td></tr>
 568
 569 </table>
 570
 571 <table>
 572
 573 <tr><td> <? xl("Lumb flexion response",'e') ?> </td> <td><input type="text" name="lumb_flexion_response"  /></td></tr>
 574
 575 </table>
 576
 577 <table>
 578
 579 <tr><td> <? xl("Lumb extension rom",'e') ?> </td> <td><input type="text" name="lumb_extension_rom"  /></td></tr>
 580
 581 </table>
 582
 583 <table>
 584
 585 <tr><td> <? xl("Lumb extension pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_extension_pain" value="yes" /></label></td></tr>
 586
 587 </table>
 588
 589 <table>
 590
 591 <tr><td> <? xl("Lumb extension response",'e') ?> </td> <td><input type="text" name="lumb_extension_response"  /></td></tr>
 592
 593 </table>
 594
 595 <table>
 596
 597 <tr><td> <? xl("Lumb lt lat flex rom",'e') ?> </td> <td><input type="text" name="lumb_lt_lat_flex_rom"  /></td></tr>
 598
 599 </table>
 600
 601 <table>
 602
 603 <tr><td> <? xl("Lumb lt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_lt_lat_flex_pain" value="yes" /></label></td></tr>
 604
 605 </table>
 606
 607 <table>
 608
 609 <tr><td> <? xl("Lumb lt lat flex response",'e') ?> </td> <td><input type="text" name="lumb_lt_lat_flex_response"  /></td></tr>
 610
 611 </table>
 612
 613 <table>
 614
 615 <tr><td> <? xl("Lumb rt lat flex rom",'e') ?> </td> <td><input type="text" name="lumb_rt_lat_flex_rom"  /></td></tr>
 616
 617 </table>
 618
 619 <table>
 620
 621 <tr><td> <? xl("Lumb rt lat flex pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_rt_lat_flex_pain" value="yes" /></label></td></tr>
 622
 623 </table>
 624
 625 <table>
 626
 627 <tr><td> <? xl("Lumb rt lat flex response",'e') ?> </td> <td><input type="text" name="lumb_rt_lat_flex_response"  /></td></tr>
 628
 629 </table>
 630
 631 <table>
 632
 633 <tr><td> <? xl("Lumb lt rotation rom",'e') ?> </td> <td><input type="text" name="lumb_lt_rotation_rom"  /></td></tr>
 634
 635 </table>
 636
 637 <table>
 638
 639 <tr><td> <? xl("Lumb lt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_lt_rotation_pain" value="yes" /></label></td></tr>
 640
 641 </table>
 642
 643 <table>
 644
 645 <tr><td> <? xl("Lumb lt rotation response",'e') ?> </td> <td><input type="text" name="lumb_lt_rotation_response"  /></td></tr>
 646
 647 </table>
 648
 649 <table>
 650
 651 <tr><td> <? xl("Lumb rt rotation rom",'e') ?> </td> <td><input type="text" name="lumb_rt_rotation_rom"  /></td></tr>
 652
 653 </table>
 654
 655 <table>
 656
 657 <tr><td> <? xl("Lumb rt rotation pain",'e') ?> </td> <td><label><input type="checkbox" name="lumb_rt_rotation_pain" value="yes" /></label></td></tr>
 658
 659 </table>
 660
 661 <table>
 662
 663 <tr><td> <? xl("Lumb rt rotation response",'e') ?> </td> <td><input type="text" name="lumb_rt_rotation_response"  /></td></tr>
 664
 665 </table>
 666 <br>
 667 <h3> <? xl("Orthopedic Neurological",'e') ?> </h3>
 668
 669 <table>
 670
 671 <tr><td> <? xl("Cervical test",'e') ?> </td> <td><label><input type="checkbox" name="cervical_test" value="yes" /></label></td></tr>
 672
 673 </table>
 674
 675 <table>
 676
 677 <tr><td> <? xl("Lt cervical comp",'e') ?> </td> <td><label><input type="checkbox" name="lt_cervical_comp[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_cervical_comp[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 678
 679 </table>
 680
 681 <table>
 682
 683 <tr><td> <? xl("Lt cervical comp response",'e') ?> </td> <td><input type="text" name="lt_cervical_comp_response"  /></td></tr>
 684
 685 </table>
 686
 687 <table>
 688
 689 <tr><td> <? xl("Rt cervical comp",'e') ?> </td> <td><label><input type="checkbox" name="rt_cervical_comp[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_cervical_comp[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 690
 691 </table>
 692
 693 <table>
 694
 695 <tr><td> <? xl("Rt cervical comp response",'e') ?> </td> <td><input type="text" name="rt_cervical_comp_response"  /></td></tr>
 696
 697 </table>
 698
 699 <table>
 700
 701 <tr><td> <? xl("Soto hall",'e') ?> </td> <td><label><input type="checkbox" name="soto_hall[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="soto_hall[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 702
 703 </table>
 704
 705 <table>
 706
 707 <tr><td> <? xl("Soto hall response",'e') ?> </td> <td><input type="text" name="soto_hall_response"  /></td></tr>
 708
 709 </table>
 710
 711 <table>
 712
 713 <tr><td> <? xl("Lt shoulder depression",'e') ?> </td> <td><label><input type="checkbox" name="lt_shoulder_depression[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_shoulder_depression[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 714
 715 </table>
 716
 717 <table>
 718
 719 <tr><td> <? xl("Lt shoulder depression response",'e') ?> </td> <td><input type="text" name="lt_shoulder_depression_response"  /></td></tr>
 720
 721 </table>
 722
 723 <table>
 724
 725 <tr><td> <? xl("Rt shoulder depression",'e') ?> </td> <td><label><input type="checkbox" name="rt_shoulder_depression[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_shoulder_depression[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 726
 727 </table>
 728
 729 <table>
 730
 731 <tr><td> <? xl("Rt shoulder depression response",'e') ?> </td> <td><input type="text" name="rt_shoulder_depression_response"  /></td></tr>
 732
 733 </table>
 734
 735 <table>
 736
 737 <tr><td> <? xl("Ditraction test",'e') ?> </td> <td><label><input type="checkbox" name="ditraction_test[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="ditraction_test[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 738
 739 </table>
 740
 741 <table>
 742
 743 <tr><td> <? xl("Ditraction test response",'e') ?> </td> <td><input type="text" name="ditraction_test_response"  /></td></tr>
 744
 745 </table>
 746
 747 <table>
 748
 749 <tr><td> <? xl("Extremity other",'e') ?> </td> <td><label><input type="checkbox" name="extremity_other[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="extremity_other[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 750
 751 </table>
 752
 753 <table>
 754
 755 <tr><td> <? xl("Extremity other response",'e') ?> </td> <td><input type="text" name="extremity_other_response"  /></td></tr>
 756
 757 </table>
 758
 759 <table>
 760
 761 <tr><td> <? xl("Lumbar test",'e') ?> </td> <td><label><input type="checkbox" name="lumbar_test" value="yes" /></label></td></tr>
 762
 763 </table>
 764
 765 <table>
 766
 767 <tr><td> <? xl("Left slr",'e') ?> </td> <td><label><input type="checkbox" name="left_slr[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="left_slr[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 768
 769 </table>
 770
 771 <table>
 772
