contrib/forms/patient_intake_history/view.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2
   3 "http://www.w3.org/TR/html4/loose.dtd">
   4
   5 <?php
   6
   7 include_once("../../globals.php");
   8
   9 include_once("$srcdir/api.inc");
  10
  11 include_once("$srcdir/forms.inc");
  12
  13 include_once("$srcdir/calendar.inc");
  14
  15 ?>
  16
  17
  18
  19 <html>
  20
  21 <head>
  22 <?php html_header_show();?>
  23
  24 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  25
  26 <link rel="stylesheet" href="../../acog.css" type="text/css">
  27
  28 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  29
  30 <script language="JavaScript" type="text/JavaScript">
  31
  32 window.onload = initialize;
  33
  34 </script>
  35
  36 </head>
  37
  38
  39
  40 <body class="body_top">
  41
  42
  43
  44 <?php
  45
  46    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  47
  48    if ($fres){
  49
  50      $patient = sqlFetchArray($fres);
  51
  52    }
  53
  54    $fres=sqlStatement("select * from form_patient_intake_history where id=$id");
  55
  56    if ($fres){
  57
  58      $fdata = sqlFetchArray($fres);
  59
  60    }
  61
  62    $fres=sqlStatement("select * from form_patient_intake_history_ros where id=".$fdata['linked_ros_id']);
  63
  64    if ($fres){
  65
  66      $fros = sqlFetchArray($fres);
  67
  68    }
  69
  70 ?>
  71
  72 <form action="<?php echo $rootdir;?>/forms/patient_intake_history/save.php?mode=update&id=<?php echo $id; ?>" method="post" enctype="multipart/form-data" name="my_form">
  73
  74 <?php
  75
  76 $addmenu = <<<EOL
  77
  78 <blockquote>
  79
  80   <small><strong>Local sections: </strong><br>
  81
  82   <a href="#gh">Gynecologic history</a> |
  83
  84   <a href="#oh">Obstetric history</a> | <a href="#cm">Current medications</a> |
  85
  86   <a href="#fh">Family history</a> | <a href="#sh">Social history</a> |
  87
  88   <a href="#pp">Personal profile</a> |
  89
  90   <a href="#ih">Personal past history of illnesses</a> | <a href="#op">Operations/Hospitalizations</a> |
  91
  92   <a href="#ii">Injuries/Illnesses</a> | <a href="#im">Immunizations/Test</a> |
  93
  94   <a href="#ros">Review of systems</a></small>
  95
  96 </blockquote>
  97
  98 EOL;
  99
 100 ?>
 101
 102 <?php include("../../acog_menu.inc"); ?>
 103
 104   <table width="50%"  border="0" cellspacing="0" cellpadding="2">
 105
 106     <tr>
 107
 108       <td align="left" valign="bottom" nowrap class="fibody3">For office use only </td>
 109
 110     </tr>
 111
 112     <tr>
 113
 114       <td align="left" valign="bottom" nowrap class="fibody3"> <input name="pih_patient" type="radio" value="0"  <?php echo (($fdata{'pih_patient'} == '0')?' checked ':''); ?>>
 115
 116       New patient </td>
 117
 118     </tr>
 119
 120     <tr>
 121
 122       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_patient" type="radio" value="1" <?php echo (($fdata{'pih_patient'} == '1')?' checked ':''); ?>>
 123
 124       Established patient </td>
 125
 126     </tr>
 127
 128     <tr>
 129
 130       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_consultation" type="checkbox"  value="1" <?php echo (($fdata{'pih_consultation'} == '1')?' checked ':''); ?>>
 131
 132       Consultation</td>
 133
 134     </tr>
 135
 136     <tr>
 137
 138       <td align="left" valign="bottom" nowrap class="fibody3"><input name="pih_report_sent" type="checkbox"  value="1" <?php echo (($fdata{'pih_report_sent'} == '1')?' checked ':''); ?>>
 139
 140       Report sent
 141
 142       <input name="pih_report_sent_date" type="text" class="fullin"  style="width:90px"  value="<?php echo $fdata{'pih_report_sent_date'}; ?>"></td>
 143
 144     </tr>
 145
 146 </table>
 147
 148 <?php
 149
 150 $tip1 = <<<EOL
 151
 152 <strong>Patient Intake History</strong> is an optional form
 153
 154 giving practices the flexibility to have patients complete
 155
 156 their own history at or before the visit. It uses language
 157
 158 that a patient is likely to understand and includes ample
 159
 160 space for physician notes. Space at the end of the form
 161
 162 allows physicians to review the history and sign off for 4
 163
 164 years. At year 5, the patient should be asked to complete
 165
 166 a new Patient Intake History.
 167
 168 EOL;
 169
 170 $tip1 = strtr($tip1, "\n\r", "  ");
 171
 172 ?>
 173
 174 <div class="srvChapter">Patient Intake 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>
 175
 176 <div style="border: solid 2px black; background-color: white;">
 177
 178 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 179
 180   <tr>
 181
 182     <td align="left" valign="top" class="fibody2" style="border-bottom: 2px solid black"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
 183
 184       <tr align="left" valign="bottom" class="fibody">
 185
 186         <td width="40%" class="bordR">Patient name <br>
 187
 188           <input name="pname" type="text" class="fullin" id="pname" value="<?php
 189
 190           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
 191
 192           ?>"></td>
 193
 194         <td width="20%" class="bordR">birth date
 195
 196           <br>
 197
 198           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
 199
 200           echo $patient{'DOB'};
 201
 202           ?>" size="12"> </td>
 203
 204         <td width="20%" class="bordR">ID No<br>
 205
 206           <input name="pih_pid" type="text" class="fullin" id="pih_pid" size="12" value="<?php
 207
 208           echo $patient{'id'};
 209
 210           ?>"></td>
 211
 212         <td width="20%">date<br>
 213
 214         <input name="pih_date" type="text" class="fullin" id="pih_date" value="<?php
 215
 216         echo date('Y-m-d');
 217
 218         ?>" size="12"></td>
 219
 220       </tr>
 221
 222     </table>
 223
 224 </td>
 225
 226   </tr>
 227
 228   <tr>
 229
 230     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 231
 232       <tr align="left" valign="bottom">
 233
 234         <td colspan="3" class="fibody2">Address:
 235
 236           <input name="address" type="text" class="fullin"  style="width: 90%" value="<?php echo $fdata{'address'}; ?>"></td>
 237
 238         </tr>
 239
 240       <tr align="left" valign="bottom">
 241
 242         <td width="50%" class="fibody2" id="bordR">City:
 243
 244           <input name="city" type="text" class="fullin"  style="width: 250px" value="<?php echo $fdata{'city'}; ?>"></td>
 245
 246         <td width="50%" colspan="2" class="fibody2">State/ZIP:
 247
 248           <input name="state" type="text" class="fullin"  style="width: 250px" value="<?php echo $fdata{'state'}; ?>"></td>
 249
 250       </tr>
 251
 252       <tr align="left" valign="bottom">
 253
 254         <td class="fibody2" id="bordR">Home telephone:
 255
 256           <span style="width:auto">
 257
 258           <input name="home_phone" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'home_phone'}; ?>">
 259
 260           </span></td>
 261
 262         <td colspan="2" class="fibody2">Work telephone:
 263
 264           <input name="work_phone" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'work_phone'}; ?>"></td>
 265
 266       </tr>
 267
 268       <tr align="left" valign="bottom">
 269
 270         <td class="fibody2" id="bordR">Employer:
 271
 272           <input name="employer" type="text" class="fullin"  style="width: 80%" value="<?php echo $fdata{'employer'}; ?>"></td>
 273
 274         <td width="25%" class="fibody2" id="bordR">Insurance
 275
 276           <input name="insurance" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'insurance'}; ?>"></td>
 277
 278         <td width="25%" class="fibody2">Policy No:
 279
 280           <input name="policy_no" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'policy_no'}; ?>"></td>
 281
 282       </tr>
 283
 284       <tr align="left" valign="bottom">
 285
 286         <td class="fibody2" id="bordR">Name you would like us to use:           <input name="name_to_use" type="text" class="fullin"  style="width: 50%" value="<?php echo $fdata{'name_to_use'}; ?>"> </td>
 287
 288         <td colspan="2" class="fibody2">Primary language:
 289
 290           <input name="primary_language" type="text" class="fullin"  style="width: 150px" value="<?php echo $fdata{'primary_language'}; ?>"></td>
 291
 292       </tr>
 293
 294     </table></td>
 295
 296   </tr>
 297
 298   <tr>
 299
 300     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 301
 302       <tr align="left" valign="bottom">
 303
 304         <td width="40%" class="fibody2" id="bordR">Name of spouse/partner: </td>
 305
 306         <td colspan="2" class="fibody2">Emergency contact:
 307
 308           <input name="partner_emergency_contact" type="text" class="fullin"  style="width: 70%" value="<?php echo $fdata{'partner_emergency_contact'}; ?>"></td>
 309
 310         </tr>
 311
 312       <tr align="left" valign="bottom">
 313
 314         <td rowspan="2" valign="top" class="fibody2" id="bordR"><textarea name="partner_name" rows="2" wrap="VIRTUAL" class="fullin2"  style="height:100%"><?php echo $fdata{'partner_name'}; ?></textarea></td>
 315
 316         <td colspan="2" class="fibody2">Relationship:
 317
 318           <input name="relationship" type="text" class="fullin"  style="width:80%" value="<?php echo $fdata{'relationship'}; ?>"></td>
 319
 320         </tr>
 321
 322       <tr align="left" valign="bottom">
 323
 324         <td width="30%" class="fibody2" id="bordR">Home telephone:
 325
 326           <input name="partner_home_phone" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'partner_home_phone'}; ?>"></td>
 327
 328         <td width="30%" class="fibody2">Work telephone:
 329
 330           <input name="partner_work_phone" type="text" class="fullin"  style="width: 120px" value="<?php echo $fdata{'partner_work_phone'}; ?>"></td>
 331
 332       </tr>
 333
 334     </table></td>
 335
 336   </tr>
 337
 338   <tr>
 339
 340     <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 341
 342       <tr>
 343
 344         <td align="left" valign="bottom" class="fibody2">Referred by:
 345
 346           <input name="referred_by" type="text" class="fullin"  style="width: 85%;" value="<?php echo $fdata{'referred_by'}; ?>"></td>
 347
 348       </tr>
 349
 350       <tr>
 351
 352         <td align="left" valign="bottom" class="fibody2">Why have you come to the office today?
 353
 354           <input name="why_come_to_office" type="text" class="fullin"  value="<?php echo $fdata{'why_come_to_office'}; ?>"></td>
 355
 356       </tr>
 357
 358       <tr>
 359
 360         <td align="left" valign="bottom" class="fibody2">If you are here for the annual examination is this a
 361
 362           <input name="primary_care_visit" type="radio" value="1"  <?php echo (($fdata{'primary_care_visit'} == '1')?' checked ':''); ?>>
 363
 364           Primary care visit or
 365
 366           <input name="primary_care_visit" type="radio" value="0" <?php echo (($fdata{'primary_care_visit'} == '0')?' checked ':''); ?>>
 367
 368           Gynecology only </td>
 369
 370       </tr>
 371
 372       <tr>
 373
 374         <td align="left" valign="bottom" class="fibody2">Is this a new problem?
 375
 376           <input name="new_problem" type="radio" value="1"  <?php echo (($fdata{'new_problem'} == '1')?' checked ':''); ?>>
 377
 378           yes &nbsp;&nbsp;&nbsp;&nbsp;
 379
 380           <input name="new_problem" type="radio" value="0" <?php echo (($fdata{'new_problem'} == '0')?' checked ':''); ?>>
 381
 382           no</td>
 383
 384       </tr>
 385
 386       <tr>
 387
 388         <td align="left" valign="bottom" class="fibody2">Please, describe your problem, including, where it is, how severe it is, and how long it has lasted <br>
 389
 390           <textarea name="problem_description" rows="6" class="fullin2" ><?php echo $fdata{'problem_description'}; ?></textarea></td>
 391
 392       </tr>
 393
 394     </table></td>
 395
 396   </tr>
 397
 398 </table>
 399
 400 </div>
 401
 402 <h2 align="center"><small>If you are uncomfortable answering any questions, leave them blank; you can discuss them with your doctor or nurse.</small></h2>
 403
 404 <p align="center">&nbsp;</p>
 405
 406 <h2 align="center"><a name="gh"></a>Gynecologic history <br>
 407
 408   </h2>
 409
 410 <div style="border: solid 2px black; background-color: white;">
 411
 412     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 413
 414       <tr>
 415
 416         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 417
 418           <tr align="left" valign="bottom">
 419
 420             <td width="50%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 421
 422             <td width="50%" align="center" class="ficaption2">Physicians notes </td>
 423
 424           </tr>
 425
 426           <tr align="left" valign="bottom">
 427
 428             <td nowrap class="fibody2" id="bordR">Last normal menstrual period (first day)
 429
 430               <input name="last_period_date" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'last_period_date'}; ?>"></td>
 431
 432             <td class="fibody2"><input name="gh_notes_1" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_1'}; ?>"></td>
 433
 434           </tr>
 435
 436           <tr align="left" valign="bottom">
 437
 438             <td nowrap class="fibody2" id="bordR">Age periods began:
 439
 440               <input name="periods_began" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'periods_began'}; ?>"></td>
 441
 442             <td class="fibody2"><input name="gh_notes_2" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_2'}; ?>"></td>
 443
 444           </tr>
 445
 446           <tr align="left" valign="bottom">
 447
 448             <td nowrap class="fibody2" id="bordR">Length of periods (number of days of bleeding):
 449
 450               <input name="period_lenght" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'period_lenght'}; ?>"></td>
 451
 452             <td class="fibody2"><input name="gh_notes_3" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_3'}; ?>"></td>
 453
 454           </tr>
 455
 456           <tr align="left" valign="bottom">
 457
 458             <td nowrap class="fibody2" id="bordR">Number of days between periods:
 459
 460               <input name="period_days_between" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'period_days_between'}; ?>"></td>
 461
 462             <td class="fibody2"><input name="gh_notes_4" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_4'}; ?>"></td>
 463
 464           </tr>
 465
 466           <tr align="left" valign="bottom">
 467
 468             <td nowrap class="fibody2" id="bordR">Any recent changes in periods?
 469
 470               <input name="period_changes" type="radio" value="1" <?php echo (($fdata{'period_changes'} == '1')?' checked ':''); ?>>
 471
 472 Yes
 473
 474 <input name="pih_gh_recent_changes_periods" type="radio" value="0"  <?php echo (($fdata{'pih_gh_recent_changes_periods'} == '0')?' checked ':''); ?>>
 475
 476 No</td>
 477
 478             <td class="fibody2"><input name="gh_notes_5" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_5'}; ?>"></td>
 479
 480           </tr>
 481
 482           <tr align="left" valign="bottom">
 483
 484             <td nowrap class="fibody2" id="bordR">Are you currently sexually active?
