contrib/forms/physician_history/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 include_once("$srcdir/lists.inc");
   7 $frmn = 'form_physician_history';
   8 $ftitle = 'Physician history';
   9 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
  10 if ($old) {
  11   $dt = sqlFetchArray($old);
  12   $fid = $dt{'form_id'};
  13   if ($fid && ($fid != 0) && ($fid != '')){
  14   $fdir = $dt{'formdir'};
  15   unset($dt);
  16   $dt = formFetch($frmn, $fid);
  17   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  18   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  19   $id = $newid;
  20   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  21   exit;
  22   }
  23 }
  24 ?>
  25 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  26 "http://www.w3.org/TR/html4/loose.dtd">
  27
  28 <html>
  29 <head>
  30 <?php html_header_show();?>
  31 <title>Physician history</title>
  32 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  33 <link rel="stylesheet" href="../../acog.css" type="text/css">
  34 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  35 <script language="JavaScript" src="../../acogros.js" type="text/JavaScript"></script>
  36 <script language="JavaScript" type="text/JavaScript">
  37 window.onload = initialize;
  38 </script>
  39 </head>
  40
  41 <?php
  42    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  43    if ($fres){
  44      $patient = sqlFetchArray($fres);
  45    }
  46    if ($encounter != ''){
  47    $fres=sqlStatement("select * from form_encounter where encounter=$encounter");
  48    if ($fres){
  49      $edata = sqlFetchArray($fres);
  50    }
  51    }
  52    $fres=sqlStatement("select * from history_data where pid=$pid");
  53    if ($fres){
  54      $history = sqlFetchArray($fres);
  55    }
  56 ?>
  57 <body class="body_top">
  58 <form action="<?php echo $rootdir;?>/forms/physician_history/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  59 <?php
  60 $addmenu = <<<EOL
  61 <blockquote>
  62 <small><strong>Local sections:</strong><br>
  63 <a href="#gh">Gynecologic history</a> | <a href="#oh">Obstetric history</a> |
  64 <a href="#ph">Past history</a> | <a href="#fh">Family history</a> |
  65 <a href="#sh">Social history</a> | <a href="#ros">Review of systems</a>
  66 </small>
  67 </blockquote>
  68 EOL;
  69 ?>
  70 <?php include("../../acog_menu.inc"); ?>
  71 <table width="70%"  border="0" cellspacing="0" cellpadding="4">
  72   <tr>
  73     <td width="120" align="left" valign="bottom" class="srvCaption">Patient name:</td>
  74     <td align="left" valign="bottom"><input name="pname" type="text" class="fullin" id="pname" value="<?php
  75           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  76           ?>"></td>
  77   </tr>
  78   <tr>
  79     <td width="120" align="left" valign="bottom" class="srvCaption">Birth date: </td>
  80     <td align="left" valign="bottom"><input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
  81           echo $patient{'DOB'};
  82           ?>"></td>
  83   </tr>
  84   <tr>
  85     <td width="120" align="left" valign="bottom" class="srvCaption">ID No:</td>
  86     <td align="left" valign="bottom"><input name="ph_pid" type="text" class="fullin" id="ph_pid" value="<?php
  87           echo $patient{'id'};
  88           ?>"></td>
  89   </tr>
  90   <tr>
  91     <td width="120" align="left" valign="bottom" class="srvCaption">Date</td>
  92     <td align="left" valign="bottom"><input name="ph_date" type="text" class="fullin" id="ph_date" value="<?php
  93         echo date('Y-m-d');
  94         ?>"></td>
  95   </tr>
  96 </table>
  97 <?php
  98 $tip1 = <<<EOL
  99 The <strong>Physician History</strong> can be used record the history for every type of outpatient encounter, including consultations. A new Physician History should be completed by the physician at each visit when clinically indicated.
 100 EOL;
 101 ?>
 102 <div class="srvChapter">Physician history <a href="#" onMouseOver="toolTip('<?php echo $tip1; ?>', 300)" onMouseOut="toolTip();"><img src="../../pic/mark_q.png" width="13" height="13" border="0" align="texttop"></a></div>
 103 <div style="border: solid 2px black; background-color:#FFFFFF;">
 104   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 105     <tr>
 106       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 107           <tr align="left" valign="baseline">
 108             <td width="25%" class="fibody2" id="bordR"><input name="established" type="radio" value="0" checked>
 109               New patient </td>
 110             <td width="25%" class="fibody2" id="bordR"><input name="established" type="radio" value="1">
 111               Established patient </td>
 112             <td width="20%" nowrap class="fibody2" id="bordR"><input name="consultation" type="checkbox" id="consultation" value="1">
 113               Consultation</td>
 114             <td width="30%" valign="bottom" class="fibody2"><table width="100%"  border="0" cellspacing="0" cellpadding="0">
 115                 <tr>
 116                   <td width="60%" align="left" valign="bottom"><input name="report_sent" type="checkbox" id="ph_report_sent2" value="1">
 117                     Report sent</td>
 118                   <td width="40%" align="left" valign="bottom"><input name="report_sent_date" type="text" class="fullin2" id="ph_report_sent_date2" value="YYYY-MM-DD" size="12"></td>
 119                 </tr>
 120             </table></td>
 121           </tr>
 122           <tr align="left" valign="bottom">
 123             <td colspan="2" class="fibody2" id="bordR">Primary care physician:<br>
 124                 <input name="primary_care" type="text" class="fullin2" id="primary_care"></td>
 125             <td colspan="2" class="fibody2">Who sent patient:<br>
 126                 <input name="who_sent" type="text" class="fullin2" id="who_sent"></td>
 127           </tr>
 128           <tr align="left" valign="bottom">
 129             <td colspan="2" class="fibody2" id="bordR"> Other physician(s):<br>
 130                 <input name="other_physician" type="text" class="fullin2" id="other_physician">
 131             </td>
 132             <td colspan="2" class="fibody2">&nbsp;</td>
 133           </tr>
 134       </table></td>
 135     </tr>
 136     <tr>
 137       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 138           <tr align="left" valign="baseline">
 139             <td width="50%" class="ficaption2" id="bordR">Chief complaint (CC) (<small>Required for all visits except preventive</small>):</td>
 140             <td width="50%" class="ficaption2">Current prescription medications: </td>
 141           </tr>
 142           <tr align="left" valign="baseline">
 143             <td width="50%" nowrap class="fibody2" id="bordR"><textarea name="chief_complaint" rows="3" wrap="VIRTUAL" class="fullin2" id="chief_complaint"><?php echo $edata['reason']; ?></textarea>
 144             </td>
 145             <td width="50%" nowrap class="fibody2"><textarea name="current_prescription" rows="3" wrap="VIRTUAL" class="fullin2" id="current_prescription"><?php
 146 if ($result = getListByType($pid, "medication", "id,title,comments,activity,date", 1, "all", 0)){
 147         foreach ($result as $iter) {