 773 <tr><td> <? xl("Left slr response",'e') ?> </td> <td><input type="text" name="left_slr_response"  /></td></tr>
 774
 775 </table>
 776
 777 <table>
 778
 779 <tr><td> <? xl("Right slr",'e') ?> </td> <td><label><input type="checkbox" name="right_slr[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="right_slr[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 780
 781 </table>
 782
 783 <table>
 784
 785 <tr><td> <? xl("Right slr response",'e') ?> </td> <td><input type="text" name="right_slr_response"  /></td></tr>
 786
 787 </table>
 788
 789 <table>
 790
 791 <tr><td> <? xl("Lt braggards",'e') ?> </td> <td><label><input type="checkbox" name="lt_braggards[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_braggards[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 792
 793 </table>
 794
 795 <table>
 796
 797 <tr><td> <? xl("Lt braggards response",'e') ?> </td> <td><input type="text" name="lt_braggards_response"  /></td></tr>
 798
 799 </table>
 800
 801 <table>
 802
 803 <tr><td> <? xl("Rt braggards",'e') ?> </td> <td><label><input type="checkbox" name="rt_braggards[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_braggards[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 804
 805 </table>
 806
 807 <table>
 808
 809 <tr><td> <? xl("Rt braggards response",'e') ?> </td> <td><input type="text" name="rt_braggards_response"  /></td></tr>
 810
 811 </table>
 812
 813 <table>
 814
 815 <tr><td> <? xl("Lt patricks faber",'e') ?> </td> <td><label><input type="checkbox" name="lt_patricks_faber[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_patricks_faber[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 816
 817 </table>
 818
 819 <table>
 820
 821 <tr><td> <? xl("Lt patricks faber response",'e') ?> </td> <td><input type="text" name="lt_patricks_faber_response"  /></td></tr>
 822
 823 </table>
 824
 825 <table>
 826
 827 <tr><td> <? xl("Rt patricks faber",'e') ?> </td> <td><label><input type="checkbox" name="rt_patricks_faber[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_patricks_faber[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 828
 829 </table>
 830
 831 <table>
 832
 833 <tr><td> <? xl("Rt patricks faber response",'e') ?> </td> <td><input type="text" name="rt_patricks_faber_response"  /></td></tr>
 834
 835 </table>
 836
 837 <table>
 838
 839 <tr><td> <? xl("Lt elys",'e') ?> </td> <td><label><input type="checkbox" name="lt_elys[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_elys[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 840
 841 </table>
 842
 843 <table>
 844
 845 <tr><td> <? xl("Lt elys response",'e') ?> </td> <td><input type="text" name="lt_elys_response"  /></td></tr>
 846
 847 </table>
 848
 849 <table>
 850
 851 <tr><td> <? xl("Rt elys",'e') ?> </td> <td><label><input type="checkbox" name="rt_elys[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_elys[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 852
 853 </table>
 854
 855 <table>
 856
 857 <tr><td> <? xl("Rt elys response",'e') ?> </td> <td><input type="text" name="rt_elys_response"  /></td></tr>
 858
 859 </table>
 860
 861 <table>
 862
 863 <tr><td> <? xl("Milgrams",'e') ?> </td> <td><label><input type="checkbox" name="milgrams[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="milgrams[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 864
 865 </table>
 866
 867 <table>
 868
 869 <tr><td> <? xl("Milgrams response",'e') ?> </td> <td><input type="text" name="milgrams_response"  /></td></tr>
 870
 871 </table>
 872
 873 <table>
 874
 875 <tr><td> <? xl("Lt yeomans",'e') ?> </td> <td><label><input type="checkbox" name="lt_yeomans[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="lt_yeomans[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 876
 877 </table>
 878
 879 <table>
 880
 881 <tr><td> <? xl("Lt yeomans response",'e') ?> </td> <td><input type="text" name="lt_yeomans_response"  /></td></tr>
 882
 883 </table>
 884
 885 <table>
 886
 887 <tr><td> <? xl("Rt yeomans",'e') ?> </td> <td><label><input type="checkbox" name="rt_yeomans[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="rt_yeomans[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
 888
 889 </table>
 890
 891 <table>
 892
 893 <tr><td> <? xl("Rt yeomans response",'e') ?> </td> <td><input type="text" name="rt_yeomans_response"  /></td></tr>
 894
 895 </table>
 896 <br>
 897 <h3> <? xl("Palpatory Tenderness",'e') ?> </h3>
 898
 899 <table>
 900
 901 <tr><td> <? xl("Oc c1",'e') ?> </td> <td><label><input type="checkbox" name="oc_c1[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="oc_c1[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 902
 903 </table>
 904
 905 <table>
 906
 907 <tr><td> <? xl("C1 c2",'e') ?> </td> <td><label><input type="checkbox" name="c1_c2[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c1_c2[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 908
 909 </table>
 910
 911 <table>
 912
 913 <tr><td> <? xl("C2 c3",'e') ?> </td> <td><label><input type="checkbox" name="c2_c3[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c2_c3[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 914
 915 </table>
 916
 917 <table>
 918
 919 <tr><td> <? xl("C3 c4",'e') ?> </td> <td><label><input type="checkbox" name="c3_c4[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c3_c4[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 920
 921 </table>
 922
 923 <table>
 924
 925 <tr><td> <? xl("C4 c5",'e') ?> </td> <td><label><input type="checkbox" name="c4_c5[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c4_c5[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 926
 927 </table>
 928
 929 <table>
 930
 931 <tr><td> <? xl("C5 c6",'e') ?> </td> <td><label><input type="checkbox" name="c5_c6[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c5_c6[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 932
 933 </table>
 934
 935 <table>
 936
 937 <tr><td> <? xl("C6 c7",'e') ?> </td> <td><label><input type="checkbox" name="c6_c7[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c6_c7[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 938
 939 </table>
 940
 941 <table>
 942
 943 <tr><td> <? xl("C7 t1",'e') ?> </td> <td><label><input type="checkbox" name="c7_t1[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="c7_t1[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 944
 945 </table>
 946
 947 <table>
 948
 949 <tr><td> <? xl("T1 t2",'e') ?> </td> <td><label><input type="checkbox" name="t1_t2[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t1_t2[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 950
 951 </table>
 952
 953 <table>
 954