 485
 486               <input name="sexually_active" type="radio" value="1"  <?php echo (($fdata{'sexually_active'} == '1')?' checked ':''); ?>>
 487
 488 Yes
 489
 490 <input name="sexually_active" type="radio" value="0" <?php echo (($fdata{'sexually_active'} == '0')?' checked ':''); ?>>
 491
 492 No</td>
 493
 494             <td class="fibody2"><input name="gh_notes_6" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_6'}; ?>"></td>
 495
 496           </tr>
 497
 498           <tr align="left" valign="bottom">
 499
 500             <td nowrap class="fibody2" id="bordR">have you ever had sex?
 501
 502               <input name="ever_had_sex" type="radio" value="1"  <?php echo (($fdata{'ever_had_sex'} == '1')?' checked ':''); ?>>
 503
 504 Yes
 505
 506 <input name="ever_had_sex" type="radio" value="0" <?php echo (($fdata{'ever_had_sex'} == '0')?' checked ':''); ?>>
 507
 508 No</td>
 509
 510             <td class="fibody2"><input name="gh_notes_7" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_7'}; ?>"></td>
 511
 512           </tr>
 513
 514           <tr align="left" valign="bottom">
 515
 516             <td nowrap class="fibody2" id="bordR">Number of sexual partners (Lifetime):
 517
 518               <input name="number_of_partners" type="text" class="fullin"  style="width: 90px"  value="<?php echo $fdata{'number_of_partners'}; ?>"></td>
 519
 520             <td class="fibody2"><input name="gh_notes_8" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_8'}; ?>"></td>
 521
 522           </tr>
 523
 524           <tr align="left" valign="bottom">
 525
 526             <td nowrap class="fibody2" id="bordR">Sexual partners are
 527
 528               <input name="partners" type="radio" value="men"  <?php echo (($fdata{'partners'} == 'men')?' checked ':''); ?>>
 529
 530               Men
 531
 532               <input name="partners" type="radio" value="women" <?php echo (($fdata{'partners'} == 'women')?' checked ':''); ?>>
 533
 534               Women
 535
 536               <input name="partners" type="radio" value="both" <?php echo (($fdata{'partners'} == 'both')?' checked ':''); ?>>
 537
 538               Both </td>
 539
 540             <td class="fibody2"><input name="gh_notes_9" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_9'}; ?>"></td>
 541
 542           </tr>
 543
 544           <tr align="left" valign="bottom">
 545
 546             <td nowrap class="fibody2" id="bordR">Present method of birth control:
 547
 548               <input name="present_birth_control" type="text" class="fullin"  style="width: 90px"  value="<?php echo $fdata{'present_birth_control'}; ?>"></td>
 549
 550             <td class="fibody2"><input name="gh_notes_10" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_10'}; ?>"></td>
 551
 552           </tr>
 553
 554           <tr align="left" valign="bottom">
 555
 556             <td nowrap class="fibody2" id="bordR">Have you ever used an intrauterine device (IUD) or birth control pills ?
 557
 558               <input name="pills_iud" type="radio" value="1" <?php echo (($fdata{'pills_iud'} == '1')?' checked ':''); ?>>
 559
 560 Yes
 561
 562 <input name="pills_iud" type="radio" value="0"  <?php echo (($fdata{'pills_iud'} == '0')?' checked ':''); ?>>
 563
 564 No </td>
 565
 566             <td class="fibody2"><input name="gh_notes_11" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_11'}; ?>"></td>
 567
 568           </tr>
 569
 570           <tr align="left" valign="bottom">
 571
 572             <td nowrap class="fibody2" id="bordR">if yes, for how long?
 573
 574               <input name="pills_how_long" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'pills_how_long'}; ?>"></td>
 575
 576             <td class="fibody2"><input name="gh_notes_12" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_12'}; ?>"></td>
 577
 578           </tr>
 579
 580           <tr align="left" valign="bottom">
 581
 582             <td nowrap class="fibody2" id="bordR">When was your last PAP test?
 583
 584               <input name="pap_test" type="text" class="fullin"  style="width: 90px" value="<?php echo $fdata{'pap_test'}; ?>"></td>
 585
 586             <td class="fibody2"><input name="gh_notes_13" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_13'}; ?>"></td>
 587
 588           </tr>
 589
 590           <tr align="left" valign="bottom">
 591
 592             <td nowrap class="fibody2" id="bordR">Do you do breast self examinations?
 593
 594               <input name="breast_self_exam" type="radio" value="1" <?php echo (($fdata{'breast_self_exam'} == '1')?' checked ':''); ?>>
 595
 596               Yes
 597
 598               <input name="breast_self_exam" type="radio" value="0"  <?php echo (($fdata{'breast_self_exam'} == '0')?' checked ':''); ?>>
 599
 600               No</td>
 601
 602             <td class="fibody2"><input name="gh_notes_14" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_14'}; ?>"></td>
 603
 604           </tr>
 605
 606           <tr align="left" valign="bottom">
 607
 608             <td nowrap class="fibody2" id="bordR">Have you been exposed to diethylstilbestrol (DES)?
 609
 610               <input name="des" type="radio" value="1" <?php echo (($fdata{'des'} == '1')?' checked ':''); ?>>
 611
 612 Yes
 613
 614 <input name="des" type="radio" value="0" <?php echo (($fdata{'des'} == '0')?' checked ':''); ?>>
 615
 616 No </td>
 617
 618             <td class="fibody2"><input name="gh_notes_15" type="text" class="fullin2"  value="<?php echo $fdata{'gh_notes_15'}; ?>"></td>
 619
 620           </tr>
 621
 622         </table></td>
 623
 624       </tr>
 625
 626     </table>
 627
 628   </div>
 629
 630   <p align="center">&nbsp;</p>
 631
 632   <h2 align="center"><a name="oh"></a>Obstetric history <br>
 633
 634   </h2>
 635
 636   <div style="border: solid 2px black; background-color:#FFFFFF;">
 637
 638     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 639
 640       <tr>
 641
 642         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 643
 644             <tr align="left" valign="bottom">
 645
 646               <td width="30%" nowrap class="fibody2" id="bordR">&nbsp;</td>
 647
 648               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 649
 650               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 651
 652               <td width="50" align="center" nowrap class="ficaption2" id="bordR">Number</td>
 653
 654               <td width="30%" align="center" nowrap class="fibody2" id="bordR">&nbsp;</td>
 655
 656               <td width="50" align="center" nowrap class="ficaption2">Number</td>
 657
 658             </tr>
 659
 660             <tr align="left" valign="bottom">
 661
 662               <td width="30%" nowrap class="fibody2" id="bordR">Pregnancies</td>
 663
 664               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_pregnancies" type="text" class="fullin2"   value="<?php echo $fdata{'oh_pregnancies'}; ?>"></td>
 665
 666               <td width="30%" nowrap class="fibody2" id="bordR">abortions</td>
 667
 668               <td width="50" nowrap class="fibody2" id="bordR"><input name="oh_abortions" type="text" class="fullin2"   value="<?php echo $fdata{'oh_abortions'}; ?>"></td>
 669
 670               <td width="30%" nowrap class="fibody2" id="bordR">miscarriages</td>
 671
 672               <td width="50" nowrap class="fibody2"><input name="oh_miscarriages" type="text" class="fullin2"   value="<?php echo $fdata{'oh_miscarriages'}; ?>"></td>
 673
 674             </tr>
 675
 676             <tr align="left" valign="bottom">
 677
 678               <td width="30%" nowrap class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 679
 680               <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>
 681
 682               <td width="30%" nowrap class="fibody2" id="bordR">live births </td>
 683
 684               <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>
 685
 686               <td width="30%" nowrap class="fibody2" id="bordR">living children </td>
 687
 688               <td width="50" nowrap class="fibody2"><input name="oh_living_children" type="text" class="fullin2"  value="<?php echo $fdata{'oh_living_children'}; ?>"></td>
 689
 690             </tr>
 691
 692         </table></td>
 693
 694       </tr>
 695
 696       <tr>
 697
 698         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 699
 700             <tr align="center" valign="middle">
 701
 702               <td class="ficaption2" id="bordR">No</td>
 703
 704               <td class="ficaption2" id="bordR">birth date </td>
 705
 706               <td class="ficaption2" id="bordR">weight at birth </td>
 707
 708               <td class="ficaption2" id="bordR">baby's sex </td>
 709
 710               <td class="ficaption2" id="bordR">weeks pregnant </td>
 711
 712               <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 713
 714               <td class="ficaption2">physician's notes</td>
 715
 716             </tr>
 717
 718 <?php
 719
 720   $bi = 0;
 721
 722   while ($bi<4) {
 723
 724     $n = $bi+1;
 725
 726     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 727
 728     print <<<EOL
 729
 730         <tr align="left" valign="bottom">
 731
 732           <td nowrap class="fibody2" id="bordR">$n.</td>
 733
 734           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_date_${bi}" type="text" value="${oh_ch_date}" class="fullin2"></td>
 735
 736           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_width_${bi}" type="text" value="${oh_ch_width}"  class="fullin2"></td>
 737
 738           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_sex_${bi}" type="text" value="${oh_ch_sex}"  class="fullin2"></td>
 739
 740           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_weeks_${bi}" type="text" value="${oh_ch_weeks}"  class="fullin2"></td>
 741
 742           <td nowrap class="fibody2" id="bordR"><input name="oh_ch_delivery_${bi}" type="text" value="${oh_ch_delivery}"  class="fullin2"></td>
 743
 744           <td nowrap class="fibody2"><input name="oh_ch_notes_${bi}" type="text" value="${oh_ch_notes}"  class="fullin2"></td>
 745
 746         </tr>
 747
 748 EOL;
 749
 750      $bi++;
 751
 752   }
 753
 754 ?>
 755
 756         </table></td>
 757
 758       </tr>
 759
 760       <tr>
 761
 762         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 763
 764             <tr align="left" valign="bottom">
 765
 766               <td width="23%" nowrap class="fibody2">Any pregnancy complications? </td>
 767
 768               <td class="fibody2"><input name="oh_complications" type="text" class="fullin2"   value="<?php echo $fdata{'oh_complications'}; ?>"></td>
 769
 770             </tr>
 771
 772         </table></td>
 773
 774       </tr>
 775
 776       <tr>
 777
 778         <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 779
 780             <tr align="left" valign="bottom">
 781
 782               <td colspan="2" class="fibody2"><input name="oh_diabetes" type="checkbox"  value="1" <?php echo (($fdata{'oh_diabetes'} == '1')?' checked ':''); ?>>
 783
 784               diabetes
 785
 786                 <input name="oh_hipertension" type="checkbox"  value="1" <?php echo (($fdata{'oh_hipertension'} == '1')?' checked ':''); ?>>
 787
 788               hypertension/high blood pressure
 789
 790               <input name="oh_preemclampsia" type="checkbox"  value="1" <?php echo (($fdata{'oh_preemclampsia'} == '1')?' checked ':''); ?>>
 791
 792               preeclampsia/foxemia
 793
 794               <input name="oh_complic_other" type="checkbox"  value="1" <?php echo (($fdata{'oh_complic_other'} == '1')?' checked ':''); ?>>
 795
 796               other </td>
 797
 798             </tr>
 799
 800             <tr align="left" valign="bottom">
 801
 802               <td width="472" nowrap class="fibody2">any history of depression before or after pregnancy?