 148           $tmp_med[] = $iter{"title"}.' ('.$iter{"comments"}.') ';
 149         }
 150 echo join(', ', $tmp_med);
 151 }
 152 ?>
 153 </textarea></td>
 154           </tr>
 155           <tr align="left" valign="baseline">
 156             <td width="50%" valign="bottom" class="ficaption2" id="bordR">History of present ilness (HPI): <br>
 157             </td>
 158             <td width="50%" valign="bottom" class="ficaption2">Current nonpresription, complementary, and alternative medications: </td>
 159           </tr>
 160           <tr align="left" valign="baseline">
 161             <td width="50%" valign="bottom" nowrap class="fibody2" id="bordR"><textarea name="hpi" rows="3" wrap="VIRTUAL" class="fullin2" id="hpi"></textarea></td>
 162             <td width="50%" valign="bottom" nowrap class="fibody2"><textarea name="current_nonprescription" rows="3" wrap="VIRTUAL" class="fullin2" id="current_nonprescription"></textarea></td>
 163           </tr>
 164       </table></td>
 165     </tr>
 166     <tr>
 167       <td class="fibody2">&nbsp;</td>
 168     </tr>
 169     <tr>
 170       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 171           <tr align="left" valign="bottom">
 172             <td width="200" class="ficaption2">Changes since last visit </td>
 173             <td width="40" align="center" class="ficaption2">yes</td>
 174             <td width="40" align="center" class="ficaption2" id="bordR">no</td>
 175             <td colspan="2" align="center" class="ficaption2">Notes</td>
 176           </tr>
 177           <tr align="left" valign="bottom">
 178             <td width="200" class="fibody2">Illnesses</td>
 179             <td width="40" align="center" class="fibody2"><input name="ph_lvch_ill" type="radio" value="1"></td>
 180             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_ill" type="radio" value="0" checked></td>
 181             <td colspan="2" rowspan="7" valign="top" class="fibody2"><textarea name="ph_lvch_notes" rows="7" wrap="VIRTUAL" class="fullin2" id="ph_lvch_notes" style="height: 100%"></textarea></td>
 182           </tr>
 183           <tr align="left" valign="bottom">
 184             <td width="200" class="fibody2">Surgery</td>
 185             <td width="40" align="center" class="fibody2"><input name="ph_lvch_surg" type="radio" value="1"></td>
 186             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_surg" type="radio" value="0" checked></td>
 187           </tr>
 188           <tr align="left" valign="bottom">
 189             <td width="200" class="fibody2">New medications </td>
 190             <td width="40" align="center" class="fibody2"><input name="ph_lvch_newmed" type="radio" value="1"></td>
 191             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_newmed" type="radio" value="0" checked></td>
 192           </tr>
 193           <tr align="left" valign="bottom">
 194             <td width="200" class="fibody2">Change in family history </td>
 195             <td width="40" align="center" class="fibody2"><input name="ph_lvch_famhist" type="radio" value="1"></td>
 196             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_famhist" type="radio" value="0" checked></td>
 197           </tr>
 198           <tr align="left" valign="bottom">
 199             <td width="200" class="fibody2">New allergies </td>
 200             <td width="40" align="center" class="fibody2"><input name="ph_lvch_newallerg" type="radio" value="1"></td>
 201             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_newallerg" type="radio" value="0" checked></td>
 202           </tr>
 203           <tr align="left" valign="bottom">
 204             <td width="200" class="fibody2">Change in gynecologic history </td>
 205             <td width="40" align="center" class="fibody2"><input name="ph_lvch_gynhist" type="radio" value="1"></td>
 206             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_gynhist" type="radio" value="0" checked></td>
 207           </tr>
 208           <tr align="left" valign="bottom">
 209             <td width="200" class="fibody2">Change in obstetric history </td>
 210             <td width="40" align="center" class="fibody2"><input name="ph_lvch_obsthist" type="radio" value="1"></td>
 211             <td width="40" align="center" class="fibody2" id="bordR"><input name="ph_lvch_obsthist" type="radio" value="0" checked></td>
 212           </tr>
 213       </table></td>
 214     </tr>
 215     <tr>
 216       <td class="fibody2">&nbsp;</td>
 217     </tr>
 218     <tr>
 219       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 220           <tr align="left" valign="bottom">
 221             <?php
 222 $allergies = ''; $checked = 'checked';
 223 if ($result = getListByType($pid, "allergy", "id,title,comments,activity,date", 1, "all", 0)){
 224         foreach ($result as $iter) {
 225           $al_tmp[] = $iter{"title"}.' ('.$iter{"comments"}.') ';
 226           $checked = '';
 227         }
 228         $allergies = join(',', $al_tmp);
 229 }
 230 ?>
 231             <td width="225" class="fibody2"><a name="allergies"></a>Allergies (describe reaction):
 232                 <input name="ph_allergies_none" type="checkbox" id="ph_allergies_none" value="1" <?php echo $checked ?>>
 233               None</td>
 234             <td class="fibody2"><input name="ph_allergies_data" type="text" class="fullin2" id="ph_allergies_data" value="<?php echo $allergies; ?>"></td>
 235           </tr>
 236       </table></td>
 237     </tr>
 238     <tr>
 239       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 240           <tr align="left" valign="bottom">
 241             <td width="70%" class="fibody2" id="bordR">Last cervical cancer screening:
 242                 <input name="cancer_scr_cytology" type="checkbox" id="cancer_scr_cytology" value="1">
 243               Cytology
 244               <input name="cancer_scr_cytology_date" type="text" class="fullin2" id="cancer_scr_cytology_date" style="width: 70px" value="YYYY-MM-DD">
 245               <input name="cancer_scr_hpv" type="checkbox" id="cancer_scr_hpv" value="checkbox">
 246               HPV test
 247               <input name="cancer_scr_hpv_date" type="text" class="fullin2" id="cancer_scr_hpv_date" style="width: 70px" value="YYYY-MM-DD"></td>
 248             <td width="30%" class="fibody2"><input name="cancer_scr_notes" type="text" class="fullin2" id="cancer_scr_notes"></td>
 249           </tr>
 250           <tr align="left" valign="bottom">
 251             <td width="70%" class="fibody2" id="bordR">last mammogram:
 252                 <input name="last_mammogram" type="text" class="fullin2" id="last_mammogram" style="width: 70px" value="<?php echo $history{'last_mammogram'}; ?>"></td>
 253         <td class="fibody2"><input name="last_mammogram_notes" type="text" class="fullin2" id="last_mammogram_notes"></td>
 254       </tr>
 255       <tr align="left" valign="bottom">
 256         <td width="70%" class="fibody2" id="bordR">Last colorectal screening:
 257           <input name="last_colorectal" type="text" class="fullin2" id="last_colorectal" style="width: 70px" value="YYYY-MM-DD"></td>
 258         <td class="fibody2"><input name="last_colorectal_notes" type="text" class="fullin2" id="last_colorectal_notes"></td>