 955 <tr><td> <? xl("T2 t3",'e') ?> </td> <td><label><input type="checkbox" name="t2_t3[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t2_t3[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 956
 957 </table>
 958
 959 <table>
 960
 961 <tr><td> <? xl("T3 t4",'e') ?> </td> <td><label><input type="checkbox" name="t3_t4[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t3_t4[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 962
 963 </table>
 964
 965 <table>
 966
 967 <tr><td> <? xl("T4 t5",'e') ?> </td> <td><label><input type="checkbox" name="t4_t5[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t4_t5[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 968
 969 </table>
 970
 971 <table>
 972
 973 <tr><td> <? xl("T5 t6",'e') ?> </td> <td><label><input type="checkbox" name="t5_t6[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t5_t6[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 974
 975 </table>
 976
 977 <table>
 978
 979 <tr><td> <? xl("T6 t7",'e') ?> </td> <td><label><input type="checkbox" name="t6_t7[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t6_t7[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 980
 981 </table>
 982
 983 <table>
 984
 985 <tr><td> <? xl("T7 t8",'e') ?> </td> <td><label><input type="checkbox" name="t7_t8[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t7_t8[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 986
 987 </table>
 988
 989 <table>
 990
 991 <tr><td> <? xl("T8 t9",'e') ?> </td> <td><label><input type="checkbox" name="t8_t9[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t8_t9[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 992
 993 </table>
 994
 995 <table>
 996
 997 <tr><td> <? xl("T9 t10",'e') ?> </td> <td><label><input type="checkbox" name="t9_t10[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t9_t10[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
 998
 999 </table>
1000
1001 <table>
1002
1003 <tr><td> <? xl("T10 t11",'e') ?> </td> <td><label><input type="checkbox" name="t10_t11[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t10_t11[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1004
1005 </table>
1006
1007 <table>
1008
1009 <tr><td> <? xl("T11 t12",'e') ?> </td> <td><label><input type="checkbox" name="t11_t12[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t11_t12[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1010
1011 </table>
1012
1013 <table>
1014
1015 <tr><td> <? xl("T12 l1",'e') ?> </td> <td><label><input type="checkbox" name="t12_l1[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="t12_l1[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1016
1017 </table>
1018
1019 <table>
1020
1021 <tr><td> <? xl("L1 l2",'e') ?> </td> <td><label><input type="checkbox" name="l1_l2[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="l1_l2[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1022
1023 </table>
1024
1025 <table>
1026
1027 <tr><td> <? xl("L2 l3",'e') ?> </td> <td><label><input type="checkbox" name="l2_l3[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="l2_l3[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1028
1029 </table>
1030
1031 <table>
1032
1033 <tr><td> <? xl("L3 l4",'e') ?> </td> <td><label><input type="checkbox" name="l3_l4[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="l3_l4[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1034
1035 </table>
1036
1037 <table>
1038
1039 <tr><td> <? xl("L4 l5",'e') ?> </td> <td><label><input type="checkbox" name="l4_l5[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="l4_l5[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1040
1041 </table>
1042
1043 <table>
1044
1045 <tr><td> <? xl("L5 si",'e') ?> </td> <td><label><input type="checkbox" name="l5_si[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="l5_si[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1046
1047 </table>
1048
1049 <table>
1050
1051 <tr><td> <? xl("Si",'e') ?> </td> <td><label><input type="checkbox" name="si[]" value="Left" /> <? xl("Left",'e') ?> </label> <label><input type="checkbox" name="si[]" value="Right" /> <? xl("Right",'e') ?> </label></td></tr>
1052
1053 </table>
1054
1055 <table>
1056
1057 <tr><td> <? xl("Reflexes",'e') ?> </td> <td><label><input type="checkbox" name="reflexes" value="yes" /></label></td></tr>
1058
1059 </table>
1060
1061 <table>
1062
1063 <tr><td> <? xl("Bicep left",'e') ?> </td> <td><select name="bicep_left" >
1064 <option value=""></option>
1065 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1066 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1067 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1068 </select></td></tr>
1069
1070 </table>
1071
1072 <table>
1073
1074 <tr><td> <? xl("Bicep right",'e') ?> </td> <td><select name="bicep_right" >
1075 <option value=""></option>
1076 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1077 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1078 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1079 </select></td></tr>
1080
1081 </table>
1082
1083 <table>
1084
1085 <tr><td> <? xl("Brachio left",'e') ?> </td> <td><select name="brachio_left" >
1086 <option value=""></option>
1087 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1088 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1089 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1090 </select></td></tr>
1091
1092 </table>
1093
1094 <table>
1095
1096 <tr><td> <? xl("Brachio right",'e') ?> </td> <td><select name="brachio_right" >
1097 <option value=""></option>
1098 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1099 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1100 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1101 </select></td></tr>
1102
1103 </table>
1104
1105 <table>
1106
1107 <tr><td> <? xl("Tricep left",'e') ?> </td> <td><select name="tricep_left" >
1108 <option value=""></option>
1109 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1110 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1111 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1112 </select></td></tr>
1113
1114 </table>
1115
1116 <table>
1117
1118 <tr><td> <? xl("Tricep right",'e') ?> </td> <td><select name="tricep_right" >
1119 <option value=""></option>
1120 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1121 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1122 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1123 </select></td></tr>
1124
1125 </table>
1126
1127 <table>
1128
1129 <tr><td> <? xl("Patellar left",'e') ?> </td> <td><select name="patellar_left" >
1130 <option value=""></option>
1131 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1132 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1133 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1134 </select></td></tr>