 803
 804                   <input name="oh_depression" type="radio" value="0"  <?php echo (($fdata{'oh_depression'} == '0')?' checked ':''); ?>>
 805
 806               no
 807
 808               <input name="oh_depression" type="radio" value="1" <?php echo (($fdata{'oh_depression'} == '1')?' checked ':''); ?>>
 809
 810               yes, How treated </td>
 811
 812               <td class="fibody2"><input name="oh_depression_treated" type="text" class="fullin2"  value="<?php echo $fdata{'oh_depression_treated'}; ?>"></td>
 813
 814             </tr>
 815
 816         </table></td>
 817
 818       </tr>
 819
 820     </table>
 821
 822   </div>
 823
 824   <p align="center">&nbsp;</p>
 825
 826   <h2 align="center"><a name="cm"></a>Current medications <br>
 827
 828     <small>(Including hormones, vitamins, herbs, nonprescription medications) </small><br>
 829
 830   </h2>
 831
 832   <div style="border: solid 2px black; background-color: white;">
 833
 834     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 835
 836       <tr align="center">
 837
 838         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 839
 840         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 841
 842         <td valign="top" class="ficaption2" id="bordR">Who prescribed </td>
 843
 844         <td valign="top" class="ficaption2" id="bordR">Drug name </td>
 845
 846         <td valign="top" class="ficaption2" id="bordR">Dosage</td>
 847
 848         <td valign="top" class="ficaption2">Who prescribed</td>
 849
 850       </tr>
 851
 852 <?php
 853
 854   $bi = 0;
 855
 856   while ($bi<5) {
 857
 858   $bi2 = $bi+5;
 859
 860       list ($pres_drug, $pres_dosage, $pres_who) = explode('|~', $fdata["pres_drug_rec_".$bi] );
 861
 862       list ($pres_drug1, $pres_dosage1, $pres_who1) = explode('|~', $fdata["pres_drug_rec_".$bi2] );
 863
 864     print <<<EOL
 865
 866       <tr>
 867
 868         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi}" value="${pres_dosage}" type="text" class="fullin2"></td>
 869
 870         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi}" value="${pres_drug}" type="text" class="fullin2"></td>
 871
 872         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_who_${bi}" value="${pres_who}" type="text" class="fullin2"></td>
 873
 874         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_drug_${bi2}" value="${pres_drug1}" type="text" class="fullin2"></td>
 875
 876         <td align="left" valign="top" class="fibody2" id="bordR"><input name="pres_dosage_${bi2}" value="${pres_dosage1}" type="text" class="fullin2"></td>
 877
 878         <td align="left" valign="top" class="fibody2"><input name="pres_who_${bi2}" type="text" value="${pres_who1}" class="fullin2"></td>
 879
 880       </tr>
 881
 882 EOL;
 883
 884      $bi++;
 885
 886   }
 887
 888 ?>
 889
 890     </table>
 891
 892   </div>
 893
 894   <p align="center">&nbsp;</p>
 895
 896   <h2 align="center"><a name="fh"></a>Family history <br>
 897
 898   </h2>
 899
 900   <div style="border: solid 2px black; background-color: white;">
 901
 902     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 903
 904       <tr>
 905
 906         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 907
 908           <tr align="left" valign="bottom">
 909
 910             <td width="50%" nowrap class="fibody2" id="bordR">Mother:
 911
 912               <input name="fh_mother" type="radio" value="0"  <?php echo (($fdata{'fh_mother'} == '0')?' checked ':''); ?>>
 913
 914               living
 915
 916               <input name="fh_mother" type="radio" value="1" <?php echo (($fdata{'fh_mother'} == '1')?' checked ':''); ?>>
 917
 918               deceased - cause:
 919
 920               <input name="fh_mother_dec_cause" type="text" class="fullin"  style="width: 20%" value="<?php echo $fdata{'fh_mother_dec_cause'}; ?>">
 921
 922               Age:
 923
 924               <input name="fh_mother_dec_age" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_mother_dec_age'}; ?>"></td>
 925
 926             <td width="50%" nowrap class="fibody2">father:
 927
 928               <input name="fh_father" type="radio" value="0"  <?php echo (($fdata{'fh_father'} == '0')?' checked ':''); ?>>
 929
 930 living
 931
 932 <input name="fh_father" type="radio" value="1" <?php echo (($fdata{'fh_father'} == '1')?' checked ':''); ?>>
 933
 934 deceased - cause:
 935
 936 <input name="fh_father_dec_cause" type="text" class="fullin"  style="width: 20%" value="<?php echo $fdata{'fh_father_dec_cause'}; ?>">
 937
 938 Age:
 939
 940 <input name="fh_father_dec_age" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_father_dec_age'}; ?>"></td>
 941
 942           </tr>
 943
 944           <tr align="left" valign="bottom">
 945
 946             <td nowrap class="fibody2">Siblings: Num.living:
 947
 948               <input name="fh_sibl_living" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_sibl_living'}; ?>">
 949
 950               , num.deceased:
 951
 952               <input name="fh_sib_deceased" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_sib_deceased'}; ?>">
 953
 954               , cause(s)/age(s): </td>
 955
 956             <td nowrap class="fibody2"><input name="fh_sib_dec_cause" type="text" class="fullin"  value="<?php echo $fdata{'fh_sib_dec_cause'}; ?>"></td>
 957
 958           </tr>
 959
 960           <tr align="left" valign="bottom">
 961
 962             <td nowrap class="fibody2">Children: Num.living:
 963
 964               <input name="fh_children_living" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_children_living'}; ?>">
 965
 966 , num.deceased:
 967
 968 <input name="fh_children_deceased" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'fh_children_deceased'}; ?>">
 969
 970 , cause(s)/age(s):</td>
 971
 972             <td nowrap class="fibody2"><input name="fh_children_dec_cause" type="text" class="fullin"  value="<?php echo $fdata{'fh_children_dec_cause'}; ?>"></td>
 973
 974           </tr>
 975
 976         </table></td>
 977
 978       </tr>
 979
 980       <tr>
 981
 982         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 983
 984           <tr valign="bottom">
 985
 986             <td width="120" align="left" nowrap class="ficaption2" id="bordR">Illness</td>
 987
 988             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
 989
 990             <td width="250" align="center" class="ficaption2" id="bordR">which relative(s) and age of onset </td>
 991
 992             <td align="center" class="ficaption2">Physician's notes </td>
 993
 994           </tr>
 995
 996           <tr align="left" valign="bottom">
 997
 998             <td nowrap class="fibody2" id="bordR">diabetes</td>
 999
1000             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_diabetes" type="checkbox"  value="1" <?php echo (($fdata{'fh_diabetes'} == '1')?' checked ':''); ?>></td>
1001
1002             <td class="fibody2" id="bordR"><input name="fh_diabetes_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_diabetes_info'}; ?>"></td>
1003
1004             <td class="fibody2"><input name="fh_notes_1" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_1'}; ?>"></td>
1005
1006           </tr>
1007
1008           <tr align="left" valign="bottom">
1009
1010             <td nowrap class="fibody2" id="bordR">Stroke</td>
1011
1012             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_stroke" type="checkbox"  value="1" <?php echo (($fdata{'fh_stroke'} == '1')?' checked ':''); ?>></td>
1013
1014             <td class="fibody2" id="bordR"><input name="fh_stroke_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_stroke_info'}; ?>"></td>
1015
1016             <td class="fibody2"><input name="fh_notes_2" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_2'}; ?>"></td>
1017
1018           </tr>
1019
1020           <tr align="left" valign="bottom">
1021
1022             <td nowrap class="fibody2" id="bordR">Heart dIsease </td>
1023
1024             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_heart_disease" type="checkbox"  value="1" <?php echo (($fdata{'fh_heart_disease'} == '1')?' checked ':''); ?>></td>
1025
1026             <td class="fibody2" id="bordR"> <input name="fh_heart_disease_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_heart_disease_info'}; ?>"></td>
1027
1028             <td class="fibody2"><input name="fh_notes_3" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_3'}; ?>"></td>
1029
1030           </tr>
1031
1032           <tr align="left" valign="bottom">
1033
1034             <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
1035
1036             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fhbllod_clots" type="checkbox"  value="1" <?php echo (($fdata{'fhbllod_clots'} == '1')?' checked ':''); ?>></td>
1037
1038             <td class="fibody2" id="bordR"><input name="fhbllod_clots_info" type="text" class="fullin2"  value="<?php echo $fdata{'fhbllod_clots_info'}; ?>"></td>
1039
1040             <td class="fibody2"><input name="fh_notes_4" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_4'}; ?>"></td>
1041
1042           </tr>
1043
1044           <tr align="left" valign="bottom">
1045
1046             <td nowrap class="fibody2" id="bordR">High blood pressure </td>
1047
1048             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_pressure" type="checkbox"  value="1" <?php echo (($fdata{'fh_high_pressure'} == '1')?' checked ':''); ?>></td>
1049
1050             <td class="fibody2" id="bordR"><input name="fh_high_pressure_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_high_pressure_info'}; ?>"></td>
1051
1052             <td class="fibody2"><input name="fh_notes_5" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_5'}; ?>"></td>
1053
1054           </tr>
1055
1056           <tr align="left" valign="bottom">
1057
1058             <td nowrap class="fibody2" id="bordR">High cholesterol</td>
1059
1060             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_high_cholesterol" type="checkbox"  value="1" <?php echo (($fdata{'fh_high_cholesterol'} == '1')?' checked ':''); ?>></td>
1061
1062             <td class="fibody2" id="bordR"><input name="fh_high_cholesterol_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_high_cholesterol_info'}; ?>"></td>
1063
1064             <td class="fibody2"><input name="fh_notes_6" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_6'}; ?>"></td>
1065
1066           </tr>
1067
1068           <tr align="left" valign="bottom">
1069
1070             <td nowrap class="fibody2" id="bordR">Osteoporosis (weak bones) </td>
1071
1072             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_osteoporosis" type="checkbox"  value="1" <?php echo (($fdata{'fh_osteoporosis'} == '1')?' checked ':''); ?>></td>
1073
1074             <td class="fibody2" id="bordR"><input name="fh_osteoporosis_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_osteoporosis_info'}; ?>"></td>
1075
1076             <td class="fibody2"><input name="fh_notes_7" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_7'}; ?>"></td>
1077
1078           </tr>
1079
1080           <tr align="left" valign="bottom">
1081
1082             <td nowrap class="fibody2" id="bordR">Hepatitis</td>
1083
1084             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hepatitis" type="checkbox"  value="1" <?php echo (($fdata{'fh_hepatitis'} == '1')?' checked ':''); ?>></td>
1085
1086             <td class="fibody2" id="bordR"><input name="fh_hepatitis_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_hepatitis_info'}; ?>"></td>
1087
1088             <td class="fibody2"><input name="fh_notes_8" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_8'}; ?>"></td>
1089
1090           </tr>
1091
1092           <tr align="left" valign="bottom">
1093
1094             <td nowrap class="fibody2" id="bordR">HIV / AIDS</td>
1095
1096             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_hiv" type="checkbox"  value="1" <?php echo (($fdata{'fh_hiv'} == '1')?' checked ':''); ?>></td>
1097
1098             <td class="fibody2" id="bordR"><input name="fh_hiv_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_hiv_info'}; ?>"></td>
1099
1100             <td class="fibody2"><input name="fh_notes_9" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_9'}; ?>"></td>
1101
1102           </tr>
1103
1104           <tr align="left" valign="bottom">
1105
1106             <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
1107
1108             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_tuberculosis" type="checkbox"  value="1" <?php echo (($fdata{'fh_tuberculosis'} == '1')?' checked ':''); ?>></td>
1109
1110             <td class="fibody2" id="bordR"><input name="fh_tuberculosis_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_tuberculosis_info'}; ?>"></td>
1111
1112             <td class="fibody2"><input name="fh_notes_10" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_10'}; ?>"></td>
1113
1114           </tr>
1115
1116           <tr align="left" valign="bottom">
1117
1118             <td nowrap class="fibody2" id="bordR">Birth defects </td>
1119
1120             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="dh_birth_defects" type="checkbox"  value="1" <?php echo (($fdata{'dh_birth_defects'} == '1')?' checked ':''); ?>></td>
1121
1122             <td class="fibody2" id="bordR"><input name="dh_birth_defects_info" type="text" class="fullin2"  value="<?php echo $fdata{'dh_birth_defects_info'}; ?>"></td>
1123
1124             <td class="fibody2"><input name="fh_notes_11" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_11'}; ?>"></td>
1125
1126           </tr>
1127
1128           <tr align="left" valign="bottom">
1129
1130             <td nowrap class="fibody2" id="bordR">Alcohol or drug problems </td>
1131
1132             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alcohol_drugs" type="checkbox"  value="1" <?php echo (($fdata{'fh_alcohol_drugs'} == '1')?' checked ':''); ?>></td>
1133
1134             <td class="fibody2" id="bordR"><input name="fh_alcohol_drugs_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_alcohol_drugs_info'}; ?>"></td>
1135
1136             <td class="fibody2"><input name="fh_notes_12" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_12'}; ?>"></td>
1137
1138           </tr>
1139
1140           <tr align="left" valign="bottom">
1141
1142             <td nowrap class="fibody2" id="bordR">Breast cancer </td>
1143
1144             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_breast_cancer" type="checkbox"  value="1" <?php echo (($fdata{'fh_breast_cancer'} == '1')?' checked ':''); ?>></td>
1145
1146             <td class="fibody2" id="bordR"><input name="fh_breast_cancer_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_breast_cancer_info'}; ?>"></td>
1147
1148             <td class="fibody2"><input name="fh_notes_13" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_13'}; ?>"></td>
1149
1150           </tr>
1151
1152           <tr align="left" valign="bottom">
1153
1154             <td nowrap class="fibody2" id="bordR">Colon cancer </td>
1155
1156             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_colon_cancer" type="checkbox"  value="1" <?php echo (($fdata{'fh_colon_cancer'} == '1')?' checked ':''); ?>></td>
1157
1158             <td class="fibody2" id="bordR"><input name="fh_colon_cancer_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_colon_cancer_info'}; ?>"></td>
1159
1160             <td class="fibody2"><input name="fh_notes_14" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_14'}; ?>"></td>
1161
1162           </tr>
1163
1164           <tr align="left" valign="bottom">
1165
1166             <td nowrap class="fibody2" id="bordR">Ovarian cancer </td>
1167
1168             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="checkbox"  value="1" <?php echo (($fdata{'fh_ovarian_cancer'} == '1')?' checked ':''); ?>></td>
1169
1170             <td class="fibody2" id="bordR"><input name="fh_ovarian_cancer" type="text" class="fullin2"  value="<?php echo $fdata{'fh_ovarian_cancer'}; ?>"></td>
1171
1172             <td class="fibody2"><input name="fh_notes_15" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_15'}; ?>"></td>
1173
1174           </tr>
1175
1176           <tr align="left" valign="bottom">
1177
1178             <td nowrap class="fibody2" id="bordR">Uterine cancer </td>
1179
1180             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_uterine_cancer" type="checkbox"  value="1" <?php echo (($fdata{'fh_uterine_cancer'} == '1')?' checked ':''); ?>></td>
1181
1182             <td class="fibody2" id="bordR"><input name="fh_uterine_cancer_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_uterine_cancer_info'}; ?>"></td>
1183
1184             <td class="fibody2"><input name="fh_notes_16" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_16'}; ?>"></td>
1185
1186           </tr>
1187
1188           <tr align="left" valign="bottom">
1189
1190             <td nowrap class="fibody2" id="bordR">Mental illness/Depression </td>
1191
1192             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_mental_illness" type="checkbox"  value="1" <?php echo (($fdata{'fh_mental_illness'} == '1')?' checked ':''); ?>></td>
1193
1194             <td class="fibody2" id="bordR"><input name="fh_mental_illness_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_mental_illness_info'}; ?>"></td>
1195
1196             <td class="fibody2"><input name="fh_notes_17" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_17'}; ?>"></td>
1197
1198           </tr>
1199
1200           <tr align="left" valign="bottom">
1201
1202             <td nowrap class="fibody2" id="bordR">Alzheimer's disease </td>
1203
1204             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_alzheimer" type="checkbox"  value="1" <?php echo (($fdata{'fh_alzheimer'} == '1')?' checked ':''); ?>></td>
1205
1206             <td class="fibody2" id="bordR"><input name="fh_alzheimer_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_alzheimer_info'}; ?>"></td>
1207
1208             <td class="fibody2"><input name="fh_notes_18" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_18'}; ?>"></td>
1209
1210           </tr>
1211
1212           <tr align="left" valign="bottom">
1213
1214             <td nowrap class="fibody2" id="bordR">Other</td>
1215
1216             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="fh_other_illness" type="checkbox"  value="1" <?php echo (($fdata{'fh_other_illness'} == '1')?' checked ':''); ?>></td>
1217
1218             <td class="fibody2" id="bordR"><input name="fh_other_illness_info" type="text" class="fullin2"  value="<?php echo $fdata{'fh_other_illness_info'}; ?>"></td>
1219
1220             <td class="fibody2"><input name="fh_notes_19" type="text" class="fullin2"  value="<?php echo $fdata{'fh_notes_19'}; ?>"></td>
1221
1222           </tr>
1223
1224         </table></td>
1225
1226       </tr>
1227
1228     </table>
1229
1230   </div>
1231
1232   <p align="center">&nbsp;</p>
1233
1234   <h2 align="center"><a name="sh"></a>Social history <br>
1235
1236   </h2>
1237
1238   <div style="border: solid 2px black; background-color: white;">
1239
1240     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
1241
1242       <tr>
1243
1244         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
1245
1246           <tr align="left" valign="bottom">
1247
1248             <td width="400" class="ficaption2" id="bordR">&nbsp;</td>
1249
1250             <td width="30" align="center" class="ficaption2" id="bordR">yes</td>
1251
1252             <td width="30" align="center" class="ficaption2" id="bordR">no</td>
1253
1254             <td align="center" class="ficaption2">physician's notes                           </td>
1255
1256           </tr>
1257
1258           <tr align="left" valign="bottom">
1259
1260             <td nowrap class="fibody2" id="bordR">Ever smoked? current smoking: packs/day:
1261
1262               <input name="sh_smoked_packs" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_smoked_packs'}; ?>">
1263
1264               , years:
1265
1266               <input name="sh_smoked_years" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_smoked_years'}; ?>"></td>
1267
1268             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="1" <?php echo (($fdata{'pih_smoked'} == '1')?' checked ':''); ?>></td>
1269
1270             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_smoked" type="radio" value="0"  <?php echo (($fdata{'pih_smoked'} == '0')?' checked ':''); ?>></td>
1271
1272             <td class="fibody2"><input name="sh_notes_1" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_1'}; ?>"></td>
1273
1274           </tr>
1275
1276           <tr align="left" valign="bottom">
1277
1278             <td nowrap class="fibody2" id="bordR">alcohol: drinks/day:
1279
1280               <input name="sh_alcohol_drinks_day" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_alcohol_drinks_day'}; ?>">
1281
1282               ,
1283
1284               drinks/week:
1285
1286               <input name="sh_alcohol_drinks_week" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_alcohol_drinks_week'}; ?>">
1287
1288               ,
1289
1290               type of drink:
1291
1292               <input name="sh_alcohol_drinks_type" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_alcohol_drinks_type'}; ?>"></td>
1293
1294             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="1" <?php echo (($fdata{'pih_alcohol'} == '1')?' checked ':''); ?>></td>
1295
1296             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_alcohol" type="radio" value="0"  <?php echo (($fdata{'pih_alcohol'} == '0')?' checked ':''); ?>></td>
1297
1298             <td class="fibody2"><input name="sh_notes_2" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_2'}; ?>"></td>
1299
1300           </tr>
1301
1302           <tr align="left" valign="bottom">
1303
1304             <td nowrap class="fibody2" id="bordR">Drug use </td>
1305
1306             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="1" <?php echo (($fdata{'pih_drug'} == '1')?' checked ':''); ?>></td>
1307
1308             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_drug" type="radio" value="0"  <?php echo (($fdata{'pih_drug'} == '0')?' checked ':''); ?>></td>
1309
1310             <td class="fibody2"><input name="sh_notes_3" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_3'}; ?>"></td>
1311
1312           </tr>
1313
1314           <tr align="left" valign="bottom">
1315
1316             <td nowrap class="fibody2" id="bordR">seat belt use </td>
1317
1318             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="1" <?php echo (($fdata{'pih_seat_belt'} == '1')?' checked ':''); ?>></td>
1319
1320             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_seat_belt" type="radio" value="0"  <?php echo (($fdata{'pih_seat_belt'} == '0')?' checked ':''); ?>></td>
1321
1322             <td class="fibody2"><input name="sh_notes_4" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_4'}; ?>"></td>
1323
1324           </tr>
1325
1326           <tr align="left" valign="bottom">
1327
1328             <td nowrap class="fibody2" id="bordR">regular exercise: how long and how often?