 259       </tr>
 260     </table></td>
 261   </tr>
 262 </table>
 263 </div>
 264 <p>&nbsp;</p>
 265 <h2 align="center"><a name="gh"></a>Gynecologic history (PH)</h2>
 266 <div style="border: solid 2px black; background-color:#FFFFFF;">
 267   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 268     <tr align="left" valign="bottom">
 269       <td colspan="4"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 270         <tr align="left" valign="bottom">
 271           <td nowrap class="fibody2">Imp</td>
 272           <td nowrap class="fibody2"><input name="gh_imp" type="text" class="fullin2" id="gh_imp" style="width: 70px" value="YYYY-MM-DD"></td>
 273           <td nowrap class="fibody2">Age at menarche </td>
 274           <td nowrap class="fibody2"><input name="gh_age_at_menarche" type="text" class="fullin" id="gh_age_at_menarche"></td>
 275           <td nowrap class="fibody2">Length of flow </td>
 276           <td nowrap class="fibody2"><input name="gh_length_of_flow" type="text" class="fullin" id="gh_length_of_flow"></td>
 277           <td nowrap class="fibody2">Interval between periods </td>
 278           <td nowrap class="fibody2"><input name="gh_interval_periods" type="text" class="fullin" id="gh_interval_periods"></td>
 279           <td nowrap class="fibody2">Recent changes </td>
 280           <td nowrap class="fibody2"><input name="gh_recent_changes" type="text" class="fullin" id="gh_recent_changes"></td>
 281         </tr>
 282       </table></td>
 283     </tr>
 284     <tr align="left" valign="bottom">
 285       <td colspan="4" nowrap class="fibody2">Sexually active:
 286         <input name="gh_sexually_active" type="radio" value="1" checked>
 287         Yes
 288         <input name="gh_sexually_active" type="radio" value="0">
 289         No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ever had sex:
 290         <input name="gh_had_sex" type="radio" value="1" checked>
 291 Yes
 292 <input name="gh_had_sex" type="radio" value="0">
 293 No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Number of partners (Lifetime)
 294 <input name="gh_partners" type="text" class="fullin" id="gh_partners" style="width: 70px"></td>
 295       </tr>
 296     <tr align="left" valign="bottom">
 297       <td colspan="4" nowrap class="fibody2">Partners are:
 298         <input name="gh_partners_are" type="radio" value="men" checked>
 299         men
 300         <input name="gh_partners_are" type="radio" value="women">
 301         women
 302         <input name="ph_gh_partners_are" type="radio" value="both">
 303         both</td>
 304       </tr>
 305     <tr align="left" valign="bottom">
 306       <td width="202" nowrap class="fibody2">Current method of contraception: </td>
 307       <td width="30%" nowrap class="fibody2"><input name="gh_method_contraception" type="text" class="fullin2" id="gh_method_contraception" value="none"></td>
 308       <td width="161" nowrap class="fibody2">past contraceptive history:</td>
 309       <td width="34%" nowrap class="fibody2"><input name="gh_contraceptive_history" type="text" class="fullin2" id="gh_contraceptive_history"></td>
 310     </tr>
 311   </table>
 312 </div>
 313 <p>&nbsp;</p>
 314 <h2 align="center"><a name="oh"></a>Obstetric history (PH)</h2>
 315 <div style="border: solid 2px black; background-color:#FFFFFF;">
 316   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 317     <tr>
 318       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 319         <tr align="left" valign="bottom">
 320           <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 321           <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 322           <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 323           <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 324           <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 325           <td width="50" align="center" nowrap class="ficaption2">Number</td>
 326         </tr>
 327         <tr align="left" valign="bottom">
 328           <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 329           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2" id="oh_pregnancies" value="0"></td>
 330           <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 331           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2" id="gh_abortions" value="0"></td>
 332           <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 333           <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2" id="oh_miscarriages" value="0"></td>
 334         </tr>
 335         <tr align="left" valign="bottom">
 336           <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 337           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_premature_births" type="text" class="fullin2" value="0"></td>
 338           <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 339           <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_live_births" type="text" class="fullin2" value="0"></td>
 340           <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 341           <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2" value="0"></td>
 342         </tr>
 343       </table></td>
 344     </tr>
 345     <tr>
 346       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 347         <tr align="center" valign="middle">
 348           <td class="ficaption2" id="bordR">No</td>
 349           <td class="ficaption2" id="bordR">birth date </td>
 350           <td class="ficaption2" id="bordR">weight at birth </td>
 351           <td class="ficaption2" id="bordR">baby's sex </td>
 352           <td class="ficaption2" id="bordR">weeks pregnant </td>
 353           <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 354           <td class="ficaption2">physician's notes</td>
 355         </tr>
 356 <?php
 357   $bi = 0;
 358   while ($bi<4) {
 359     $n = $bi+1;
 360     print <<<EOL
 361         <tr align="left" valign="bottom">
 362           <td nowrap class="fibody2" id="bordR">$n.</td>
 363           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" class="fullin2"></td>
 364           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" class="fullin2"></td>
 365           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" class="fullin2"></td>
 366           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" class="fullin2"></td>
 367           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" class="fullin2"></td>
 368           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" class="fullin2"></td>
 369         </tr>
 370 EOL;
 371      $bi++;
 372   }
 373 ?>
 374       </table></td>
 375     </tr>
 376     <tr>
 377       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 378           <tr align="left" valign="bottom">
 379             <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 380             <td class="fibody2"><input name="oh_complications" type="text" class="fullin2" id="oh_complications" value="n/a"></td>
 381           </tr>
 382       </table></td>
 383     </tr>
 384     <tr>
 385       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 386           <tr align="left" valign="bottom">
 387             <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox" id="oh_diabetes" value="1">