1135
1136 </table>
1137
1138 <table>
1139
1140 <tr><td> <? xl("Patellar right",'e') ?> </td> <td><select name="patellar_right" >
1141 <option value=""></option>
1142 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1143 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1144 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1145 </select></td></tr>
1146
1147 </table>
1148
1149 <table>
1150
1151 <tr><td> <? xl("Achilles left",'e') ?> </td> <td><select name="achilles_left" >
1152 <option value=""></option>
1153 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1154 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1155 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1156 </select></td></tr>
1157
1158 </table>
1159
1160 <table>
1161
1162 <tr><td> <? xl("Achilles right",'e') ?> </td> <td><select name="achilles_right" >
1163 <option value=""></option>
1164 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1165 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1166 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1167 </select></td></tr>
1168
1169 </table>
1170
1171 <table>
1172
1173 <tr><td> <? xl("Vbi",'e') ?> </td> <td><label><input type="checkbox" name="vbi[]" value="Negative" /> <? xl("Negative",'e') ?> </label> <label><input type="checkbox" name="vbi[]" value="Positive" /> <? xl("Positive",'e') ?> </label></td></tr>
1174
1175 </table>
1176
1177 <table>
1178
1179 <tr><td> <? xl("Neurology",'e') ?> </td> <td><label><input type="checkbox" name="neurology" value="yes" /></label></td></tr>
1180
1181 </table>
1182
1183 <table>
1184
1185 <tr><td> <? xl("C5 motor",'e') ?> </td> <td><select name="c5_motor" >
1186 <option value=""></option>
1187 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1188 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1189 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1190 </select></td></tr>
1191
1192 </table>
1193
1194 <table>
1195
1196 <tr><td> <? xl("C5 sensation",'e') ?> </td> <td><select name="c5_sensation" >
1197 <option value=""></option>
1198 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1199 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1200 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1201 </select></td></tr>
1202
1203 </table>
1204
1205 <table>
1206
1207 <tr><td> <? xl("C6 motor",'e') ?> </td> <td><select name="c6_motor" >
1208 <option value=""></option>
1209 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1210 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1211 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1212 </select></td></tr>
1213
1214 </table>
1215
1216 <table>
1217
1218 <tr><td> <? xl("C6 sensation",'e') ?> </td> <td><select name="c6_sensation" >
1219 <option value=""></option>
1220 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1221 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1222 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1223 </select></td></tr>
1224
1225 </table>
1226
1227 <table>
1228
1229 <tr><td> <? xl("C7 motor",'e') ?> </td> <td><select name="c7_motor" >
1230 <option value=""></option>
1231 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1232 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1233 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1234 </select></td></tr>
1235
1236 </table>
1237
1238 <table>
1239
1240 <tr><td> <? xl("C7 sensation",'e') ?> </td> <td><select name="c7_sensation" >
1241 <option value=""></option>
1242 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1243 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1244 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1245 </select></td></tr>
1246
1247 </table>
1248
1249 <table>
1250
1251 <tr><td> <? xl("C8 motor",'e') ?> </td> <td><select name="c8_motor" >
1252 <option value=""></option>
1253 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1254 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1255 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1256 </select></td></tr>
1257
1258 </table>
1259
1260 <table>
1261
1262 <tr><td> <? xl("C8 sensation",'e') ?> </td> <td><select name="c8_sensation" >
1263 <option value=""></option>
1264 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1265 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1266 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1267 </select></td></tr>
1268
1269 </table>
1270
1271 <table>
1272
1273 <tr><td> <? xl("T1 motor",'e') ?> </td> <td><select name="t1_motor" >
1274 <option value=""></option>
1275 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1276 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1277 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1278 </select></td></tr>
1279
1280 </table>
1281
1282 <table>
1283
1284 <tr><td> <? xl("T1 sensation",'e') ?> </td> <td><select name="t1_sensation" >
1285 <option value=""></option>
1286 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1287 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1288 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1289 </select></td></tr>
1290
1291 </table>
1292
1293 <table>
1294
1295 <tr><td> <? xl("L4 motor",'e') ?> </td> <td><select name="l4_motor" >
1296 <option value=""></option>
1297 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1298 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1299 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1300 </select></td></tr>
1301
1302 </table>
1303
1304 <table>
1305
1306 <tr><td> <? xl("L4 sensation",'e') ?> </td> <td><select name="l4_sensation" >
1307 <option value=""></option>
1308 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1309 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1310 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1311 </select></td></tr>
1312
1313 </table>
1314
1315 <table>
1316
1317 <tr><td> <? xl("L5 motor",'e') ?> </td> <td><select name="l5_motor" >
1318 <option value=""></option>
1319 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1320 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1321 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1322 </select></td></tr>
1323
1324 </table>
1325
1326 <table>
1327
1328 <tr><td> <? xl("L5 sensation",'e') ?> </td> <td><select name="l5_sensation" >
1329 <option value=""></option>
1330 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1331 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1332 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1333 </select></td></tr>
1334
1335 </table>
1336
1337 <table>
1338
1339 <tr><td> <? xl("S1 motor",'e') ?> </td> <td><select name="s1_motor" >
1340 <option value=""></option>