1329
1330               <input name="sh_exercise_info" type="text" class="fullin"  style="width: 150px" value="<?php echo $fdata{'sh_exercise_info'}; ?>"></td>
1331
1332             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="1" <?php echo (($fdata{'pih_exercise'} == '1')?' checked ':''); ?>></td>
1333
1334             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_exercise" type="radio" value="0"  <?php echo (($fdata{'pih_exercise'} == '0')?' checked ':''); ?>></td>
1335
1336             <td width="400" class="fibody2"><input name="sh_notes_5" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_5'}; ?>"></td>
1337
1338           </tr>
1339
1340           <tr align="left" valign="bottom">
1341
1342             <td nowrap class="fibody2" id="bordR">Dairy product intake and/or calcium supplements: daily intake:
1343
1344               <input name="sh_dairy_daily" type="text" class="fullin"  style="width: 40px" value="<?php echo $fdata{'sh_dairy_daily'}; ?>"></td>
1345
1346             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="1" <?php echo (($fdata{'pih_dairy'} == '1')?' checked ':''); ?>></td>
1347
1348             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_dairy" type="radio" value="0"  <?php echo (($fdata{'pih_dairy'} == '0')?' checked ':''); ?>></td>
1349
1350             <td width="400" class="fibody2"><input name="sh_notes_6" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_6'}; ?>"></td>
1351
1352           </tr>
1353
1354           <tr align="left" valign="bottom">
1355
1356             <td nowrap class="fibody2" id="bordR">health hazards at home or work? </td>
1357
1358             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="1" <?php echo (($fdata{'pih_hazards'} == '1')?' checked ':''); ?>></td>
1359
1360             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_hazards" type="radio" value="0"  <?php echo (($fdata{'pih_hazards'} == '0')?' checked ':''); ?>></td>
1361
1362             <td width="400" class="fibody2"><input name="sh_notes_7" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_7'}; ?>"></td>
1363
1364           </tr>
1365
1366           <tr align="left" valign="bottom">
1367
1368             <td nowrap class="fibody2" id="bordR">have you been sexually abused, threatened or hurt by anyone? </td>
1369
1370             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="1" <?php echo (($fdata{'pih_abuse'} == '1')?' checked ':''); ?>></td>
1371
1372             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_abuse" type="radio" value="0"  <?php echo (($fdata{'pih_abuse'} == '0')?' checked ':''); ?>></td>
1373
1374             <td width="400" class="fibody2"><input name="sh_notes_8" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_8'}; ?>"></td>
1375
1376           </tr>
1377
1378           <tr align="left" valign="bottom">
1379
1380             <td nowrap class="fibody2" id="bordR">do you have an advance directive (living will)?</td>
1381
1382             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="1" <?php echo (($fdata{'pih_living_will'} == '1')?' checked ':''); ?>></td>
1383
1384             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_living_will" type="radio" value="0"  <?php echo (($fdata{'pih_living_will'} == '0')?' checked ':''); ?>></td>
1385
1386             <td class="fibody2"><input name="sh_notes_9" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_9'}; ?>"></td>
1387
1388           </tr>
1389
1390           <tr align="left" valign="bottom">
1391
1392             <td nowrap class="fibody2" id="bordR">Are you an organ donor? </td>
1393
1394             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="1" <?php echo (($fdata{'pih_donor'} == '1')?' checked ':''); ?>></td>
1395
1396             <td align="center" valign="middle" class="fibody2" id="bordR"><input name="pih_donor" type="radio" value="0"  <?php echo (($fdata{'pih_donor'} == '0')?' checked ':''); ?>></td>
1397
1398             <td class="fibody2"><input name="sh_notes_10" type="text" class="fullin2"  value="<?php echo $fdata{'sh_notes_10'}; ?>"></td>
1399
1400           </tr>
1401
1402         </table></td>
1403
1404       </tr>
1405
1406     </table>
1407
1408   </div>
1409
1410   <p align="center">&nbsp;</p>
1411
1412   <h2 align="center"><a name="pp"></a>Personal profile <br>
1413
1414   </h2>
1415
1416   <div style="border: solid 2px black; background-color: white;">
1417
1418     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
1419
1420       <tr>
1421
1422         <td align="left" valign="bottom" class="fibody2">Sexual orientation:
1423
1424           <input name="pih_pp_orientation" type="radio" value="hetero"  <?php echo (($fdata{'pih_pp_orientation'} == 'hetero')?' checked ':''); ?>>
1425
1426         heterosexual
1427
1428         <input name="pih_pp_orientation" type="radio" value="homo" <?php echo (($fdata{'pih_pp_orientation'} == 'homo')?' checked ':''); ?>>
1429
1430         homosexual
1431
1432         <input name="pih_pp_orientation" type="radio" value="bi" <?php echo (($fdata{'pih_pp_orientation'} == 'bi')?' checked ':''); ?>>
1433
1434         bisexual </td>
1435
1436       </tr>
1437
1438       <tr>
1439
1440         <td align="left" valign="bottom" class="fibody2">Marital status:
1441
1442           <input name="pih_pp_status" type="radio" value="married" <?php echo (($fdata{'pih_pp_status'} == 'married')?' checked ':''); ?>>
1443
1444         married
1445
1446         &nbsp;&nbsp;
1447
1448         <input name="pih_pp_status" type="radio" value="partner" <?php echo (($fdata{'pih_pp_status'} == 'partner')?' checked ':''); ?>>
1449
1450         living with partner&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="single"  <?php echo (($fdata{'pih_pp_status'} == 'single')?' checked ':''); ?>>
1451
1452         single
1453
1454         &nbsp;&nbsp;
1455
1456         <input name="pih_pp_status" type="radio" value="widowed" <?php echo (($fdata{'pih_pp_status'} == 'widowed')?' checked ':''); ?>>
1457
1458         widowed&nbsp;&nbsp;        <input name="pih_pp_status" type="radio" value="divorced" <?php echo (($fdata{'pih_pp_status'} == 'divorced')?' checked ':''); ?>>
1459
1460         divorced </td>
1461
1462       </tr>
1463
1464       <tr>
1465
1466         <td align="left" valign="bottom" class="fibody2">Number of living children:
1467
1468         <input name="pp_living_children" type="text" class="fullin"  style="width: 70px"  value="<?php echo $fdata{'pp_living_children'}; ?>"></td>
1469
1470       </tr>
1471
1472       <tr>
1473
1474         <td align="left" valign="bottom" class="fibody2">Number of people in household:
1475
1476         <input name="pp_number_household" type="text" class="fullin"  style="width: 70px"  value="<?php echo $fdata{'pp_number_household'}; ?>"></td>
1477
1478       </tr>
1479
1480       <tr>
1481
1482         <td align="left" valign="bottom" class="fibody2">School completed:
1483
1484           <input name="pih_pp_education" type="radio"  value="highschool" <?php echo (($fdata{'pih_pp_education'} == 'highschool')?' checked ':''); ?>>
1485
1486         high school
1487
1488         <input name="pih_pp_education" type="radio"  value="aadegree" <?php echo (($fdata{'pih_pp_education'} == 'aadegree')?' checked ':''); ?>>
1489
1490         some college/AA degree
1491
1492         <input name="pih_pp_education" type="radio"  value="college" <?php echo (($fdata{'pih_pp_education'} == 'college')?' checked ':''); ?>>
1493
1494         college
1495
1496         <input name="pih_pp_education" type="radio"  value="gdegree" <?php echo (($fdata{'pih_pp_education'} == 'gdegree')?' checked ':''); ?>>
1497
1498         graduate degree
1499
1500         <input name="pih_pp_education" type="radio"  value="other"  <?php echo (($fdata{'pih_pp_education'} == 'other')?' checked ':''); ?>>
1501
1502         other </td>
1503
1504       </tr>
1505
1506       <tr>
1507
1508         <td align="left" valign="bottom" class="fibody2">Current or most recent job:
1509
1510         <input name="pp_current_job" type="text" class="fullin"  style="width: 77%"  value="<?php echo $fdata{'pp_current_job'}; ?>"></td>
1511
1512       </tr>
1513
1514       <tr>
1515
1516         <td align="left" valign="bottom" class="fibody3">Travel outside the United States?