 388               diabetes
 389                 <input name="oh_hipertension" type="checkbox" id="oh_hipertension" value="1">
 390               hypertension/high blood pressure
 391               <input name="oh_preemclampsia" type="checkbox" id="oh_preemclampsia" value="1">
 392               preeclampsia/foxemia
 393               <input name="oh_complic_other" type="checkbox" id="oh_complic_other" value="1">
 394               other </td>
 395           </tr>
 396           <tr align="left" valign="bottom">
 397             <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 398                 <input name="oh_depression" type="radio" value="0" checked>
 399               no
 400               <input name="oh_depression" type="radio" value="1">
 401               yes, How treated </td>
 402             <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2" id="oh_depression_treated"></td>
 403           </tr>
 404       </table></td>
 405     </tr>
 406   </table>
 407 </div>
 408 <p>&nbsp;</p>
 409 <h2 align="center"><a name="ph"></a>Past history (PH)</h2>
 410 <div style="border: solid 2px black; background-color:#FFFFFF;">
 411   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 412     <tr>
 413       <td class="fibody2"><input name="ph_noncontrib" type="checkbox" id="ph_noncontrib" value="1">
 414         Noncontributory
 415         <input name="ph_nochange_since" type="checkbox" id="ph_nochange_since" value="1">
 416         no interval change since
 417         <input name="ph_nochange_since_date" type="text" class="fullin2" id="ph_nochange_since_date" style="width: 70px" value="YYYY-MM-DD"></td>
 418     </tr>
 419     <tr>
 420       <td class="fibody2">SUrgeries:<br>
 421         <textarea name="ph_surgeries" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_surgeries">none</textarea></td>
 422     </tr>
 423     <tr>
 424       <td class="fibody2">Illnesses (Physical and mental):<br>
 425         <textarea name="ph_illnesses" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_illnesses">none</textarea></td>
 426     </tr>
 427     <tr>
 428       <td class="fibody2">Injuries:<br>
 429         <textarea name="ph_injuries" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_injuries">none</textarea></td>
 430     </tr>
 431     <tr>
 432       <td class="fibody2">Immunizations/Tuberculosis test: <br>
 433 <textarea name="ph_immunizations_tuberculosis" rows="3" wrap="VIRTUAL" class="fullin2" id="ph_immunizations_tuberculosis">
 434 <?php
 435 if ($result = getListByType($pid, "immunization", "id,title,comments,activity,date", 1, "all", 0)){
 436 foreach ($result as $iter) {
 437   $tmp_im[] = $iter{'date'}.' - '.$iter{'title'}.' ('.$iter{'comments'}.')';
 438 }
 439 $imm = join(', ', $tmp_im);
 440 echo $imm;}
 441 ?>
 442 </textarea></td>
 443     </tr>
 444   </table>
 445 </div>
 446 <p>&nbsp;</p>
 447 <h2 align="center"><a name="fh"></a>Family history (FH) </h2>
 448 <div style="border: solid 2px black; background-color:#FFFFFF;">
 449   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 450     <tr align="left" valign="bottom">
 451       <td colspan="3" class="fibody2"><input name="fh_noncontrib" type="checkbox" id="fh_noncontrib" value="checkbox">
 452 Noncontributory
 453   <input name="fh_nochange_since" type="checkbox" id="fh_nochange_since" value="checkbox">
 454 no interval change since
 455 <input name="fh_nochange_since_date" type="text" class="fullin2" id="fh_nochange_since_date" style="width: 70px" value="YYYY-MM-DD"></td>
 456     </tr>
 457     <tr align="left" valign="bottom">
 458       <td colspan="3" class="fibody2">Mother:
 459         <input name="fh_mother" type="radio" value="0" checked>
 460         living
 461         <input name="fh_mother" type="radio" value="1">
 462         deceased - cause:
 463         <input name="fh_mother_dec_cause" type="text" class="fullin" id="fh_mother_dec_cause" style="width: 7%">
 464         age:
 465         <input name="fh_mother_dec_age" type="text" class="fullin" id="fh_mother_dec_age" style="width: 30px">
 466 &nbsp;&nbsp;&nbsp;        Father:
 467         <input name="fh_father" type="radio" value="0" checked>
 468 living
 469 <input name="fh_father" type="radio" value="1">
 470 deceased - cause:
 471 <input name="fh_father_dec_cause" type="text" class="fullin" id="fh_father_dec_cause" style="width: 7%">
 472 age:
 473 <input name="fh_father_dec_age" type="text" class="fullin" id="fh_father_dec_age" style="width: 30px"></td>
 474     </tr>
 475     <tr align="left" valign="bottom">
 476       <td colspan="3" class="fibody2">Siblings: number living:
 477         <input name="fh_sibl_living" type="text" class="fullin" id="fh_sibl_living" style="width: 7%">
 478         Number deceased:
 479         <input name="fh_sibl_deceased" type="text" class="fullin" id="fh_sibl_deceased" style="width: 7%">
 480         cause(s) / Age(s) :<br>
 481         <input name="fh_sibl_cause" type="text" class="fullin2" id="fh_sibl_cause"></td>
 482     </tr>
 483     <tr align="left" valign="bottom">
 484       <td colspan="3" class="fibody2">Children: number living:
 485         <input name="fh_children_living" type="text" class="fullin" id="fh_children_living" style="width: 7%">
 486 Number deceased:
 487 <input name="fh_children_deceased" type="text" class="fullin" id="fh_children_deceased" style="width: 7%">
 488 cause(s) / Age(s) :<br>
 489 <input name="fh_children_cause" type="text" class="fullin2" id="fh_children_cause"></td>
 490     </tr>
 491     <tr align="left" valign="bottom">
 492       <td colspan="3" class="fibody2" style="border: none">(IF YES, indicate whom, and age of diagnosis) </td>
 493     </tr>
 494     <tr align="left" valign="bottom">
 495       <td width="33%" class="fibody2" id="bordR"><input name="fhd_diabetes" type="checkbox" id="fhd_diabetes" value="1">
 496         diabetes
 497         <input name="fhd_diabetes_who" type="text" class="fullin" id="fhd_diabetes" style="width:50%"></td>
 498       <td width="33%" class="fibody2" id="bordR"><input name="fhd_heart" type="checkbox" id="fhd_heart" value="1">
 499         heart disease
 500         <input name="fhd_heart_who" type="text" class="fullin" id="fhd_heart_who" style="width:50%"></td>
 501       <td width="33%" class="fibody2"> <input name="fhd_hyperlipidemia" type="checkbox" id="fhd_hyperlipidemia" value="1">
 502         hyperlipidemia
 503         <input name="fhd_hyperlipidemia_who" type="text" class="fullin" id="fhd_hyperlipidemia_who" style="width:50%"></td>
 504     </tr>
 505     <tr align="left" valign="bottom">
 506       <td class="fibody2" id="bordR"><input name="fhd_cancer" type="checkbox" id="fhd_cancer" value="1">
 507         cancer
 508         <input name="fhd_cancer_who" type="text" class="fullin" id="fhd_cancer_who" style="width:50%"></td>
 509       <td class="fibody2" id="bordR"><input name="fhd_hipertension" type="checkbox" id="fhd_hipertension" value="1">
 510         Hypertension
 511         <input name="fhd_hipertension_who" type="text" class="fullin" id="fhd_hipertension_who" style="width:50%"></td>
 512       <td rowspan="2" valign="middle" class="fibody2"><input name="fhd_deepvenous" type="checkbox" id="fhd_deepvenous" value="1">