1341 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1342 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1343 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1344 </select></td></tr>
1345
1346 </table>
1347
1348 <table>
1349
1350 <tr><td> <? xl("S1 sensation",'e') ?> </td> <td><select name="s1_sensation" >
1351 <option value=""></option>
1352 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1353 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1354 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1355 </select></td></tr>
1356
1357 </table>
1358
1359 <table>
1360
1361 <tr><td> <? xl("Coordination sensation",'e') ?> </td> <td><select name="coordination_sensation" >
1362 <option value=""></option>
1363 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1364 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1365 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1366 </select></td></tr>
1367
1368 </table>
1369
1370 <table>
1371
1372 <tr><td> <? xl("Muscle testing",'e') ?> </td> <td><label><input type="checkbox" name="muscle_testing" value="yes" /></label></td></tr>
1373
1374 </table>
1375
1376 <table>
1377
1378 <tr><td> <? xl("Cerv flex strgth",'e') ?> </td> <td><select name="cerv_flex_strgth" >
1379 <option value=""></option>
1380 <option value="0">0</option>
1381 <option value="1">1</option>
1382 <option value="2">2</option>
1383 <option value="3">3</option>
1384 <option value="4">4</option>
1385 <option value="5">5</option>
1386 </select></td></tr>
1387
1388 </table>
1389
1390 <table>
1391
1392 <tr><td> <? xl("Cerv flex tone",'e') ?> </td> <td><select name="cerv_flex_tone" >
1393 <option value=""></option>
1394 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1395 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1396 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1397 </select></td></tr>
1398
1399 </table>
1400
1401 <table>
1402
1403 <tr><td> <? xl("Cerv flex spasm",'e') ?> </td> <td><label><input type="checkbox" name="cerv_flex_spasm" value="yes" /></label></td></tr>
1404
1405 </table>
1406
1407 <table>
1408
1409 <tr><td> <? xl("Cerv flex pain",'e') ?> </td> <td><select name="cerv_flex_pain" >
1410 <option value=""></option>
1411 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1412 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1413 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1414 </select></td></tr>
1415
1416 </table>
1417
1418 <table>
1419
1420 <tr><td> <? xl("Scm strgth",'e') ?> </td> <td><select name="scm_strgth" >
1421 <option value=""></option>
1422 <option value="0">0</option>
1423 <option value="1">1</option>
1424 <option value="2">2</option>
1425 <option value="3">3</option>
1426 <option value="4">4</option>
1427 <option value="5">5</option>
1428 </select></td></tr>
1429
1430 </table>
1431
1432 <table>
1433
1434 <tr><td> <? xl("Scm tone",'e') ?> </td> <td><select name="scm_tone" >
1435 <option value=""></option>
1436 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1437 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1438 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1439 </select></td></tr>
1440
1441 </table>
1442
1443 <table>
1444
1445 <tr><td> <? xl("Scm spasm",'e') ?> </td> <td><label><input type="checkbox" name="scm_spasm" value="yes" /></label></td></tr>
1446
1447 </table>
1448
1449 <table>
1450
1451 <tr><td> <? xl("Scm pain",'e') ?> </td> <td><select name="scm_pain" >
1452 <option value=""></option>
1453 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1454 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1455 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1456 </select></td></tr>
1457
1458 </table>
1459
1460 <table>
1461
1462 <tr><td> <? xl("Upper trap strgth",'e') ?> </td> <td><select name="upper_trap_strgth" >
1463 <option value=""></option>
1464 <option value="0">0</option>
1465 <option value="1">1</option>
1466 <option value="2">2</option>
1467 <option value="3">3</option>
1468 <option value="4">4</option>
1469 <option value="5">5</option>
1470 </select></td></tr>
1471
1472 </table>
1473
1474 <table>
1475
1476 <tr><td> <? xl("Upper trap tone",'e') ?> </td> <td><select name="upper_trap_tone" >
1477 <option value=""></option>
1478 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1479 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1480 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1481 </select></td></tr>
1482
1483 </table>
1484
1485 <table>
1486
1487 <tr><td> <? xl("Upper trap spasm",'e') ?> </td> <td><label><input type="checkbox" name="upper_trap_spasm" value="yes" /></label></td></tr>
1488
1489 </table>
1490
1491 <table>
1492
1493 <tr><td> <? xl("Upper trap pain",'e') ?> </td> <td><select name="upper_trap_pain" >
1494 <option value=""></option>
1495 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1496 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1497 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1498 </select></td></tr>
1499
1500 </table>
1501
1502 <table>
1503
1504 <tr><td> <? xl("Mid trap strgth",'e') ?> </td> <td><select name="mid_trap_strgth" >
1505 <option value=""></option>
1506 <option value="0">0</option>
1507 <option value="1">1</option>
1508 <option value="2">2</option>
1509 <option value="3">3</option>
1510 <option value="4">4</option>
1511 <option value="5">5</option>
1512 </select></td></tr>
1513
1514 </table>
1515
1516 <table>
1517
1518 <tr><td> <? xl("Mid trap tone",'e') ?> </td> <td><select name="mid_trap_tone" >
1519 <option value=""></option>
1520 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1521 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1522 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1523 </select></td></tr>
1524
1525 </table>
1526
1527 <table>
1528
1529 <tr><td> <? xl("Mid trap spasm",'e') ?> </td> <td><label><input type="checkbox" name="mid_trap_spasm" value="yes" /></label></td></tr>
1530
1531 </table>
1532
1533 <table>
1534
1535 <tr><td> <? xl("Mid trap pain",'e') ?> </td> <td><select name="mid_trap_pain" >
1536 <option value=""></option>
1537 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1538 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1539 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1540 </select></td></tr>
1541
1542 </table>
1543
1544 <table>
1545
1546 <tr><td> <? xl("Lower trap strgth",'e') ?> </td> <td><select name="lower_trap_strgth" >
1547 <option value=""></option>
1548 <option value="0">0</option>
1549 <option value="1">1</option>
1550 <option value="2">2</option>
1551 <option value="3">3</option>
1552 <option value="4">4</option>
1553 <option value="5">5</option>
1554 </select></td></tr>
1555
1556 </table>
1557