1517
1518           <input name="pp_travel_outside_us" type="radio" value="1" <?php echo (($fdata{'pp_travel_outside_us'} == '1')?' checked ':''); ?>>
1519
1520           yes
1521
1522           <input name="pp_travel_outside_us" type="radio" value="0"  <?php echo (($fdata{'pp_travel_outside_us'} == '0')?' checked ':''); ?>>
1523
1524           no.&nbsp;&nbsp;&nbsp;Location(s): <span class="fibody2">
1525
1526           <input name="pp_travel_outside_locations" type="text" class="fullin"  style="width:50%" value="<?php echo $fdata{'pp_travel_outside_locations'}; ?>">
1527
1528         </span></td>
1529
1530       </tr>
1531
1532     </table>
1533
1534   </div>
1535
1536   <p align="center">&nbsp;</p>
1537
1538   <h2 align="center"><a name="ih"></a>Personal past history of illnesses <br>
1539
1540   </h2>
1541
1542   <div style="border: solid 2px black; background-color: white;">
1543
1544     <table width="100%"  border="0" cellspacing="0" cellpadding="0">
1545
1546       <tr>
1547
1548         <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
1549
1550             <tr align="left" valign="bottom">
1551
1552               <td width="200" nowrap class="ficaption2" id="bordR">major illnesses </td>
1553
1554               <td width="100" align="center" class="ficaption2" id="bordR">yes (date) </td>
1555
1556               <td width="30" align="center" class="ficaption2" id="bordR">no</td>
1557
1558               <td width="58" align="center" class="ficaption2" id="bordR">Not sure </td>
1559
1560               <td align="center" class="ficaption2">Physician's notes </td>
1561
1562             </tr>
1563
1564             <tr align="left" valign="bottom">
1565
1566               <td nowrap class="fibody2" id="bordR">Asthma</td>
1567
1568               <td class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="1" <?php echo (($fdata{'pih_ih_asthma'} == '1')?' checked ':''); ?>>
1569
1570                   <input name="pih_ih_asthma_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_asthma_date'}; ?>"></td>
1571
1572               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="0"  <?php echo (($fdata{'pih_ih_asthma'} == '0')?' checked ':''); ?>></td>
1573
1574               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_asthma" type="radio" value="2" <?php echo (($fdata{'pih_ih_asthma'} == '2')?' checked ':''); ?>></td>
1575
1576               <td class="fibody2"><input name="ih_notes_1" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_1'}; ?>"></td>
1577
1578             </tr>
1579
1580             <tr align="left" valign="bottom">
1581
1582               <td nowrap class="fibody2" id="bordR">Pneumonia/lungs disease </td>
1583
1584               <td class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="1" <?php echo (($fdata{'pih_ih_pneumonia'} == '1')?' checked ':''); ?>>
1585
1586                   <input name="pih_ih_pneumonia_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_pneumonia_date'}; ?>"></td>
1587
1588               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="0"  <?php echo (($fdata{'pih_ih_pneumonia'} == '0')?' checked ':''); ?>></td>
1589
1590               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_pneumonia" type="radio" value="2" <?php echo (($fdata{'pih_ih_pneumonia'} == '2')?' checked ':''); ?>></td>
1591
1592               <td class="fibody2"><input name="ih_notes_2" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_2'}; ?>"></td>
1593
1594             </tr>
1595
1596             <tr align="left" valign="bottom">
1597
1598               <td nowrap class="fibody2" id="bordR">Kidney infections/stones </td>
1599
1600               <td class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="1" <?php echo (($fdata{'pih_ih_kidney'} == '1')?' checked ':''); ?>>
1601
1602                   <input name="pih_ih_kidney_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_kidney_date'}; ?>"></td>
1603
1604               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="0"  <?php echo (($fdata{'pih_ih_kidney'} == '0')?' checked ':''); ?>></td>
1605
1606               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_kidney" type="radio" value="2" <?php echo (($fdata{'pih_ih_kidney'} == '2')?' checked ':''); ?>></td>
1607
1608               <td class="fibody2"><input name="ih_notes_3" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_3'}; ?>"></td>
1609
1610             </tr>
1611
1612             <tr align="left" valign="bottom">
1613
1614               <td nowrap class="fibody2" id="bordR">Tuberculosis</td>
1615
1616               <td class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="1" <?php echo (($fdata{'pih_ih_tuber'} == '1')?' checked ':''); ?>>
1617
1618                   <input name="pih_ih_tuber_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_tuber_date'}; ?>"></td>
1619
1620               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="0"  <?php echo (($fdata{'pih_ih_tuber'} == '0')?' checked ':''); ?>></td>
1621
1622               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_tuber" type="radio" value="2" <?php echo (($fdata{'pih_ih_tuber'} == '2')?' checked ':''); ?>></td>
1623
1624               <td class="fibody2"><input name="ih_notes_4" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_4'}; ?>"></td>
1625
1626             </tr>
1627
1628             <tr align="left" valign="bottom">
1629
1630               <td nowrap class="fibody2" id="bordR">Fibroids</td>
1631
1632               <td class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="1" <?php echo (($fdata{'pih_ih_fibroids'} == '1')?' checked ':''); ?>>
1633
1634                   <input name="pih_ih_fibroids_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_fibroids_date'}; ?>"></td>
1635
1636               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="0"  <?php echo (($fdata{'pih_ih_fibroids'} == '0')?' checked ':''); ?>></td>
1637
1638               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_fibroids" type="radio" value="2" <?php echo (($fdata{'pih_ih_fibroids'} == '2')?' checked ':''); ?>></td>
1639
1640               <td class="fibody2"><input name="ih_notes_5" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_5'}; ?>"></td>
1641
1642             </tr>
1643
1644             <tr align="left" valign="bottom">
1645
1646               <td nowrap class="fibody2" id="bordR">Sexually transmitted disease/chlamydia </td>
1647
1648               <td class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="1" <?php echo (($fdata{'pih_ih_sexually'} == '1')?' checked ':''); ?>>
1649
1650                   <input name="pih_ih_sexually_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_sexually_date'}; ?>"></td>
1651
1652               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="0"  <?php echo (($fdata{'pih_ih_sexually'} == '0')?' checked ':''); ?>></td>
1653
1654               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_sexually" type="radio" value="2" <?php echo (($fdata{'pih_ih_sexually'} == '2')?' checked ':''); ?>></td>
1655
1656               <td class="fibody2"><input name="ih_notes_6" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_6'}; ?>"></td>
1657
1658             </tr>
1659
1660             <tr align="left" valign="bottom">
1661
1662               <td nowrap class="fibody2" id="bordR">Infertility</td>
1663
1664               <td class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="1" <?php echo (($fdata{'pih_ih_infertil'} == '1')?' checked ':''); ?>>
1665
1666                   <input name="pih_ih_infertil_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_infertil_date'}; ?>"></td>
1667
1668               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="0"  <?php echo (($fdata{'pih_ih_infertil'} == '0')?' checked ':''); ?>></td>
1669
1670               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_infertil" type="radio" value="2" <?php echo (($fdata{'pih_ih_infertil'} == '2')?' checked ':''); ?>></td>
1671
1672               <td class="fibody2"><input name="ih_notes_7" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_7'}; ?>"></td>
1673
1674             </tr>
1675
1676             <tr align="left" valign="bottom">
1677
1678               <td nowrap class="fibody2" id="bordR">HIV / AIDS </td>
1679
1680               <td class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="1" <?php echo (($fdata{'pih_ih_hiv'} == '1')?' checked ':''); ?>>
1681
1682                   <input name="pih_ih_hiv_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_hiv_date'}; ?>"></td>
1683
1684               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="0"  <?php echo (($fdata{'pih_ih_hiv'} == '0')?' checked ':''); ?>></td>
1685
1686               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hiv" type="radio" value="2" <?php echo (($fdata{'pih_ih_hiv'} == '2')?' checked ':''); ?>></td>
1687
1688               <td class="fibody2"><input name="ih_notes_8" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_8'}; ?>"></td>
1689
1690             </tr>
1691
1692             <tr align="left" valign="bottom">
1693
1694               <td nowrap class="fibody2" id="bordR">Heart attack / Disease </td>
1695
1696               <td class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="1" <?php echo (($fdata{'pih_ih_heart'} == '1')?' checked ':''); ?>>
1697
1698                   <input name="pih_ih_heart_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_heart_date'}; ?>"></td>
1699
1700               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="0"  <?php echo (($fdata{'pih_ih_heart'} == '0')?' checked ':''); ?>></td>
1701
1702               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_heart" type="radio" value="2" <?php echo (($fdata{'pih_ih_heart'} == '2')?' checked ':''); ?>></td>
1703
1704               <td class="fibody2"><input name="ih_notes_9" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_9'}; ?>"></td>
1705
1706             </tr>
1707
1708             <tr align="left" valign="bottom">
1709
1710               <td nowrap class="fibody2" id="bordR">Diabetes</td>
1711
1712               <td class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="1" <?php echo (($fdata{'pih_ih_diabetes'} == '1')?' checked ':''); ?>>
1713
1714                   <input name="pih_ih_diabetes_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_diabetes_date'}; ?>"></td>
1715
1716               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="0"  <?php echo (($fdata{'pih_ih_diabetes'} == '0')?' checked ':''); ?>></td>
1717
1718               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_diabetes" type="radio" value="2" <?php echo (($fdata{'pih_ih_diabetes'} == '2')?' checked ':''); ?>></td>
1719
1720               <td class="fibody2"><input name="ih_notes_10" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_10'}; ?>"></td>
1721
1722             </tr>
1723
1724             <tr align="left" valign="bottom">
1725
1726               <td nowrap class="fibody2" id="bordR">High blood pressure </td>
1727
1728               <td class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="1" <?php echo (($fdata{'pih_ih_high_pressure'} == '1')?' checked ':''); ?>>
1729
1730                   <input name="pih_ih_high_pressure_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_high_pressure_date'}; ?>"></td>
1731
1732               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="0"  <?php echo (($fdata{'pih_ih_high_pressure'} == '0')?' checked ':''); ?>></td>
1733
1734               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_high_pressure" type="radio" value="2" <?php echo (($fdata{'pih_ih_high_pressure'} == '2')?' checked ':''); ?>></td>
1735
1736               <td class="fibody2"><input name="ih_notes_11" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_11'}; ?>"></td>
1737
1738             </tr>
1739
1740             <tr align="left" valign="bottom">
1741
1742               <td nowrap class="fibody2" id="bordR">Stroke</td>
1743
1744               <td class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="1" <?php echo (($fdata{'pih_ih_stroke'} == '1')?' checked ':''); ?>>
1745
1746                   <input name="pih_ih_stroke_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_stroke_date'}; ?>"></td>
1747
1748               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="0"  <?php echo (($fdata{'pih_ih_stroke'} == '0')?' checked ':''); ?>></td>
1749
1750               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_stroke" type="radio" value="2" <?php echo (($fdata{'pih_ih_stroke'} == '2')?' checked ':''); ?>></td>
1751
1752               <td class="fibody2"><input name="ih_notes_12" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_12'}; ?>"></td>
1753
1754             </tr>
1755
1756             <tr align="left" valign="bottom">
1757
1758               <td nowrap class="fibody2" id="bordR">Rheumatic fever </td>
1759
1760               <td class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="1" <?php echo (($fdata{'pih_ih_rheumatic'} == '1')?' checked ':''); ?>>
1761
1762                   <input name="pih_ih_rheumatic_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_rheumatic_date'}; ?>"></td>
1763
1764               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="0"  <?php echo (($fdata{'pih_ih_rheumatic'} == '0')?' checked ':''); ?>></td>
1765
1766               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_rheumatic" type="radio" value="2" <?php echo (($fdata{'pih_ih_rheumatic'} == '2')?' checked ':''); ?>></td>
1767
1768               <td class="fibody2"><input name="ih_notes_13" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_13'}; ?>"></td>
1769
1770             </tr>
1771
1772             <tr align="left" valign="bottom">
1773
1774               <td nowrap class="fibody2" id="bordR">Blood clots in lungs or legs </td>
1775
1776               <td class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="1" <?php echo (($fdata{'pih_ih_blood_clots'} == '1')?' checked ':''); ?>>
1777
1778                   <input name="pih_ih_blood_clots_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_blood_clots_date'}; ?>"></td>
1779
1780               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="0"  <?php echo (($fdata{'pih_ih_blood_clots'} == '0')?' checked ':''); ?>></td>
1781
1782               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_clots" type="radio" value="2" <?php echo (($fdata{'pih_ih_blood_clots'} == '2')?' checked ':''); ?>></td>
1783
1784               <td class="fibody2"><input name="ih_notes_14" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_14'}; ?>"></td>
1785
1786             </tr>
1787
1788             <tr align="left" valign="bottom">
1789
1790               <td nowrap class="fibody2" id="bordR">Eating disorders </td>
1791
1792               <td class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="1" <?php echo (($fdata{'pih_ih_eating_disorder'} == '1')?' checked ':''); ?>>
1793
1794                   <input name="pih_ih_eating_disorder_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_eating_disorder_date'}; ?>"></td>
1795
1796               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="0"  <?php echo (($fdata{'pih_ih_eating_disorder'} == '0')?' checked ':''); ?>></td>
1797
1798               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_eating_disorder" type="radio" value="2" <?php echo (($fdata{'pih_ih_eating_disorder'} == '2')?' checked ':''); ?>></td>
1799
1800               <td class="fibody2"><input name="ih_notes_15" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_15'}; ?>"></td>
1801
1802             </tr>
1803
1804             <tr align="left" valign="bottom">
1805
1806               <td nowrap class="fibody2" id="bordR">Autoimmune disease (Lupus)</td>
1807
1808               <td class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="1" <?php echo (($fdata{'pih_ih_autoimmune'} == '1')?' checked ':''); ?>>
1809
1810                   <input name="pih_ih_autoimmune_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_autoimmune_date'}; ?>"></td>
1811
1812               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="0"  <?php echo (($fdata{'pih_ih_autoimmune'} == '0')?' checked ':''); ?>></td>
1813
1814               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_autoimmune" type="radio" value="2" <?php echo (($fdata{'pih_ih_autoimmune'} == '2')?' checked ':''); ?>></td>
1815
1816               <td class="fibody2"><input name="ih_notes_16" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_16'}; ?>"></td>
1817
1818             </tr>
1819
1820             <tr align="left" valign="bottom">
1821
1822               <td nowrap class="fibody2" id="bordR">Chickenpox</td>
1823
1824               <td class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="1" <?php echo (($fdata{'pih_ih_chickenpox'} == '1')?' checked ':''); ?>>
1825
1826                   <input name="pih_ih_chickenpox_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_chickenpox_date'}; ?>"></td>
1827
1828               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="0"  <?php echo (($fdata{'pih_ih_chickenpox'} == '0')?' checked ':''); ?>></td>
1829
1830               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_chickenpox" type="radio" value="2" <?php echo (($fdata{'pih_ih_chickenpox'} == '2')?' checked ':''); ?>></td>
1831
1832               <td class="fibody2"><input name="ih_notes_17" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_17'}; ?>"></td>
1833
1834             </tr>
1835
1836             <tr align="left" valign="bottom">
1837
1838               <td nowrap class="fibody2" id="bordR">Cancer</td>
1839
1840               <td class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="1" <?php echo (($fdata{'pih_ih_cancer'} == '1')?' checked ':''); ?>>