 513         deep venous tromboembolIsm / Pulmonary embolism
 514         <input name="fhd_deepvenous_who" type="text" class="fullin" id="fhd_deepvenous_who" style="width:50%"></td>
 515     </tr>
 516     <tr align="left" valign="bottom">
 517       <td class="fibody2" id="bordR"><input name="fhd_osteoporosis" type="checkbox" id="fhd_osteoporosis" value="1">
 518         osteoporosis
 519         <input name="fhd_osteoporosis_who" type="text" class="fullin" id="fhd_osteoporosis_who" style="width:50%"></td>
 520       <td class="fibody2" id="bordR"><input name="fhd_other" type="checkbox" id="fhd_other" value="1">
 521         other illnesses
 522         <input name="fhd_other_who" type="text" class="fullin" id="fhd_other_who" style="width:50%"></td>
 523       </tr>
 524   </table>
 525 </div>
 526 <p></p>
 527 <p>&nbsp;</p>
 528 <h2 align="center"><a name="sh"></a>Social history (SH) </h2>
 529 <div style="border: solid 2px black; background-color:#FFFFFF;">
 530   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 531     <tr>
 532       <td align="left" valign="bottom" class="fibody2">        <input name="sh_noncontrib" type="checkbox" id="sh_noncontrib" value="checkbox">
 533 Noncontributory
 534 <input name="sh_nochange_since" type="checkbox" id="sh_nochange_since" value="checkbox">
 535 no interval change since
 536 <input name="sh_nochange_since_date" type="text" class="fullin2" id="sh_nochange_since_date" style="width: 70px" value="YYYY-MM-DD">      </td>
 537     </tr>
 538     <tr>
 539       <td align="left" valign="bottom"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 540         <tr align="center" valign="bottom">
 541           <td width="190" class="ficaption2">&nbsp;</td>
 542           <td width="30" class="ficaption2">yes</td>
 543           <td width="30" class="ficaption2" id="bordR">no</td>
 544           <td class="ficaption2" id="bordR">notes</td>
 545           <td width="190" class="ficaption2">&nbsp;</td>
 546           <td width="30" class="ficaption2">yes</td>
 547           <td width="30" class="ficaption2" id="bordR">no</td>
 548           <td class="ficaption2">notes</td>
 549         </tr>
 550         <tr align="left" valign="bottom">
 551           <td nowrap class="fibody2">Tobacco use </td>
 552           <td class="fibody2"><input name="sh_tobacco" type="radio" value="1"></td>
 553           <td class="fibody2" id="bordR"><input name="sh_tobacco" type="radio" value="0"></td>
 554           <td class="fibody2" id="bordR"><input name="sh_notes_1" type="text" class="fullin2" id="sh_notes_1"></td>
 555           <td nowrap class="fibody2">diet discussed </td>
 556           <td class="fibody2"><input name="sh_diet" type="radio" value="1"></td>
 557           <td class="fibody2" id="bordR"><input name="sh_diet" type="radio" value="0"></td>
 558           <td class="fibody2">
 559             <input name="sh_notes_9" type="text" class="fullin2" id="sh_notes_9"></td>
 560         </tr>
 561         <tr align="left" valign="bottom">
 562           <td rowspan="2" valign="middle" nowrap class="fibody2">Alcohol use<br>
 563             specify amount and type<br>
 564             <small>12 OZ beer = 5 oz wine = 1 1/2 oz liquor</small>  </td>
 565           <td rowspan="2" valign="middle" class="fibody2"><input name="sh_alcohol" type="radio" value="1"></td>
 566           <td rowspan="2" valign="middle" class="fibody2" id="bordR"><input name="sh_alcohol" type="radio" value="0"></td>
 567           <td rowspan="2" valign="middle" class="fibody2" id="bordR"><input name="sh_notes_2" type="text" class="fullin2" id="sh_notes_2"></td>
 568           <td nowrap class="fibody2">folic acid intake </td>
 569           <td class="fibody2"><input name="sh_folic_acid" type="radio" value="1"></td>
 570           <td class="fibody2" id="bordR"><input name="sh_folic_acid" type="radio" value="0"></td>
 571           <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2" id="sh_notes_10"></td>
 572         </tr>
 573         <tr align="left" valign="bottom">
 574           <td nowrap class="fibody2">calcium intake </td>
 575           <td class="fibody2"><input name="sh_calcium" type="radio" value="1"></td>
 576           <td class="fibody2" id="bordR"><input name="sh_calcium" type="radio" value="0"></td>
 577           <td class="fibody2"><input name="sh_notes_11" type="text" class="fullin2" id="sh_notes_11"></td>
 578         </tr>
 579         <tr align="left" valign="bottom">
 580           <td nowrap class="fibody2">Illegal/Street drug use </td>
 581           <td class="fibody2"><input name="sh_drugs" type="radio" value="1"></td>
 582           <td class="fibody2" id="bordR"><input name="sh_drugs" type="radio" value="0"></td>
 583           <td class="fibody2" id="bordR"><input name="sh_notes_3" type="text" class="fullin2" id="sh_notes_3"></td>
 584           <td nowrap class="fibody2">regular exercise </td>
 585           <td class="fibody2"><input name="sh_reg_exercise" type="radio" value="1"></td>
 586           <td class="fibody2" id="bordR"><input name="sh_reg_exercise" type="radio" value="0"></td>
 587           <td class="fibody2"><input name="sh_notes_12" type="text" class="fullin2" id="sh_notes_12"></td>
 588         </tr>
 589         <tr align="left" valign="bottom">
 590           <td nowrap class="fibody2">misuse of prescription drugs </td>
 591           <td class="fibody2"><input name="sh_misuse" type="radio" value="1"></td>
 592           <td class="fibody2" id="bordR"><input name="sh_misuse" type="radio" value="0"></td>
 593           <td class="fibody2" id="bordR"><input name="sh_notes_4" type="text" class="fullin2" id="sh_notes_4"></td>
 594           <td nowrap class="fibody2">caffeine intake </td>
 595           <td class="fibody2"><input name="sh_caffeine" type="radio" value="1"></td>
 596           <td class="fibody2" id="bordR"><input name="sh_caffeine" type="radio" value="0"></td>
 597           <td class="fibody2"><input name="sh_notes_13" type="text" class="fullin2" id="sh_notes_13"></td>
 598         </tr>
 599         <tr align="left" valign="bottom">
 600           <td nowrap class="fibody2">intimate partner violence </td>
 601           <td class="fibody2"><input name="sh_partner_violence" type="radio" value="1"></td>
 602           <td class="fibody2" id="bordR"><input name="sh_partner_violence" type="radio" value="0"></td>
 603           <td class="fibody2" id="bordR"><input name="sh_notes_5" type="text" class="fullin2" id="sh_notes_5"></td>
 604           <td nowrap class="fibody2">advance directive (living will) </td>
 605           <td class="fibody2"><input name="sh_advance" type="radio" value="1"></td>
 606           <td class="fibody2" id="bordR"><input name="sh_advance" type="radio" value="0"></td>
 607           <td class="fibody2"><input name="sh_notes_14" type="text" class="fullin2" id="sh_notes_14"></td>
 608         </tr>
 609         <tr align="left" valign="bottom">
 610           <td nowrap class="fibody2">sexual abuse </td>
 611           <td class="fibody2"><input name="sh_sexual_abuse" type="radio" value="1"></td>
 612           <td class="fibody2" id="bordR"><input name="sh_sexual_abuse" type="radio" value="0"></td>
 613           <td class="fibody2" id="bordR"><input name="sh_notes_6" type="text" class="fullin2" id="sh_notes_6"></td>