1558 <table>
1559
1560 <tr><td> <? xl("Lower trap tone",'e') ?> </td> <td><select name="lower_trap_tone" >
1561 <option value=""></option>
1562 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1563 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1564 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1565 </select></td></tr>
1566
1567 </table>
1568
1569 <table>
1570
1571 <tr><td> <? xl("Lower trap spasm",'e') ?> </td> <td><label><input type="checkbox" name="lower_trap_spasm" value="yes" /></label></td></tr>
1572
1573 </table>
1574
1575 <table>
1576
1577 <tr><td> <? xl("Lower trap pain",'e') ?> </td> <td><select name="lower_trap_pain" >
1578 <option value=""></option>
1579 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1580 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1581 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1582 </select></td></tr>
1583
1584 </table>
1585
1586 <table>
1587
1588 <tr><td> <? xl("Scalenes strgth",'e') ?> </td> <td><select name="scalenes_strgth" >
1589 <option value=""></option>
1590 <option value="0">0</option>
1591 <option value="1">1</option>
1592 <option value="2">2</option>
1593 <option value="3">3</option>
1594 <option value="4">4</option>
1595 <option value="5">5</option>
1596 </select></td></tr>
1597
1598 </table>
1599
1600 <table>
1601
1602 <tr><td> <? xl("Scalenes tone",'e') ?> </td> <td><select name="scalenes_tone" >
1603 <option value=""></option>
1604 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1605 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1606 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1607 </select></td></tr>
1608
1609 </table>
1610
1611 <table>
1612
1613 <tr><td> <? xl("Scalenes spasm",'e') ?> </td> <td><label><input type="checkbox" name="scalenes_spasm" value="yes" /></label></td></tr>
1614
1615 </table>
1616
1617 <table>
1618
1619 <tr><td> <? xl("Scalenes pain",'e') ?> </td> <td><select name="scalenes_pain" >
1620 <option value=""></option>
1621 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1622 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1623 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1624 </select></td></tr>
1625
1626 </table>
1627
1628 <table>
1629
1630 <tr><td> <? xl("Subscap strgth",'e') ?> </td> <td><select name="subscap_strgth" >
1631 <option value=""></option>
1632 <option value="0">0</option>
1633 <option value="1">1</option>
1634 <option value="2">2</option>
1635 <option value="3">3</option>
1636 <option value="4">4</option>
1637 <option value="5">5</option>
1638 </select></td></tr>
1639
1640 </table>
1641
1642 <table>
1643
1644 <tr><td> <? xl("Subscap tone",'e') ?> </td> <td><select name="subscap_tone" >
1645 <option value=""></option>
1646 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1647 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1648 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1649 </select></td></tr>
1650
1651 </table>
1652
1653 <table>
1654
1655 <tr><td> <? xl("Subscap spasm",'e') ?> </td> <td><label><input type="checkbox" name="subscap_spasm" value="yes" /></label></td></tr>
1656
1657 </table>
1658
1659 <table>
1660
1661 <tr><td> <? xl("Subscap pain",'e') ?> </td> <td><select name="subscap_pain" >
1662 <option value=""></option>
1663 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1664 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1665 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1666 </select></td></tr>
1667
1668 </table>
1669
1670 <table>
1671
1672 <tr><td> <? xl("Supraspin strgth",'e') ?> </td> <td><select name="supraspin_strgth" >
1673 <option value=""></option>
1674 <option value="0">0</option>
1675 <option value="1">1</option>
1676 <option value="2">2</option>
1677 <option value="3">3</option>
1678 <option value="4">4</option>
1679 <option value="5">5</option>
1680 </select></td></tr>
1681
1682 </table>
1683
1684 <table>
1685
1686 <tr><td> <? xl("Supraspin tone",'e') ?> </td> <td><select name="supraspin_tone" >
1687 <option value=""></option>
1688 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1689 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1690 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1691 </select></td></tr>
1692
1693 </table>
1694
1695 <table>
1696
1697 <tr><td> <? xl("Supraspin spasm",'e') ?> </td> <td><label><input type="checkbox" name="supraspin_spasm" value="yes" /></label></td></tr>
1698
1699 </table>
1700
1701 <table>
1702
1703 <tr><td> <? xl("Supraspin pain",'e') ?> </td> <td><select name="supraspin_pain" >
1704 <option value=""></option>
1705 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1706 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1707 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1708 </select></td></tr>
1709
1710 </table>
1711
1712 <table>
1713
1714 <tr><td> <? xl("Teres strgth",'e') ?> </td> <td><select name="teres_strgth" >
1715 <option value=""></option>
1716 <option value="0">0</option>
1717 <option value="1">1</option>
1718 <option value="2">2</option>
1719 <option value="3">3</option>
1720 <option value="4">4</option>
1721 <option value="5">5</option>
1722 </select></td></tr>
1723
1724 </table>
1725
1726 <table>
1727
1728 <tr><td> <? xl("Teres tone",'e') ?> </td> <td><select name="teres_tone" >
1729 <option value=""></option>
1730 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1731 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1732 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1733 </select></td></tr>
1734
1735 </table>
1736
1737 <table>
1738
1739 <tr><td> <? xl("Teres spasm",'e') ?> </td> <td><label><input type="checkbox" name="teres_spasm" value="yes" /></label></td></tr>
1740
1741 </table>
1742
1743 <table>
1744
1745 <tr><td> <? xl("Teres pain",'e') ?> </td> <td><select name="teres_pain" >
1746 <option value=""></option>
1747 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1748 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1749 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1750 </select></td></tr>
1751
1752 </table>
1753
1754 <table>
1755
1756 <tr><td> <? xl("Quadriceps strgth",'e') ?> </td> <td><select name="quadriceps_strgth" >
1757 <option value=""></option>
1758 <option value="0">0</option>
1759 <option value="1">1</option>
1760 <option value="2">2</option>
1761 <option value="3">3</option>
1762 <option value="4">4</option>
1763 <option value="5">5</option>
1764 </select></td></tr>
1765
1766 </table>
1767
1768 <table>
1769
1770 <tr><td> <? xl("Quadriceps tone",'e') ?> </td> <td><select name="quadriceps_tone" >
1771 <option value=""></option>