1841
1842                   <input name="pih_ih_cancer_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_cancer_date'}; ?>"></td>
1843
1844               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="0"  <?php echo (($fdata{'pih_ih_cancer'} == '0')?' checked ':''); ?>></td>
1845
1846               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cancer" type="radio" value="2" <?php echo (($fdata{'pih_ih_cancer'} == '2')?' checked ':''); ?>></td>
1847
1848               <td class="fibody2"><input name="ih_notes_18" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_18'}; ?>"></td>
1849
1850             </tr>
1851
1852             <tr align="left" valign="bottom">
1853
1854               <td nowrap class="fibody2" id="bordR">Reflux / Hiatal hernia / Ulcers </td>
1855
1856               <td class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="1" <?php echo (($fdata{'pih_ih_reflux'} == '1')?' checked ':''); ?>>
1857
1858                   <input name="pih_ih_reflux_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_reflux_date'}; ?>"></td>
1859
1860               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="0"  <?php echo (($fdata{'pih_ih_reflux'} == '0')?' checked ':''); ?>></td>
1861
1862               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_reflux" type="radio" value="2" <?php echo (($fdata{'pih_ih_reflux'} == '2')?' checked ':''); ?>></td>
1863
1864               <td class="fibody2"><input name="ih_notes_19" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_19'}; ?>"></td>
1865
1866             </tr>
1867
1868             <tr align="left" valign="bottom">
1869
1870               <td nowrap class="fibody2" id="bordR">Depression / Anxiety </td>
1871
1872               <td class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="1" <?php echo (($fdata{'pih_ih_depression'} == '1')?' checked ':''); ?>>
1873
1874                   <input name="pih_ih_depression_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_depression_date'}; ?>"></td>
1875
1876               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="0"  <?php echo (($fdata{'pih_ih_depression'} == '0')?' checked ':''); ?>></td>
1877
1878               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_depression" type="radio" value="2" <?php echo (($fdata{'pih_ih_depression'} == '2')?' checked ':''); ?>></td>
1879
1880               <td class="fibody2"><input name="ih_notes_20" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_20'}; ?>"></td>
1881
1882             </tr>
1883
1884             <tr align="left" valign="bottom">
1885
1886               <td nowrap class="fibody2" id="bordR">Anemia</td>
1887
1888               <td class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="1" <?php echo (($fdata{'pih_ih_anemia'} == '1')?' checked ':''); ?>>
1889
1890                   <input name="pih_ih_anemia_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_anemia_date'}; ?>"></td>
1891
1892               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="0"  <?php echo (($fdata{'pih_ih_anemia'} == '0')?' checked ':''); ?>></td>
1893
1894               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_anemia" type="radio" value="2" <?php echo (($fdata{'pih_ih_anemia'} == '2')?' checked ':''); ?>></td>
1895
1896               <td class="fibody2"><input name="ih_notes_21" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_21'}; ?>"></td>
1897
1898             </tr>
1899
1900             <tr align="left" valign="bottom">
1901
1902               <td nowrap class="fibody2" id="bordR">Blood transfusions </td>
1903
1904               <td class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="1" <?php echo (($fdata{'pih_ih_blood_transf'} == '1')?' checked ':''); ?>>
1905
1906                   <input name="pih_ih_blood_transf_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_blood_transf_date'}; ?>"></td>
1907
1908               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="0"  <?php echo (($fdata{'pih_ih_blood_transf'} == '0')?' checked ':''); ?>></td>
1909
1910               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_blood_transf" type="radio" value="2" <?php echo (($fdata{'pih_ih_blood_transf'} == '2')?' checked ':''); ?>></td>
1911
1912               <td class="fibody2"><input name="ih_notes_22" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_22'}; ?>"></td>
1913
1914             </tr>
1915
1916             <tr align="left" valign="bottom">
1917
1918               <td nowrap class="fibody2" id="bordR">Seizures / Convulsions /Epilepsy </td>
1919
1920               <td class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="1" <?php echo (($fdata{'pih_ih_seizures'} == '1')?' checked ':''); ?>>
1921
1922                   <input name="pih_ih_seizures_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_seizures_date'}; ?>"></td>
1923
1924               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="0"  <?php echo (($fdata{'pih_ih_seizures'} == '0')?' checked ':''); ?>></td>
1925
1926               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_seizures" type="radio" value="2" <?php echo (($fdata{'pih_ih_seizures'} == '2')?' checked ':''); ?>></td>
1927
1928               <td class="fibody2"><input name="ih_notes_23" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_23'}; ?>"></td>
1929
1930             </tr>
1931
1932             <tr align="left" valign="bottom">
1933
1934               <td nowrap class="fibody2" id="bordR">Bowel problems </td>
1935
1936               <td class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="1" <?php echo (($fdata{'pih_ih_bowel_problems'} == '1')?' checked ':''); ?>>
1937
1938                   <input name="pih_ih_bowel_problems_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_bowel_problems_date'}; ?>"></td>
1939
1940               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="0"  <?php echo (($fdata{'pih_ih_bowel_problems'} == '0')?' checked ':''); ?>></td>
1941
1942               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bowel_problems" type="radio" value="2" <?php echo (($fdata{'pih_ih_bowel_problems'} == '2')?' checked ':''); ?>></td>
1943
1944               <td class="fibody2"><input name="ih_notes_24" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_24'}; ?>"></td>
1945
1946             </tr>
1947
1948             <tr align="left" valign="bottom">
1949
1950               <td nowrap class="fibody2" id="bordR">Glaucoma</td>
1951
1952               <td class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="1" <?php echo (($fdata{'pih_ih_glaucoma'} == '1')?' checked ':''); ?>>
1953
1954                   <input name="pih_ih_glaucoma_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_glaucoma_date'}; ?>"></td>
1955
1956               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="0"  <?php echo (($fdata{'pih_ih_glaucoma'} == '0')?' checked ':''); ?>></td>
1957
1958               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_glaucoma" type="radio" value="2" <?php echo (($fdata{'pih_ih_glaucoma'} == '2')?' checked ':''); ?>></td>
1959
1960               <td class="fibody2"><input name="ih_notes_25" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_25'}; ?>"></td>
1961
1962             </tr>
1963
1964             <tr align="left" valign="bottom">
1965
1966               <td nowrap class="fibody2" id="bordR">Cataracts</td>
1967
1968               <td class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="1" <?php echo (($fdata{'pih_ih_cataracts'} == '1')?' checked ':''); ?>>
1969
1970                   <input name="pih_ih_cataracts_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_cataracts_date'}; ?>"></td>
1971
1972               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="0"  <?php echo (($fdata{'pih_ih_cataracts'} == '0')?' checked ':''); ?>></td>
1973
1974               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_cataracts" type="radio" value="2" <?php echo (($fdata{'pih_ih_cataracts'} == '2')?' checked ':''); ?>></td>
1975
1976               <td class="fibody2"><input name="ih_notes_26" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_26'}; ?>"></td>
1977
1978             </tr>
1979
1980             <tr align="left" valign="bottom">
1981
1982               <td nowrap class="fibody2" id="bordR">Arthritis / Joint pain / Back problems </td>
1983
1984               <td class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="1" <?php echo (($fdata{'pih_ih_joint_pain'} == '1')?' checked ':''); ?>>
1985
1986                   <input name="pih_ih_joint_pain_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_joint_pain_date'}; ?>"></td>
1987
1988               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="0"  <?php echo (($fdata{'pih_ih_joint_pain'} == '0')?' checked ':''); ?>></td>
1989
1990               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_joint_pain" type="radio" value="2" <?php echo (($fdata{'pih_ih_joint_pain'} == '2')?' checked ':''); ?>></td>
1991
1992               <td class="fibody2"><input name="ih_notes_27" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_27'}; ?>"></td>
1993
1994             </tr>
1995
1996             <tr align="left" valign="bottom">
1997
1998               <td nowrap class="fibody2" id="bordR">Broken bones </td>
1999
2000               <td class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="1" <?php echo (($fdata{'pih_ih_broken_bones'} == '1')?' checked ':''); ?>>
2001
2002                   <input name="pih_ih_broken_bones_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_broken_bones_date'}; ?>"></td>
2003
2004               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="0"  <?php echo (($fdata{'pih_ih_broken_bones'} == '0')?' checked ':''); ?>></td>
2005
2006               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_broken_bones" type="radio" value="2" <?php echo (($fdata{'pih_ih_broken_bones'} == '2')?' checked ':''); ?>></td>
2007
2008               <td class="fibody2"><input name="ih_notes_28" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_28'}; ?>"></td>
2009
2010             </tr>
2011
2012             <tr align="left" valign="bottom">
2013
2014               <td nowrap class="fibody2" id="bordR">Hepatitis / Yellow jaundice / Liver disease </td>
2015
2016               <td class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="1" <?php echo (($fdata{'pih_ih_hepatitis'} == '1')?' checked ':''); ?>>
2017
2018                   <input name="pih_ih_hepatitis_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_hepatitis_date'}; ?>"></td>
2019
2020               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="0"  <?php echo (($fdata{'pih_ih_hepatitis'} == '0')?' checked ':''); ?>></td>
2021
2022               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_hepatitis" type="radio" value="2" <?php echo (($fdata{'pih_ih_hepatitis'} == '2')?' checked ':''); ?>></td>
2023
2024               <td class="fibody2"><input name="ih_notes_29" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_29'}; ?>"></td>
2025
2026             </tr>
2027
2028             <tr align="left" valign="bottom">
2029
2030               <td nowrap class="fibody2" id="bordR">Thyroid disease </td>
2031
2032               <td class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="1" <?php echo (($fdata{'pih_ih_thyroid'} == '1')?' checked ':''); ?>>
2033
2034                   <input name="pih_ih_thyroid_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_thyroid_date'}; ?>"></td>
2035
2036               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="0"  <?php echo (($fdata{'pih_ih_thyroid'} == '0')?' checked ':''); ?>></td>
2037
2038               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_thyroid" type="radio" value="2" <?php echo (($fdata{'pih_ih_thyroid'} == '2')?' checked ':''); ?>></td>
2039
2040               <td class="fibody2"><input name="ih_notes_30" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_30'}; ?>"></td>
2041
2042             </tr>
2043
2044             <tr align="left" valign="bottom">
2045
2046               <td nowrap class="fibody2" id="bordR">Gallbladder disease </td>
2047
2048               <td class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="1" <?php echo (($fdata{'pih_ih_galibladder'} == '1')?' checked ':''); ?>>
2049
2050                   <input name="pih_ih_galibladder_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_galibladder_date'}; ?>"></td>
2051
2052               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="0"  <?php echo (($fdata{'pih_ih_galibladder'} == '0')?' checked ':''); ?>></td>
2053
2054               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_galibladder" type="radio" value="2" <?php echo (($fdata{'pih_ih_galibladder'} == '2')?' checked ':''); ?>></td>
2055
2056               <td class="fibody2"><input name="ih_notes_31" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_31'}; ?>"></td>
2057
2058             </tr>
2059
2060             <tr align="left" valign="bottom">
2061
2062               <td nowrap class="fibody2" id="bordR">Headaches</td>
2063
2064               <td class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="1" <?php echo (($fdata{'pih_ih_headaches'} == '1')?' checked ':''); ?>>
2065
2066                   <input name="pih_ih_headaches_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_headaches_date'}; ?>"></td>
2067
2068               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="0"  <?php echo (($fdata{'pih_ih_headaches'} == '0')?' checked ':''); ?>></td>
2069
2070               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_headaches" type="radio" value="2" <?php echo (($fdata{'pih_ih_headaches'} == '2')?' checked ':''); ?>></td>
2071
2072               <td class="fibody2"><input name="ih_notes_32" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_32'}; ?>"></td>
2073
2074             </tr>
2075
2076             <tr align="left" valign="bottom">
2077
2078               <td nowrap class="fibody2" id="bordR">DES Exposure </td>
2079
2080               <td class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="1" <?php echo (($fdata{'pih_ih_des'} == '1')?' checked ':''); ?>>
2081
2082                   <input name="pih_ih_des_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_des_date'}; ?>"></td>
2083
2084               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="0"  <?php echo (($fdata{'pih_ih_des'} == '0')?' checked ':''); ?>></td>
2085
2086               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_des" type="radio" value="2" <?php echo (($fdata{'pih_ih_des'} == '2')?' checked ':''); ?>></td>
2087
2088               <td class="fibody2"><input name="ih_notes_33" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_33'}; ?>"></td>
2089
2090             </tr>
2091
2092             <tr align="left" valign="bottom">
2093
2094               <td nowrap class="fibody2" id="bordR">Bleeding disorders </td>
2095
2096               <td class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="1" <?php echo (($fdata{'pih_ih_bleeding_disorders'} == '1')?' checked ':''); ?>>
2097
2098                   <input name="pih_ih_bleeding_disorders_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_bleeding_disorders_date'}; ?>"></td>
2099
2100               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="0"  <?php echo (($fdata{'pih_ih_bleeding_disorders'} == '0')?' checked ':''); ?>></td>
2101
2102               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_bleeding_disorders" type="radio" value="2" <?php echo (($fdata{'pih_ih_bleeding_disorders'} == '2')?' checked ':''); ?>></td>
2103
2104               <td class="fibody2"><input name="ih_notes_34" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_34'}; ?>"></td>
2105
2106             </tr>
2107
2108             <tr align="left" valign="bottom">
2109
2110               <td nowrap class="fibody2" id="bordR">other</td>
2111
2112               <td class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="1" <?php echo (($fdata{'pih_ih_other'} == '1')?' checked ':''); ?>>
2113
2114                   <input name="pih_ih_other_date" type="text" class="fullin"  style="width: 70px" value="<?php echo $fdata{'pih_ih_other_date'}; ?>"></td>
2115
2116               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="0"  <?php echo (($fdata{'pih_ih_other'} == '0')?' checked ':''); ?>></td>
2117
2118               <td align="center" class="fibody2" id="bordR"><input name="pih_ih_other" type="radio" value="2" <?php echo (($fdata{'pih_ih_other'} == '2')?' checked ':''); ?>></td>
2119
2120               <td class="fibody2"><input name="ih_notes_35" type="text" class="fullin2"  value="<?php echo $fdata{'ih_notes_35'}; ?>"></td>
2121
2122             </tr>
2123
2124             <tr align="left" valign="bottom">
2125
2126               <td colspan="5" nowrap class="fibody3"><textarea name="pih_ih_extended_info" rows="4" wrap="VIRTUAL" class="fullin2" ><?php echo $fdata{'pih_ih_extended_info'}; ?></textarea></td>
2127
2128             </tr>
2129
2130         </table></td>
2131
2132       </tr>
2133
2134     </table>
2135
2136   </div>
2137
2138   <p align="center">&nbsp;</p>
2139
2140   <h2 align="center"><a name="op"></a>Operations/Hospitalizations<br>
2141
2142   </h2>
2143
2144   <div style="border: solid 2px black; background-color: white;">
2145
2146     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2147
2148       <tr>
2149
2150         <td width="50%" align="left" valign="bottom" class="ficaption2" id="bordR">Reason</td>
2151
2152         <td width="90" align="center" valign="bottom" class="ficaption2" id="bordR">Date</td>
2153
2154         <td align="center" valign="bottom" class="ficaption2">Hospital</td>
2155
2156       </tr>
2157
2158 <?php
2159
2160 $ii = 0;
2161