 614           <td nowrap class="fibody2">organ donation </td>
 615           <td class="fibody2"><input name="sh_organ_donation" type="radio" value="1"></td>
 616           <td class="fibody2" id="bordR"><input name="sh_organ_donation" type="radio" value="0"></td>
 617           <td class="fibody2"><input name="sh_notes_15" type="text" class="fullin2" id="sh_notes_15"></td>
 618         </tr>
 619         <tr align="left" valign="bottom">
 620           <td nowrap class="fibody2">health hazards at home/work </td>
 621           <td class="fibody2"><input name="sh_health_hazards" type="radio" value="1"></td>
 622           <td class="fibody2" id="bordR"><input name="sh_health_hazards" type="radio" value="0"></td>
 623           <td class="fibody2" id="bordR"><input name="sh_notes_7" type="text" class="fullin2" id="sh_notes_7"></td>
 624           <td nowrap class="fibody2">other</td>
 625           <td class="fibody2"><input name="sh_other" type="radio" value="1"></td>
 626           <td class="fibody2" id="bordR"><input name="sh_other" type="radio" value="0"></td>
 627           <td class="fibody2"><input name="sh_notes_16" type="text" class="fullin2" id="sh_notes_16"></td>
 628         </tr>
 629         <tr align="left" valign="bottom">
 630           <td nowrap class="fibody2">seat belt use </td>
 631           <td class="fibody2"><input name="sh_seat_belt" type="radio" value="1"></td>
 632           <td class="fibody2" id="bordR"><input name="sh_seat_belt" type="radio" value="0"></td>
 633           <td class="fibody2" id="bordR"><input name="sh_notes_8" type="text" class="fullin2" id="sh_notes_8"></td>
 634           <td nowrap class="fibody2"><input name="sh_nochanges_since2" type="checkbox" id="sh_nochanges_since2" value="1">
 635             no changes since              <input name="sh_nochanges_since2_date" type="text" class="fullin2" id="ph_gh_imp22222" style="width: 70px" value="YYYY-MM-DD">            </td>
 636           <td class="fibody2">&nbsp;</td>
 637           <td class="fibody2">&nbsp;</td>
 638           <td class="fibody2">&nbsp;</td>
 639         </tr>
 640       </table></td>
 641     </tr>
 642   </table>
 643 </div>
 644 <p>&nbsp;  </p>
 645 <h2 align="center"><a name="ros"></a>Review of systems (ROS)</h2>
 646 <div style="border: solid 2px black; background-color:#FFFFFF;">
 647 <table width="100%"  border="0" cellspacing="0" cellpadding="2" class="fitable">
 648   <tr>
 649     <td width="190" align="left" valign="top" class="ficaption">1. Constitutional </td>
 650     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 651       <tr align="left" valign="baseline">
 652         <td width="20%" nowrap><input name="ros_const_negative" type="checkbox" value="1" checked onClick="ToggleSection('ros_const', ros_const_negative.checked);">
 653         Negative</td>
 654         <td width="20%" nowrap><input type="checkbox" name="ros_const_weight_loss" value="1" disabled="disabled">
 655           weight loss</td>
 656         <td width="20%" nowrap><input type="checkbox" name="ros_const_weight_gain" value="1" disabled="disabled">
 657           weight gain
 658 </td>
 659         <td>&nbsp;</td>
 660         <td width="20%">&nbsp;</td>
 661       </tr>
 662       <tr align="left" valign="baseline">
 663         <td width="20%" nowrap><input name="ros_const_fever" type="checkbox" value="1" disabled="disabled">
 664           fever</td>
 665         <td width="20%" nowrap><input type="checkbox" name="ros_const_fatigue" value="1" disabled="disabled">
 666           fatigue</td>
 667         <td nowrap><input type="checkbox" name="ros_const_other" value="1" disabled="disabled">
 668           other</td>
 669         <td align="right" nowrap>tallest height&nbsp; </td>
 670         <td><input name="ros_const_tallest_height" type="text" class="fullin"></td>
 671       </tr>
 672     </table></td>
 673   </tr>
 674   <tr>
 675     <td width="190" align="left" valign="top" class="ficaption">2. Eyes </td>
 676     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 677       <tr align="left" valign="baseline">
 678         <td width="20%" nowrap><input name="ros_eyes_negative" type="checkbox" value="1" checked>
 679       Negative</td>
 680         <td colspan="2" nowrap><input type="checkbox" name="ros_eyes_vision_change" value="1" disabled="disabled">
 681       Vision change </td>
 682         <td colspan="2" nowrap><input type="checkbox" name="ros_eyes_glasses" value="1" disabled="disabled">
 683 Glasses/contacts</td>
 684         </tr>
 685       <tr align="left" valign="baseline">
 686         <td width="20%" nowrap><input type="checkbox" name="ros_eyes_other" value="1" disabled="disabled">
 687       Other</td>
 688         <td width="20%" nowrap>&nbsp;</td>
 689         <td width="20%" nowrap>&nbsp;</td>
 690         <td align="right" nowrap>&nbsp; </td>
 691         <td width="20%">&nbsp;</td>
 692       </tr>
 693     </table></td>
 694   </tr>
 695   <tr>
 696     <td width="190" align="left" valign="top" class="ficaption">3. Ear, nose and throat </td>
 697     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 698       <tr align="left" valign="baseline">
 699         <td width="20%" nowrap><input name="ros_ear_negative" type="checkbox" value="1" checked>
 700       Negative</td>
 701         <td width="20%" nowrap><input type="checkbox" name="ros_ear_ulcers" value="1" disabled="disabled">
 702       Ulcers</td>
 703         <td width="20%" nowrap><input type="checkbox" name="ros_ear_sinusitis" value="1" disabled="disabled">
 704       sinusitis</td>
 705         <td width="20%">&nbsp;</td>
 706         <td width="20%">&nbsp;</td>
 707       </tr>
 708       <tr align="left" valign="baseline">
 709         <td nowrap><input type="checkbox" name="ros_ear_headache" value="1" disabled="disabled">
 710       Headache</td>
 711         <td nowrap><input type="checkbox" name="ros_ear_hearing_loss" value="1" disabled="disabled">
 712       Hearing loss </td>
 713         <td nowrap><input type="checkbox" name="ros_ear_other" value="1" disabled="disabled">
 714       other</td>
 715         <td width="20%" align="right" nowrap>&nbsp;</td>
 716         <td>&nbsp;</td>
 717       </tr>
 718     </table></td>
 719   </tr>
 720   <tr>
 721     <td width="190" align="left" valign="top" class="ficaption">4. Cardiovascular </td>
 722     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 723       <tr align="left" valign="baseline">
 724         <td width="20%" nowrap><input name="ros_cv_negative" type="checkbox" value="1" checked>
 725       Negative</td>
 726         <td width="20%" nowrap><input type="checkbox" name="ros_cv_orthopnea" value="1" disabled="disabled">
 727       Orthopnea</td>
 728         <td width="20%" nowrap><input type="checkbox" name="ros_cv_chest_pain" value="1" disabled="disabled">
 729       Chest pain </td>
 730         <td colspan="2" rowspan="2"><input type="checkbox" name="ros_cv_difficulty_breathing" value="1" disabled="disabled">
 731           Difficulty breathing on exertion
 732 </td>
 733         </tr>
 734       <tr align="left" valign="baseline">
 735         <td nowrap><input type="checkbox" name="ros_cv_edema" value="1" disabled="disabled">
 736       Edema</td>