1772 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1773 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1774 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1775 </select></td></tr>
1776
1777 </table>
1778
1779 <table>
1780
1781 <tr><td> <? xl("Quadriceps spasm",'e') ?> </td> <td><label><input type="checkbox" name="quadriceps_spasm" value="yes" /></label></td></tr>
1782
1783 </table>
1784
1785 <table>
1786
1787 <tr><td> <? xl("Quadriceps pain",'e') ?> </td> <td><select name="quadriceps_pain" >
1788 <option value=""></option>
1789 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1790 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1791 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1792 </select></td></tr>
1793
1794 </table>
1795
1796 <table>
1797
1798 <tr><td> <? xl("Psoas strgth",'e') ?> </td> <td><select name="psoas_strgth" >
1799 <option value=""></option>
1800 <option value="0">0</option>
1801 <option value="1">1</option>
1802 <option value="2">2</option>
1803 <option value="3">3</option>
1804 <option value="4">4</option>
1805 <option value="5">5</option>
1806 </select></td></tr>
1807
1808 </table>
1809
1810 <table>
1811
1812 <tr><td> <? xl("Psoas tone",'e') ?> </td> <td><select name="psoas_tone" >
1813 <option value=""></option>
1814 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1815 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1816 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1817 </select></td></tr>
1818
1819 </table>
1820
1821 <table>
1822
1823 <tr><td> <? xl("Psoas spasm",'e') ?> </td> <td><label><input type="checkbox" name="psoas_spasm" value="yes" /></label></td></tr>
1824
1825 </table>
1826
1827 <table>
1828
1829 <tr><td> <? xl("Psoas pain",'e') ?> </td> <td><select name="psoas_pain" >
1830 <option value=""></option>
1831 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1832 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1833 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1834 </select></td></tr>
1835
1836 </table>
1837
1838 <table>
1839
1840 <tr><td> <? xl("Tfl strgth",'e') ?> </td> <td><select name="tfl_strgth" >
1841 <option value=""></option>
1842 <option value="0">0</option>
1843 <option value="1">1</option>
1844 <option value="2">2</option>
1845 <option value="3">3</option>
1846 <option value="4">4</option>
1847 <option value="5">5</option>
1848 </select></td></tr>
1849
1850 </table>
1851
1852 <table>
1853
1854 <tr><td> <? xl("Tfl tone",'e') ?> </td> <td><select name="tfl_tone" >
1855 <option value=""></option>
1856 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1857 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1858 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1859 </select></td></tr>
1860
1861 </table>
1862
1863 <table>
1864
1865 <tr><td> <? xl("Tfl spasm",'e') ?> </td> <td><label><input type="checkbox" name="tfl_spasm" value="yes" /></label></td></tr>
1866
1867 </table>
1868
1869 <table>
1870
1871 <tr><td> <? xl("Tfl pain",'e') ?> </td> <td><select name="tfl_pain" >
1872 <option value=""></option>
1873 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1874 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1875 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1876 </select></td></tr>
1877
1878 </table>
1879
1880 <table>
1881
1882 <tr><td> <? xl("Piriformis strgth",'e') ?> </td> <td><select name="piriformis_strgth" >
1883 <option value=""></option>
1884 <option value="0">0</option>
1885 <option value="1">1</option>
1886 <option value="2">2</option>
1887 <option value="3">3</option>
1888 <option value="4">4</option>
1889 <option value="5">5</option>
1890 </select></td></tr>
1891
1892 </table>
1893
1894 <table>
1895
1896 <tr><td> <? xl("Piriformis tone",'e') ?> </td> <td><select name="piriformis_tone" >
1897 <option value=""></option>
1898 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1899 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1900 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1901 </select></td></tr>
1902
1903 </table>
1904
1905 <table>
1906
1907 <tr><td> <? xl("Piriformis spasm",'e') ?> </td> <td><label><input type="checkbox" name="piriformis_spasm" value="yes" /></label></td></tr>
1908
1909 </table>
1910
1911 <table>
1912
1913 <tr><td> <? xl("Piriformis pain",'e') ?> </td> <td><select name="piriformis_pain" >
1914 <option value=""></option>
1915 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1916 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1917 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1918 </select></td></tr>
1919
1920 </table>
1921
1922 <table>
1923
1924 <tr><td> <? xl("Gluteus strgth",'e') ?> </td> <td><select name="gluteus_strgth" >
1925 <option value=""></option>
1926 <option value="0">0</option>
1927 <option value="1">1</option>
1928 <option value="2">2</option>
1929 <option value="3">3</option>
1930 <option value="4">4</option>
1931 <option value="5">5</option>
1932 </select></td></tr>
1933
1934 </table>
1935
1936 <table>
1937
1938 <tr><td> <? xl("Gluteus tone",'e') ?> </td> <td><select name="gluteus_tone" >
1939 <option value=""></option>
1940 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1941 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1942 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1943 </select></td></tr>
1944
1945 </table>
1946
1947 <table>
1948
1949 <tr><td> <? xl("Gluteus spasm",'e') ?> </td> <td><label><input type="checkbox" name="gluteus_spasm" value="yes" /></label></td></tr>
1950
1951 </table>
1952
1953 <table>
1954
1955 <tr><td> <? xl("Gluteus pain",'e') ?> </td> <td><select name="gluteus_pain" >
1956 <option value=""></option>
1957 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1958 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1959 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1960 </select></td></tr>
1961
1962 </table>
1963
1964 <table>
1965
1966 <tr><td> <? xl("Hamstring strgth",'e') ?> </td> <td><select name="hamstring_strgth" >
1967 <option value=""></option>
1968 <option value="0">0</option>
1969 <option value="1">1</option>
1970 <option value="2">2</option>
1971 <option value="3">3</option>
1972 <option value="4">4</option>
1973 <option value="5">5</option>
1974 </select></td></tr>
1975
1976 </table>
1977
1978 <table>
1979
1980 <tr><td> <? xl("Hamstring tone",'e') ?> </td> <td><select name="hamstring_tone" >
1981 <option value=""></option>
1982 <option value="Increase"> <? xl("Increase",'e') ?> </option>
1983 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
1984 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
1985 </select></td></tr>
1986
1987 </table>
1988
1989 <table>
1990
1991 <tr><td> <? xl("Hamstring spasm",'e') ?> </td> <td><label><input type="checkbox" name="hamstring_spasm" value="yes" /></label></td></tr>