2162 while ($ii<6){
2163
2164 list ($op_reason, $op_date, $op_hospital)= explode('|~', $fdata["op_rec_".$ii] );
2165
2166 print <<<EOL
2167
2168       <tr>
2169
2170         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_reason_${ii}" value="${op_reason}" type="text" class="fullin2"></td>
2171
2172         <td align="left" valign="bottom" class="fibody2" id="bordR"><input name="op_date_${ii}" value="${op_date}" type="text" class="fullin2"></td>
2173
2174         <td align="left" valign="bottom" class="fibody2"><input name="op_hospital_${ii}" value="${op_hospital}" type="text" class="fullin2"></td>
2175
2176       </tr>
2177
2178 EOL;
2179
2180 $ii++;
2181
2182 }
2183
2184 ?>
2185
2186     </table>
2187
2188   </div>
2189
2190   <p align="center">&nbsp;</p>
2191
2192   <h2 align="center"><a name="ii"></a>Injuries/Illnesses<br>
2193
2194   </h2>
2195
2196   <div style="border: solid 2px black; background-color: white;">
2197
2198     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2199
2200       <tr valign="bottom">
2201
2202         <td align="left" class="ficaption2" id="bordR">Type</td>
2203
2204         <td width="90" align="center" nowrap class="ficaption2" id="bordR">date</td>
2205
2206         <td align="left" class="ficaption2" id="bordR">Type</td>
2207
2208         <td width="90" align="center" nowrap class="ficaption2">date</td>
2209
2210       </tr>
2211
2212 <?php
2213
2214 $ii = 0;
2215
2216 while ($ii<6){
2217
2218 $ij = $ii+6;
2219
2220 list ($ii_type, $ii_date)= explode('|~', $fdata["ii_rec_".$ii] );
2221
2222 list ($ii_type1, $ii_date1)= explode('|~', $fdata["ii_rec_".$ij] );
2223
2224
2225
2226 print <<<EOL
2227
2228    <tr valign="bottom">
2229
2230      <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ii}" value="${ii_type}" type="text" class="fullin2"></td>
2231
2232      <td align="left" nowrap class="fibody2" id="bordR"><input name="ii_date_${ii}" value="${ii_date}" type="text" class="fullin2"></td>
2233
2234      <td align="left" class="fibody2" id="bordR"><input name="ii_type_${ij}" value="${ii_type1}" type="text" class="fullin2"></td>
2235
2236      <td align="left" nowrap class="fibody2"><input name="ii_date_${ij}" value="${ii_date1}" type="text" class="fullin2"></td>
2237
2238    </tr>
2239
2240 EOL;
2241
2242 $ii++;
2243
2244 }
2245
2246 ?>
2247
2248     </table>
2249
2250   </div>
2251
2252   <p align="center">&nbsp;</p>
2253
2254   <h2 align="center"><a name="im"></a>Immunizations/Test<br>
2255
2256   </h2>
2257
2258   <div style="border: solid 2px black; background-color: white;">
2259
2260     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2261
2262       <tr valign="bottom">
2263
2264         <td align="left" nowrap class="ficaption2" id="bordR">Type</td>
2265
2266         <td width="90" align="center" class="ficaption2" id="bordR">date</td>
2267
2268         <td align="left" nowrap class="ficaption2" id="bordR">type</td>
2269
2270         <td width="90" align="center" class="ficaption2">date</td>
2271
2272       </tr>
2273
2274       <tr valign="bottom">
2275
2276         <td align="left" nowrap class="fibody2" id="bordR">Tetanus-Diphteria booster </td>
2277
2278         <td align="left" nowrap class="fibody2" id="bordR">
2279
2280           <input name="imm_tetanus" type="text" class="fullin2"  value="<?php echo $fdata{'imm_tetanus'}; ?>">
2281
2282         </td>
2283
2284         <td align="left" nowrap class="fibody2" id="bordR">Influenza vaccine (Flu shot) </td>
2285
2286         <td align="left" valign="bottom" nowrap class="fibody2">
2287
2288           <input name="imm_influenza" type="text" class="fullin2"  value="<?php echo $fdata{'imm_influenza'}; ?>">
2289
2290         </td>
2291
2292       </tr>
2293
2294       <tr valign="bottom">
2295
2296         <td align="left" nowrap class="fibody2" id="bordR">hepatitis a vaccine </td>
2297
2298         <td align="left" nowrap class="fibody2" id="bordR">
2299
2300           <input name="imm_hepatitis_a" type="text" class="fullin2"  value="<?php echo $fdata{'imm_hepatitis_a'}; ?>">
2301
2302         </td>
2303
2304         <td align="left" nowrap class="fibody2" id="bordR">Hepatitis B vaccine </td>
2305
2306         <td align="left" valign="bottom" nowrap class="fibody2">
2307
2308           <input name="imm_hepatitis_b" type="text" class="fullin2"  value="<?php echo $fdata{'imm_hepatitis_b'}; ?>">
2309
2310         </td>
2311
2312       </tr>
2313
2314       <tr valign="bottom">
2315
2316         <td align="left" nowrap class="fibody2" id="bordR">varicella (Chickenpox) vaccine </td>
2317
2318         <td align="left" nowrap class="fibody2" id="bordR">
2319
2320           <input name="imm_varicella" type="text" class="fullin2"  value="<?php echo $fdata{'imm_varicella'}; ?>">
2321
2322         </td>
2323
2324         <td align="left" nowrap class="fibody2" id="bordR">pneumococcal (pneumonia) vaccine </td>
2325
2326         <td align="left" valign="bottom" nowrap class="fibody2">
2327
2328           <input name="imm_pneumococcal" type="text" class="fullin2"  value="<?php echo $fdata{'imm_pneumococcal'}; ?>">
2329
2330         </td>
2331
2332       </tr>
2333
2334       <tr valign="bottom">
2335
2336         <td align="left" nowrap class="fibody2" id="bordR">Measles-Mumps-Rubella (MMR) Vaccine </td>
2337
2338         <td align="left" nowrap class="fibody2" id="bordR">
2339
2340           <input name="imm_mmr" type="text" class="fullin2"  value="<?php echo $fdata{'imm_mmr'}; ?>">
2341
2342         </td>
2343
2344         <td align="left" nowrap class="fibody2" id="bordR">Tuberculosis (TB) Skin test:
2345
2346         <input name="imm_tuberculosis_skin" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'imm_tuberculosis_skin'}; ?>">
2347
2348         , result:
2349
2350         <input name="imm_tuberculosis_result" type="text" class="fullin"  style="width:40px" value="<?php echo $fdata{'imm_tuberculosis_result'}; ?>"></td>
2351
2352         <td align="left" valign="bottom" nowrap class="fibody2">
2353
2354           <input name="imm_tuberculosis" type="text" class="fullin2"  value="<?php echo $fdata{'imm_tuberculosis'}; ?>">
2355
2356         </td>
2357
2358       </tr>
2359
2360     </table>
2361
2362   </div>
2363
2364   <p align="center">&nbsp;</p>
2365
2366   <div style="border: solid 2px black; background-color: white;">
2367
2368     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2369
2370       <tr>
2371
2372         <td align="left" valign="top" class="fibody3">Physician's notes: <br>
2373
2374         <textarea name="imm_extended_info" rows="6" wrap="VIRTUAL" class="fullin2" ><?php echo $fdata{'imm_extended_info'}; ?></textarea></td>
2375
2376       </tr>
2377
2378     </table>
2379
2380   </div>
2381
2382   <p align="center">&nbsp;</p>
2383
2384   <a name="ros">
2385
2386   <h2 align="center"><a ></a>Review of systems<br>
2387
2388     <small>Please check (x), if any of the following symptoms
2389
2390 apply to you now or since adulthood</small> </h2>
2391
2392   <div style="border: solid 2px black; background-color: white;">
2393
2394     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
2395
2396       <tr>
2397
2398         <td width="300" align="left" valign="top" class="fibody4"  id="bordR" >&nbsp;</td>
2399
2400         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >now</td>
2401
2402         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >past</td>
2403
2404         <td width="58" align="center" valign="top" class="ficaption2"  id="bordR" >not sure </td>
2405
2406         <td align="center" valign="top" class="ficaption2">physician's notes </td>
2407
2408       </tr>
2409
2410       <tr valign="bottom">
2411
2412         <td align="left" class="ficaption2"  id="bordR" >1. Constitutional </td>
2413
2414         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2415
2416         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2417
2418         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2419
2420         <td align="left" class="fibody2">&nbsp;</td>
2421
2422       </tr>
2423
2424       <tr valign="bottom">
2425
2426         <td align="left" class="fibody4"  id="bordR" >Weight loss </td>
2427
2428         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="1" <?php echo (($fros{'ros_weight_loss_now'} == '1')?' checked ':''); ?>></td>
2429
2430         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="2" <?php echo (($fros{'ros_weight_loss_now'} == '2')?' checked ':''); ?>></td>
2431
2432         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_loss_now" value="3" <?php echo (($fros{'ros_weight_loss_now'} == '3')?' checked ':''); ?>></td>
2433
2434         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_1"   value="<?php echo $fros{'ros_notes_1'}; ?>"></td>
2435
2436       </tr>
2437
2438       <tr valign="bottom">
2439
2440         <td align="left" class="fibody4"  id="bordR" >Weight gain </td>
2441
2442         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="1" <?php echo (($fros{'ros_weight_gain_now'} == '1')?' checked ':''); ?>></td>
2443
2444         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="2" <?php echo (($fros{'ros_weight_gain_now'} == '2')?' checked ':''); ?>></td>
2445
2446         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_weight_gain_now" value="3" <?php echo (($fros{'ros_weight_gain_now'} == '3')?' checked ':''); ?>></td>
2447
2448         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_2"   value="<?php echo $fros{'ros_notes_2'}; ?>"></td>
2449
2450       </tr>
2451
2452       <tr valign="bottom">
2453
2454         <td align="left" class="fibody4"  id="bordR" >Fever</td>
2455
2456         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="1" <?php echo (($fros{'ros_fever_now'} == '1')?' checked ':''); ?>></td>
2457
2458         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="2" <?php echo (($fros{'ros_fever_now'} == '2')?' checked ':''); ?>></td>
2459
2460         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fever_now" value="3" <?php echo (($fros{'ros_fever_now'} == '3')?' checked ':''); ?>></td>
2461
2462         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_3"   value="<?php echo $fros{'ros_notes_3'}; ?>"></td>
2463
2464       </tr>
2465
2466       <tr valign="bottom">
2467
2468         <td align="left" class="fibody4"  id="bordR" >Fatigue</td>
2469
2470         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="1" <?php echo (($fros{'ros_fatigue_now'} == '1')?' checked ':''); ?>></td>
2471
2472         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="2" <?php echo (($fros{'ros_fatigue_now'} == '2')?' checked ':''); ?>></td>
2473
2474         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_fatigue_now" value="3" <?php echo (($fros{'ros_fatigue_now'} == '3')?' checked ':''); ?>></td>
2475
2476         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_4"   value="<?php echo $fros{'ros_notes_4'}; ?>"></td>
2477
2478       </tr>
2479
2480       <tr valign="bottom">
2481
2482         <td align="left" class="fibody4"  id="bordR" >Change in height </td>
2483
2484         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="1" <?php echo (($fros{'ros_height_change_now'} == '1')?' checked ':''); ?>></td>
2485
2486         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="2" <?php echo (($fros{'ros_height_change_now'} == '2')?' checked ':''); ?>></td>
2487
2488         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_height_change_now" value="3" <?php echo (($fros{'ros_height_change_now'} == '3')?' checked ':''); ?>></td>
2489
2490         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_5"   value="<?php echo $fros{'ros_notes_5'}; ?>"></td>
2491
2492       </tr>
2493
2494       <tr valign="bottom">
2495
2496         <td align="left" class="ficaption2"  id="bordR" >2. Eyes </td>
2497
2498         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2499
2500         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2501
2502         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2503
2504         <td align="left" class="fibody2">&nbsp;</td>
2505
2506       </tr>
2507
2508       <tr valign="bottom">
2509
2510         <td align="left" class="fibody4"  id="bordR" >Double vision </td>
2511
2512         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="1" <?php echo (($fros{'ros_dvision_now'} == '1')?' checked ':''); ?>></td>
2513
2514         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="2" <?php echo (($fros{'ros_dvision_now'} == '2')?' checked ':''); ?>></td>
2515
2516         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dvision_now" value="3" <?php echo (($fros{'ros_dvision_now'} == '3')?' checked ':''); ?>></td>
2517
2518         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_6"   value="<?php echo $fros{'ros_notes_6'}; ?>"></td>
2519
2520       </tr>
2521
2522       <tr valign="bottom">
2523
2524         <td align="left" class="fibody4"  id="bordR" >Spots before eyes </td>
2525
2526         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="1" <?php echo (($fros{'ros_spots_eyes_now'} == '1')?' checked ':''); ?>></td>
2527
2528         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="2" <?php echo (($fros{'ros_spots_eyes_now'} == '2')?' checked ':''); ?>></td>
2529
2530         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spots_eyes_now" value="3" <?php echo (($fros{'ros_spots_eyes_now'} == '3')?' checked ':''); ?>></td>
2531
2532         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_7"   value="<?php echo $fros{'ros_notes_7'}; ?>"></td>
2533
2534       </tr>
2535
2536       <tr valign="bottom">
2537
2538         <td align="left" class="fibody4"  id="bordR" >Vision changes </td>
2539
2540         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="1" <?php echo (($fros{'ros_vis_changes_now'} == '1')?' checked ':''); ?>></td>
2541
2542         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="2" <?php echo (($fros{'ros_vis_changes_now'} == '2')?' checked ':''); ?>></td>
2543
2544         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vis_changes_now" value="3" <?php echo (($fros{'ros_vis_changes_now'} == '3')?' checked ':''); ?>></td>
2545
2546         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_8"   value="<?php echo $fros{'ros_notes_8'}; ?>"></td>
2547
2548       </tr>
2549
2550       <tr valign="bottom">
2551
2552         <td align="left" class="fibody4"  id="bordR" >Glasses/contacts</td>
2553
2554         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="1" <?php echo (($fros{'ros_glasses_now'} == '1')?' checked ':''); ?>></td>
2555
2556         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="2" <?php echo (($fros{'ros_glasses_now'} == '2')?' checked ':''); ?>></td>
2557
2558         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_glasses_now" value="3" <?php echo (($fros{'ros_glasses_now'} == '3')?' checked ':''); ?>></td>
2559
2560         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_9"   value="<?php echo $fros{'ros_notes_9'}; ?>"></td>
2561
2562       </tr>
2563
2564       <tr valign="bottom">
2565
2566         <td align="left" class="ficaption2"  id="bordR" >3. Ear, nose and throat </td>
2567
2568         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2569
2570         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2571
2572         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2573
2574         <td align="left" class="fibody2">&nbsp;</td>
2575
2576       </tr>
2577
2578       <tr valign="bottom">
2579
2580         <td align="left" class="fibody4"  id="bordR" >Earaches</td>
2581
2582         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="1" <?php echo (($fros{'ros_earaches_now'} == '1')?' checked ':''); ?>></td>
2583
2584         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="2" <?php echo (($fros{'ros_earaches_now'} == '2')?' checked ':''); ?>></td>
2585
2586         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_earaches_now" value="3" <?php echo (($fros{'ros_earaches_now'} == '3')?' checked ':''); ?>></td>
2587
2588         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_10"   value="<?php echo $fros{'ros_notes_10'}; ?>"></td>
2589
2590       </tr>
2591
2592       <tr valign="bottom">
2593
2594         <td align="left" class="fibody4"  id="bordR" >Ringing in ears </td>
2595
2596         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="1" <?php echo (($fros{'ros_ringing_now'} == '1')?' checked ':''); ?>></td>
2597
2598         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="2" <?php echo (($fros{'ros_ringing_now'} == '2')?' checked ':''); ?>></td>
2599
2600         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_ringing_now" value="3" <?php echo (($fros{'ros_ringing_now'} == '3')?' checked ':''); ?>></td>
2601
2602         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_11"   value="<?php echo $fros{'ros_notes_11'}; ?>"></td>
2603
2604       </tr>
2605
2606       <tr valign="bottom">
2607
2608         <td align="left" class="fibody4"  id="bordR" >Hearing problems</td>
2609
2610         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="1" <?php echo (($fros{'ros_hearing_problems_now'} == '1')?' checked ':''); ?>></td>
2611
2612         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="2" <?php echo (($fros{'ros_hearing_problems_now'} == '2')?' checked ':''); ?>></td>
2613
2614         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hearing_problems_now" value="3" <?php echo (($fros{'ros_hearing_problems_now'} == '3')?' checked ':''); ?>></td>
2615
2616         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_12"   value="<?php echo $fros{'ros_notes_12'}; ?>"></td>
2617
2618       </tr>
2619
2620       <tr valign="bottom">
2621
2622         <td align="left" class="fibody4"  id="bordR" >Sinus problems </td>
2623