 737         <td nowrap><input type="checkbox" name="ros_cv_palpitation" value="1" disabled="disabled">
 738       Palpitation</td>
 739         <td nowrap><input type="checkbox" name="ros_cv_other" value="1" disabled="disabled">
 740       other</td>
 741         </tr>
 742     </table></td>
 743   </tr>
 744   <tr>
 745     <td width="190" align="left" valign="top" class="ficaption">5. Respiratory </td>
 746     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 747       <tr align="left" valign="baseline">
 748         <td width="20%" nowrap><input name="ros_resp_negative" type="checkbox" value="1" checked>
 749       Negative</td>
 750         <td width="20%" nowrap><input type="checkbox" name="ros_resp_wheezing" value="1" disabled="disabled">
 751       Wheezing</td>
 752         <td width="20%" nowrap><input name="ros_resp_hemoptysis" type="checkbox" id="ros_hemoptysis" value="1" disabled="disabled">
 753       Hemoptysis</td>
 754         <td width="20%">&nbsp;</td>
 755         <td width="20%">&nbsp;</td>
 756       </tr>
 757       <tr align="left" valign="baseline">
 758         <td colspan="2" nowrap><input type="checkbox" name="ros_resp_shortness" value="1" disabled="disabled">
 759       Shortness of breath </td>
 760         <td nowrap><input type="checkbox" name="ros_resp_cough" value="1" disabled="disabled">
 761       Cough</td>
 762         <td colspan="2" align="left" nowrap><input type="checkbox" name="ros_resp_other" value="1" disabled="disabled">
 763           Other
 764 </td>
 765         </tr>
 766     </table></td>
 767   </tr>
 768   <tr>
 769     <td width="190" align="left" valign="top" class="ficaption">6. Gastrointestinal </td>
 770     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 771       <tr align="left" valign="baseline">
 772         <td width="20%" nowrap><input name="ros_gastr_negative" type="checkbox" value="1" checked>
 773       Negative</td>
 774         <td width="20%" nowrap><input type="checkbox" name="ros_gastr_diarrhea" value="1" disabled="disabled">
 775       Diarrhea</td>
 776         <td width="20%" nowrap><input type="checkbox" name="ros_gastr_bloody_stool" value="1" disabled="disabled">
 777       Bloody stool </td>
 778         <td colspan="2"><input type="checkbox" name="ros_gastr_nausea" value="1" disabled="disabled">
 779           Nausea/Vomiting/Indigestion
 780 </td>
 781         </tr>
 782       <tr align="left" valign="baseline">
 783         <td nowrap><input type="checkbox" name="ros_gastr_constipation" value="1" disabled="disabled">
 784       Constipation</td>
 785         <td nowrap><input type="checkbox" name="ros_gastr_flatulence" value="1" disabled="disabled">
 786       Flatulence</td>
 787         <td nowrap><input type="checkbox" name="ros_gastr_pain" value="1" disabled="disabled">
 788       pain</td>
 789         <td align="left" nowrap><input type="checkbox" name="ros_gastr_fecal" value="1" disabled="disabled">
 790           Fecal incontinence</td>
 791         <td nowrap><input type="checkbox" name="ros_gastr_other" value="1" disabled="disabled">
 792           Other</td>
 793       </tr>
 794     </table></td>
 795   </tr>
 796   <tr>
 797     <td width="190" align="left" valign="top" class="ficaption">7. Genitourinary </td>
 798     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 799       <tr align="left" valign="baseline">
 800         <td width="20%" nowrap><input name="ros_genit_negative" type="checkbox" value="1" checked>
 801       Negative</td>
 802         <td width="20%" nowrap><input type="checkbox" name="ros_genit_hematuria" value="1" disabled="disabled">
 803       Hematuria</td>
 804         <td nowrap><input type="checkbox" name="ros_genit_dysuria" value="1" disabled="disabled">
 805       Dysuria</td>
 806         <td align="left" nowrap><input type="checkbox" name="ros_genit_urgency" value="1" disabled="disabled">
 807           Urgency</td>
 808         <td align="left" nowrap>&nbsp;</td>
 809       </tr>
 810       <tr align="left" valign="baseline">
 811         <td width="20%" nowrap><input type="checkbox" name="ros_genit_frequency" value="1" disabled="disabled">
 812       Frequency</td>
 813         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_incomplete_emptying" value="1" disabled="disabled">
 814       Incomplete emptying </td>
 815         <td align="left" nowrap><input type="checkbox" name="ros_genit_incontinence" value="1" disabled="disabled">
 816           Incontinence</td>
 817         <td align="left" nowrap>&nbsp;</td>
 818       </tr>
 819       <tr align="left" valign="baseline">
 820         <td width="20%" nowrap><input type="checkbox" name="ros_genit_dyspareunia" value="1" disabled="disabled">
 821   Dyspareunia</td>
 822         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_abnormal_periods" value="1" disabled="disabled">
 823           Abnormal or painful periods </td>
 824         <td nowrap><input type="checkbox" name="ros_genit_pms" value="1" disabled="disabled">
 825   PMS</td>
 826         <td align="left" nowrap>&nbsp;</td>
 827       </tr>
 828       <tr align="left" valign="baseline">
 829         <td colspan="2" nowrap><input type="checkbox" name="ros_genit_abnormal_bleeding" value="1" disabled="disabled">
 830   Abnormal vaginal bleeding </td>
 831         <td nowrap><input type="checkbox" name="ros_genit_abnormal_discharge" value="1" disabled="disabled">
 832   Abnormal vaginal discharge </td>
 833         <td nowrap><input type="checkbox" name="ros_genit_other" value="1" disabled="disabled">
 834   other</td>
 835         <td align="left" nowrap>&nbsp;</td>
 836       </tr>
 837     </table></td>
 838   </tr>
 839   <tr>
 840     <td width="190" align="left" valign="top" class="ficaption">8. Musculoskeletal </td>
 841     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 842       <tr align="left" valign="baseline">
 843         <td width="40%" nowrap><input name="ros_muscul_negative" type="checkbox" value="1" checked>
 844       Negative</td>
 845         <td width="40%" nowrap><input type="checkbox" name="ros_muscul_weakness" value="1" disabled="disabled">
 846       Muscle weakness </td>
 847         <td nowrap>&nbsp;</td>
 848         <td width="10%">&nbsp;</td>
 849         <td width="10%">&nbsp;</td>
 850       </tr>
 851       <tr align="left" valign="baseline">
 852         <td nowrap><input type="checkbox" name="ros_muscul_pain" value="1" disabled="disabled">
 853       Muscle or joint pain </td>
 854         <td width="40%" nowrap><input type="checkbox" name="ros_muscul_other" value="1" disabled="disabled">
 855 other</td>
 856         <td nowrap>&nbsp;</td>
 857         <td width="10%" align="left" nowrap>&nbsp;</td>
 858         <td width="10%">&nbsp;</td>
 859       </tr>
 860     </table></td>
 861   </tr>
 862   <tr>
 863     <td width="190" align="left" valign="top" class="ficaption">9a. Skin </td>
 864     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 865       <tr align="left" valign="baseline">
 866         <td width="20%" nowrap><input name="ros_skin_negative" type="checkbox" value="1" checked>
 867       Negative</td>
 868         <td width="20%" nowrap><input type="checkbox" name="ros_skin_rash" value="1" disabled="disabled">
 869       Rash</td>