1992
1993 </table>
1994
1995 <table>
1996
1997 <tr><td> <? xl("Hamstring pain",'e') ?> </td> <td><select name="hamstring_pain" >
1998 <option value=""></option>
1999 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2000 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2001 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2002 </select></td></tr>
2003
2004 </table>
2005
2006 <table>
2007
2008 <tr><td> <? xl("Quad lum strgth",'e') ?> </td> <td><select name="quad_lum_strgth" >
2009 <option value=""></option>
2010 <option value="0">0</option>
2011 <option value="1">1</option>
2012 <option value="2">2</option>
2013 <option value="3">3</option>
2014 <option value="4">4</option>
2015 <option value="5">5</option>
2016 </select></td></tr>
2017
2018 </table>
2019
2020 <table>
2021
2022 <tr><td> <? xl("Quad lum tone",'e') ?> </td> <td><select name="quad_lum_tone" >
2023 <option value=""></option>
2024 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2025 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2026 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2027 </select></td></tr>
2028
2029 </table>
2030
2031 <table>
2032
2033 <tr><td> <? xl("Quad lum spasm",'e') ?> </td> <td><label><input type="checkbox" name="quad_lum_spasm" value="yes" /></label></td></tr>
2034
2035 </table>
2036
2037 <table>
2038
2039 <tr><td> <? xl("Quad lum pain",'e') ?> </td> <td><select name="quad_lum_pain" >
2040 <option value=""></option>
2041 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2042 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2043 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2044 </select></td></tr>
2045
2046 </table>
2047
2048 <table>
2049
2050 <tr><td> <? xl("Lat dorsi strgth",'e') ?> </td> <td><select name="lat_dorsi_strgth" >
2051 <option value=""></option>
2052 <option value="0">0</option>
2053 <option value="1">1</option>
2054 <option value="2">2</option>
2055 <option value="3">3</option>
2056 <option value="4">4</option>
2057 <option value="5">5</option>
2058 </select></td></tr>
2059
2060 </table>
2061
2062 <table>
2063
2064 <tr><td> <? xl("Lat dorsi tone",'e') ?> </td> <td><select name="lat_dorsi_tone" >
2065 <option value=""></option>
2066 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2067 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2068 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2069 </select></td></tr>
2070
2071 </table>
2072
2073 <table>
2074
2075 <tr><td> <? xl("Lat dorsi spasm",'e') ?> </td> <td><label><input type="checkbox" name="lat_dorsi_spasm" value="yes" /></label></td></tr>
2076
2077 </table>
2078
2079 <table>
2080
2081 <tr><td> <? xl("Lat dorsi pain",'e') ?> </td> <td><select name="lat_dorsi_pain" >
2082 <option value=""></option>
2083 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2084 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2085 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2086 </select></td></tr>
2087
2088 </table>
2089
2090 <table>
2091
2092 <tr><td> <? xl("Infrspinatus strgth",'e') ?> </td> <td><select name="infrspinatus_strgth" >
2093 <option value=""></option>
2094 <option value="0">0</option>
2095 <option value="1">1</option>
2096 <option value="2">2</option>
2097 <option value="3">3</option>
2098 <option value="4">4</option>
2099 <option value="5">5</option>
2100 </select></td></tr>
2101
2102 </table>
2103
2104 <table>
2105
2106 <tr><td> <? xl("Infrspinatus tone",'e') ?> </td> <td><select name="infrspinatus_tone" >
2107 <option value=""></option>
2108 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2109 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2110 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2111 </select></td></tr>
2112
2113 </table>
2114
2115 <table>
2116
2117 <tr><td> <? xl("Infrspinatus spasm",'e') ?> </td> <td><label><input type="checkbox" name="infrspinatus_spasm" value="yes" /></label></td></tr>
2118
2119 </table>
2120
2121 <table>
2122
2123 <tr><td> <? xl("Infrspinatus pain",'e') ?> </td> <td><select name="infrspinatus_pain" >
2124 <option value=""></option>
2125 <option value="Increase"> <? xl("Increase",'e') ?> </option>
2126 <option value="Decrease"> <? xl("Decrease",'e') ?> </option>
2127 <option value="Within Normal"> <? xl("Within Normal",'e') ?> </option>
2128 </select></td></tr>
2129
2130 </table>
2131
2132 <table>
2133
2134 <tr><td> <? xl("Diagnosis",'e') ?> </td> <td><label><input type="checkbox" name="diagnosis[]" value="Cervical" /> <? xl("Cervical",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="Thoracic" /> <? xl("Thoracic",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="Lumbar" /> <? xl("Lumbar",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="SI" /> <? xl("SI",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="Dysfunction" /> <? xl("Dysfunction",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="Strain Ligamentous Injury" /> <? xl("Strain Ligamentous Injury",'e') ?> </label> <label><input type="checkbox" name="diagnosis[]" value="Muscle Spasms" /> <? xl("Muscle Spasms",'e') ?> </label></td></tr>
2135
2136 </table>
2137
2138 <table>
2139
2140 <tr><td> <? xl("Diagnosis other",'e') ?> </td> <td><input type="text" name="diagnosis_other"  /></td></tr>
2141
2142 </table>
2143
2144 <table>
2145
2146 <tr><td> <? xl("Treatment plan",'e') ?> </td> <td><label><input type="checkbox" name="treatment_plan[]" value="Manual Manipulation" /> <? xl("Manual Manipulation",'e') ?> </label> <label><input type="checkbox" name="treatment_plan[]" value="Manual Therapy Massage" /> <? xl("Manual Therapy Massage",'e') ?> </label> <label><input type="checkbox" name="treatment_plan[]" value="Exercise Prescription" /> <? xl("Exercise Prescription",'e') ?> </label></td></tr>
2147
2148 </table>
2149
2150 <table>
2151
2152 <tr><td> <? xl("Treatment plan other",'e') ?> </td> <td><input type="text" name="treatment_plan_other"  /></td></tr>
2153
2154 </table>
2155
2156 <table>
2157
2158 <tr><td> <? xl("Frequency",'e') ?> </td> <td><label><input type="checkbox" name="frequency[]" value="4-8 Tx" /> <? xl("4-8 Tx",'e') ?> </label> <label><input type="checkbox" name="frequency[]" value="12-15 Tx Then Re-Exam" /> <? xl("12-15 Tx Then Re-Exam",'e') ?> </label> <label><input type="checkbox" name="frequency[]" value="PRN Flare-Up" /> <? xl("PRN Flare-Up",'e') ?> </label></td></tr>
2159
2160 </table>
2161
2162 <table>
2163
2164 <tr><td> <? xl("Frequency other",'e') ?> </td> <td><input type="text" name="frequency_other"  /></td></tr>
2165
2166 </table>
2167 <table></table><input type="submit" name="submit form" value="submit form" />
2168 </form>
2169 <?php
2170 formFooter();
2171 ?>