contrib/forms/physician_history/view.php

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