 870         <td width="20%" nowrap><input type="checkbox" name="ros_skin_ulcers" value="1" disabled="disabled">
 871       Ulcers</td>
 872         <td width="20%">&nbsp;</td>
 873         <td width="20%">&nbsp;</td>
 874       </tr>
 875       <tr align="left" valign="baseline">
 876         <td nowrap><input type="checkbox" name="ros_skin_dry" value="1" disabled="disabled">
 877       Dry skin </td>
 878         <td colspan="2" nowrap><input type="checkbox" name="ros_skin_pigmented" value="1" disabled="disabled">
 879       Pigmented lesions </td>
 880         <td align="left" nowrap><input type="checkbox" name="ros_skin_other" value="1" disabled="disabled">
 881 other</td>
 882         <td>&nbsp;</td>
 883       </tr>
 884     </table></td>
 885   </tr>
 886   <tr>
 887     <td width="190" align="left" valign="top" class="ficaption">9b. Breast </td>
 888     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 889       <tr align="left" valign="baseline">
 890         <td width="20%" nowrap><input name="ros_breast_negative" type="checkbox" value="1" checked>
 891       Negative</td>
 892         <td width="20%" nowrap><input type="checkbox" name="ros_breast_mastalgia" value="1" disabled="disabled">
 893       Mastalgia</td>
 894         <td width="20%" nowrap>&nbsp;</td>
 895         <td width="20%">&nbsp;</td>
 896         <td width="20%">&nbsp;</td>
 897       </tr>
 898       <tr align="left" valign="baseline">
 899         <td nowrap><input type="checkbox" name="ros_breast_discharge" value="1" disabled="disabled">
 900       Discharge</td>
 901         <td nowrap><input type="checkbox" name="ros_breast_masses" value="1" disabled="disabled">
 902       Masses</td>
 903         <td nowrap><input type="checkbox" name="ros_breast_other" value="1" disabled="disabled">
 904       other</td>
 905         <td align="right" nowrap>&nbsp;</td>
 906         <td width="20%">&nbsp;</td>
 907       </tr>
 908     </table></td>
 909   </tr>
 910   <tr>
 911     <td width="190" align="left" valign="top" class="ficaption">10. Neurologic </td>
 912     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 913       <tr align="left" valign="baseline">
 914         <td width="20%" nowrap><input name="ros_neuro_negative" type="checkbox" value="1" checked>
 915       Negative</td>
 916         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_syncope" value="1" disabled="disabled">
 917       Syncope</td>
 918         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_seizures" value="1" disabled="disabled">
 919       Seizures</td>
 920         <td width="20%" nowrap><input type="checkbox" name="ros_neuro_numbness" value="1" disabled="disabled">
 921           Numbness</td>
 922         <td width="20%">&nbsp;</td>
 923       </tr>
 924       <tr align="left" valign="baseline">
 925         <td colspan="2" nowrap><input type="checkbox" name="ros_neuro_trouble_walking" value="1" disabled="disabled">
 926       Trouble walking </td>
 927         <td colspan="2" nowrap><input type="checkbox" name="ros_neuro_memory" value="1" disabled="disabled">
 928 Severe memory problems </td>
 929         <td><input type="checkbox" name="ros_neuro_other" value="1" disabled="disabled">
 930 other</td>
 931       </tr>
 932     </table></td>
 933   </tr>
 934   <tr>
 935     <td width="190" align="left" valign="top" class="ficaption">11. Psychiatric</td>
 936     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 937       <tr align="left" valign="baseline">
 938         <td nowrap><input name="ros_psych_negative" type="checkbox" value="1" checked>
 939       Negative</td>
 940         <td width="20%" nowrap><input type="checkbox" name="ros_psych_depression" value="1" disabled="disabled">
 941       Depression</td>
 942         <td width="20%" nowrap><input type="checkbox" name="ros_psych_crying" value="1" disabled="disabled">
 943       Crying</td>
 944         <td width="20%">&nbsp;</td>
 945         <td width="20%">&nbsp;</td>
 946       </tr>
 947       <tr align="left" valign="baseline">
 948         <td colspan="2" nowrap><input type="checkbox" name="ros_psych_anxiety" value="1" disabled="disabled">
 949       Severe anxiety </td>
 950         <td width="20%" nowrap><input type="checkbox" name="ros_psych_other" value="1" disabled="disabled">
 951 Other</td>
 952         <td align="right" nowrap>&nbsp;</td>
 953         <td>&nbsp;</td>
 954       </tr>
 955     </table></td>
 956   </tr>
 957   <tr>
 958     <td width="190" align="left" valign="top" class="ficaption">12. Endocrine </td>
 959     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 960       <tr align="left" valign="baseline">
 961         <td width="20%" nowrap><input name="ros_endo_negative" type="checkbox" value="1" checked>
 962       Negative</td>
 963         <td width="20%" nowrap><input type="checkbox" name="ros_endo_diabetes" value="1" disabled="disabled">
 964         Diabetes</td>
 965         <td nowrap><input type="checkbox" name="ros_endo_hipothyroid" value="1" disabled="disabled">
 966       HYpothyroid</td>
 967         <td nowrap><input type="checkbox" name="ros_endo_hiperthyroid" value="1" disabled="disabled">
 968 HYperthyroid</td>
 969       </tr>
 970       <tr align="left" valign="baseline">
 971         <td nowrap><input type="checkbox" name="ros_endo_flashes" value="1" disabled="disabled">
 972       Hot flashes </td>
 973         <td nowrap><input type="checkbox" name="ros_endo_hair_loss" value="1" disabled="disabled">
 974       Hair loss </td>
 975         <td nowrap><input type="checkbox" name="ros_endo_intolerance" value="1" disabled="disabled">
 976       Heat/cold intolerance </td>
 977         <td><input type="checkbox" name="ros_endo_other" value="1" disabled="disabled">
 978           Other
 979 </td>
 980  </tr>
 981 </table></td>
 982   </tr>
 983   <tr>
 984     <td width="190" align="left" valign="top" class="ficaption">13. Hematologic/Lymphatic</td>
 985     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 986       <tr align="left" valign="baseline">
 987         <td width="20%" nowrap><input name="ros_hemato_negative" type="checkbox" value="1" checked>
 988       Negative</td>
 989         <td width="20%" nowrap><input type="checkbox" name="ros_hemato_bruises" value="1" disabled="disabled">
 990       Bruises</td>
 991         <td width="20%" nowrap>&nbsp;</td>
 992         <td width="20%">&nbsp;</td>
 993         <td width="20%">&nbsp;</td>
 994       </tr>
 995       <tr align="left" valign="baseline">
 996         <td nowrap><input type="checkbox" name="ros_hemato_bleeding" value="1" disabled="disabled">
 997       Bleeding</td>
 998         <td nowrap><input type="checkbox" name="ros_hemato_adenopathy" value="1" disabled="disabled">
 999       Adenopathy</td>
1000         <td nowrap><input type="checkbox" name="ros_hemato_other" value="1" disabled="disabled">
1001       other</td>
1002         <td align="right" nowrap>&nbsp;</td>
1003         <td>&nbsp;</td>
1004       </tr>
1005     </table></td>
1006   </tr>
1007   <tr>
1008     <td width="190" align="left" valign="top" class="ficaption">14. Allergic/Immunologic </td>
1009     <td align="center" valign="middle" class="fibody"><a href="#allergies">See above (Page 1 of PH) </a></td>
1010   </tr>
1011 </table>
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