2624         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="1" <?php echo (($fros{'ros_sinus_problems_now'} == '1')?' checked ':''); ?>></td>
2625
2626         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="2" <?php echo (($fros{'ros_sinus_problems_now'} == '2')?' checked ':''); ?>></td>
2627
2628         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sinus_problems_now" value="3" <?php echo (($fros{'ros_sinus_problems_now'} == '3')?' checked ':''); ?>></td>
2629
2630         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_13"   value="<?php echo $fros{'ros_notes_13'}; ?>"></td>
2631
2632       </tr>
2633
2634       <tr valign="bottom">
2635
2636         <td align="left" class="fibody4"  id="bordR" >Sore throat </td>
2637
2638         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="1" <?php echo (($fros{'ros_sore_throat_now'} == '1')?' checked ':''); ?>></td>
2639
2640         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="2" <?php echo (($fros{'ros_sore_throat_now'} == '2')?' checked ':''); ?>></td>
2641
2642         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sore_throat_now" value="3" <?php echo (($fros{'ros_sore_throat_now'} == '3')?' checked ':''); ?>></td>
2643
2644         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_14"   value="<?php echo $fros{'ros_notes_14'}; ?>"></td>
2645
2646       </tr>
2647
2648       <tr valign="bottom">
2649
2650         <td align="left" class="fibody4"  id="bordR" >Mouth sores </td>
2651
2652         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="1" <?php echo (($fros{'ros_mouth_sores_now'} == '1')?' checked ':''); ?>></td>
2653
2654         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="2" <?php echo (($fros{'ros_mouth_sores_now'} == '2')?' checked ':''); ?>></td>
2655
2656         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_mouth_sores_now" value="3" <?php echo (($fros{'ros_mouth_sores_now'} == '3')?' checked ':''); ?>></td>
2657
2658         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_15"   value="<?php echo $fros{'ros_notes_15'}; ?>"></td>
2659
2660       </tr>
2661
2662       <tr valign="bottom">
2663
2664         <td align="left" class="fibody4"  id="bordR" >Dental problems </td>
2665
2666         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="1" <?php echo (($fros{'ros_dental_problems_now'} == '1')?' checked ':''); ?>></td>
2667
2668         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="2" <?php echo (($fros{'ros_dental_problems_now'} == '2')?' checked ':''); ?>></td>
2669
2670         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dental_problems_now" value="3" <?php echo (($fros{'ros_dental_problems_now'} == '3')?' checked ':''); ?>></td>
2671
2672         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_16"   value="<?php echo $fros{'ros_notes_16'}; ?>"></td>
2673
2674       </tr>
2675
2676       <tr valign="bottom">
2677
2678         <td align="left" class="ficaption2"  id="bordR" >4. Cardiovascular </td>
2679
2680         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2681
2682         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2683
2684         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2685
2686         <td align="left" class="fibody2">&nbsp;</td>
2687
2688       </tr>
2689
2690       <tr valign="bottom">
2691
2692         <td align="left" class="fibody4"  id="bordR" >Chest pain on pressure </td>
2693
2694         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="1" <?php echo (($fros{'ros_chest_pain_now'} == '1')?' checked ':''); ?>></td>
2695
2696         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="2" <?php echo (($fros{'ros_chest_pain_now'} == '2')?' checked ':''); ?>></td>
2697
2698         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chest_pain_now" value="3" <?php echo (($fros{'ros_chest_pain_now'} == '3')?' checked ':''); ?>></td>
2699
2700         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_17"   value="<?php echo $fros{'ros_notes_17'}; ?>"></td>
2701
2702       </tr>
2703
2704       <tr valign="bottom">
2705
2706         <td align="left" class="fibody4"  id="bordR" >Difficulty breathing on exertion </td>
2707
2708         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="1" <?php echo (($fros{'ros_difficulty_breathing_now'} == '1')?' checked ':''); ?>></td>
2709
2710         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="2" <?php echo (($fros{'ros_difficulty_breathing_now'} == '2')?' checked ':''); ?>></td>
2711
2712         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_difficulty_breathing_now" value="3" <?php echo (($fros{'ros_difficulty_breathing_now'} == '3')?' checked ':''); ?>></td>
2713
2714         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_18"   value="<?php echo $fros{'ros_notes_18'}; ?>"></td>
2715
2716       </tr>
2717
2718       <tr valign="bottom">
2719
2720         <td align="left" class="fibody4"  id="bordR" >Swelling on legs </td>
2721
2722         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="1" <?php echo (($fros{'ros_swelling_legs_now'} == '1')?' checked ':''); ?>></td>
2723
2724         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="2" <?php echo (($fros{'ros_swelling_legs_now'} == '2')?' checked ':''); ?>></td>
2725
2726         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_swelling_legs_now" value="3" <?php echo (($fros{'ros_swelling_legs_now'} == '3')?' checked ':''); ?>></td>
2727
2728         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_19"   value="<?php echo $fros{'ros_notes_19'}; ?>"></td>
2729
2730       </tr>
2731
2732       <tr valign="bottom">
2733
2734         <td align="left" class="fibody4"  id="bordR" >Rapid or irregular heartbeat </td>
2735
2736         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="1" <?php echo (($fros{'ros_rapid_heartbeat_now'} == '1')?' checked ':''); ?>></td>
2737
2738         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="2" <?php echo (($fros{'ros_rapid_heartbeat_now'} == '2')?' checked ':''); ?>></td>
2739
2740         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rapid_heartbeat_now" value="3" <?php echo (($fros{'ros_rapid_heartbeat_now'} == '3')?' checked ':''); ?>></td>
2741
2742         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_20"   value="<?php echo $fros{'ros_notes_20'}; ?>"></td>
2743
2744       </tr>
2745
2746       <tr valign="bottom">
2747
2748         <td align="left" class="ficaption2"  id="bordR" >5. Respiratory </td>
2749
2750         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2751
2752         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2753
2754         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2755
2756         <td align="left" class="fibody2">&nbsp;</td>
2757
2758       </tr>
2759
2760       <tr valign="bottom">
2761
2762         <td align="left" class="fibody4"  id="bordR" >Painful breathing </td>
2763
2764         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="1" <?php echo (($fros{'ros_painful_breathing_now'} == '1')?' checked ':''); ?>></td>
2765
2766         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="2" <?php echo (($fros{'ros_painful_breathing_now'} == '2')?' checked ':''); ?>></td>
2767
2768         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_breathing_now" value="3" <?php echo (($fros{'ros_painful_breathing_now'} == '3')?' checked ':''); ?>></td>
2769
2770         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_21"   value="<?php echo $fros{'ros_notes_21'}; ?>"></td>
2771
2772       </tr>
2773
2774       <tr valign="bottom">
2775
2776         <td align="left" class="fibody4"  id="bordR" >Wheezing</td>
2777
2778         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="1" <?php echo (($fros{'ros_wheezing_now'} == '1')?' checked ':''); ?>></td>
2779
2780         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="2" <?php echo (($fros{'ros_wheezing_now'} == '2')?' checked ':''); ?>></td>
2781
2782         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_wheezing_now" value="3" <?php echo (($fros{'ros_wheezing_now'} == '3')?' checked ':''); ?>></td>
2783
2784         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_22"   value="<?php echo $fros{'ros_notes_22'}; ?>"></td>
2785
2786       </tr>
2787
2788       <tr valign="bottom">
2789
2790         <td align="left" class="fibody4"  id="bordR" >Spitting up blood </td>
2791
2792         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="1" <?php echo (($fros{'ros_spitting_blood_now'} == '1')?' checked ':''); ?>></td>
2793
2794         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="2" <?php echo (($fros{'ros_spitting_blood_now'} == '2')?' checked ':''); ?>></td>
2795
2796         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_spitting_blood_now" value="3" <?php echo (($fros{'ros_spitting_blood_now'} == '3')?' checked ':''); ?>></td>
2797
2798         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_23"   value="<?php echo $fros{'ros_notes_23'}; ?>"></td>
2799
2800       </tr>
2801
2802       <tr valign="bottom">
2803
2804         <td align="left" class="fibody4"  id="bordR" >Shortness of breath </td>
2805
2806         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="1" <?php echo (($fros{'ros_breath_shortness_now'} == '1')?' checked ':''); ?>></td>
2807
2808         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="2" <?php echo (($fros{'ros_breath_shortness_now'} == '2')?' checked ':''); ?>></td>
2809
2810         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_breath_shortness_now" value="3" <?php echo (($fros{'ros_breath_shortness_now'} == '3')?' checked ':''); ?>></td>
2811
2812         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_24"   value="<?php echo $fros{'ros_notes_24'}; ?>"></td>
2813
2814       </tr>
2815
2816       <tr valign="bottom">
2817
2818         <td align="left" class="fibody4"  id="bordR" >Chronic cough </td>
2819
2820         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="1" <?php echo (($fros{'ros_chronic_cough_now'} == '1')?' checked ':''); ?>></td>
2821
2822         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="2" <?php echo (($fros{'ros_chronic_cough_now'} == '2')?' checked ':''); ?>></td>
2823
2824         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_chronic_cough_now" value="3" <?php echo (($fros{'ros_chronic_cough_now'} == '3')?' checked ':''); ?>></td>
2825
2826         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_25"   value="<?php echo $fros{'ros_notes_25'}; ?>"></td>
2827
2828       </tr>
2829
2830       <tr valign="bottom">
2831
2832         <td align="left" class="ficaption2"  id="bordR" >6. Gastrointestinal </td>
2833
2834         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2835
2836         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2837
2838         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2839
2840         <td align="left" class="fibody2">&nbsp;</td>
2841
2842       </tr>
2843
2844       <tr valign="bottom">
2845
2846         <td align="left" class="fibody4"  id="bordR" >Frequent diarrhea </td>
2847
2848         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="1" <?php echo (($fros{'ros_diarrhea_now'} == '1')?' checked ':''); ?>></td>
2849
2850         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="2" <?php echo (($fros{'ros_diarrhea_now'} == '2')?' checked ':''); ?>></td>
2851
2852         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_diarrhea_now" value="3" <?php echo (($fros{'ros_diarrhea_now'} == '3')?' checked ':''); ?>></td>
2853
2854         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_26"   value="<?php echo $fros{'ros_notes_26'}; ?>"></td>
2855
2856       </tr>
2857
2858       <tr valign="bottom">
2859
2860         <td align="left" class="fibody4"  id="bordR" >Bloody stool </td>
2861
2862         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="1" <?php echo (($fros{'ros_bloody_stool_now'} == '1')?' checked ':''); ?>></td>
2863
2864         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="2" <?php echo (($fros{'ros_bloody_stool_now'} == '2')?' checked ':''); ?>></td>
2865
2866         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_bloody_stool_now" value="3" <?php echo (($fros{'ros_bloody_stool_now'} == '3')?' checked ':''); ?>></td>
2867
2868         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_27"   value="<?php echo $fros{'ros_notes_27'}; ?>"></td>
2869
2870       </tr>
2871
2872       <tr valign="bottom">
2873
2874         <td align="left" class="fibody4"  id="bordR" >Nausea / vomiting indigestion </td>
2875
2876         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="1" <?php echo (($fros{'ros_nausea_now'} == '1')?' checked ':''); ?>></td>
2877
2878         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="2" <?php echo (($fros{'ros_nausea_now'} == '2')?' checked ':''); ?>></td>
2879
2880         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nausea_now" value="3" <?php echo (($fros{'ros_nausea_now'} == '3')?' checked ':''); ?>></td>
2881
2882         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_28"   value="<?php echo $fros{'ros_notes_28'}; ?>"></td>
2883
2884       </tr>
2885
2886       <tr valign="bottom">
2887
2888         <td align="left" class="fibody4"  id="bordR" >Constipation</td>
2889
2890         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="1" <?php echo (($fros{'ros_constipation_now'} == '1')?' checked ':''); ?>></td>
2891
2892         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="2" <?php echo (($fros{'ros_constipation_now'} == '2')?' checked ':''); ?>></td>
2893
2894         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_constipation_now" value="3" <?php echo (($fros{'ros_constipation_now'} == '3')?' checked ':''); ?>></td>
2895
2896         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_29"   value="<?php echo $fros{'ros_notes_29'}; ?>"></td>
2897
2898       </tr>
2899
2900       <tr valign="bottom">
2901
2902         <td align="left" class="fibody4"  id="bordR" >Involuntary loss of gas or stool </td>
2903
2904         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="1" <?php echo (($fros{'ros_gas_loss_now'} == '1')?' checked ':''); ?>></td>
2905
2906         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="2" <?php echo (($fros{'ros_gas_loss_now'} == '2')?' checked ':''); ?>></td>
2907
2908         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_gas_loss_now" value="3" <?php echo (($fros{'ros_gas_loss_now'} == '3')?' checked ':''); ?>></td>
2909
2910         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_30"   value="<?php echo $fros{'ros_notes_30'}; ?>"></td>
2911
2912       </tr>
2913
2914       <tr valign="bottom">
2915
2916         <td align="left" class="ficaption2"  id="bordR" >7. Genitourinary </td>
2917
2918         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2919
2920         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2921
2922         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
2923
2924         <td align="left" class="fibody2">&nbsp;</td>
2925
2926       </tr>
2927
2928       <tr valign="bottom">
2929
2930         <td align="left" class="fibody4"  id="bordR" >Blood in urine </td>
2931
2932         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="1" <?php echo (($fros{'ros_blood_urine_now'} == '1')?' checked ':''); ?>></td>
2933
2934         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="2" <?php echo (($fros{'ros_blood_urine_now'} == '2')?' checked ':''); ?>></td>
2935
2936         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_blood_urine_now" value="3" <?php echo (($fros{'ros_blood_urine_now'} == '3')?' checked ':''); ?>></td>
2937
2938         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_31"   value="<?php echo $fros{'ros_notes_31'}; ?>"></td>
2939
2940       </tr>
2941
2942       <tr valign="bottom">
2943
2944         <td align="left" class="fibody4"  id="bordR" >Pain with urination </td>
2945
2946         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="1" <?php echo (($fros{'ros_pain_urination_now'} == '1')?' checked ':''); ?>></td>
2947
2948         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="2" <?php echo (($fros{'ros_pain_urination_now'} == '2')?' checked ':''); ?>></td>
2949
2950         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_urination_now" value="3" <?php echo (($fros{'ros_pain_urination_now'} == '3')?' checked ':''); ?>></td>
2951
2952         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_32"   value="<?php echo $fros{'ros_notes_32'}; ?>"></td>
2953
2954       </tr>
2955
2956       <tr valign="bottom">
2957
2958         <td align="left" class="fibody4"  id="bordR" >Strong urgency to urinate </td>
2959
2960         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="1" <?php echo (($fros{'ros_urgency_urinate_now'} == '1')?' checked ':''); ?>></td>
2961
2962         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="2" <?php echo (($fros{'ros_urgency_urinate_now'} == '2')?' checked ':''); ?>></td>
2963
2964         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_urgency_urinate_now" value="3" <?php echo (($fros{'ros_urgency_urinate_now'} == '3')?' checked ':''); ?>></td>
2965
2966         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_33"   value="<?php echo $fros{'ros_notes_33'}; ?>"></td>
2967
2968       </tr>
2969
2970       <tr valign="bottom">
2971
2972         <td align="left" class="fibody4"  id="bordR" >Frequent urination </td>
2973
2974         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="1" <?php echo (($fros{'ros_frequent_urination_now'} == '1')?' checked ':''); ?>></td>
2975
2976         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="2" <?php echo (($fros{'ros_frequent_urination_now'} == '2')?' checked ':''); ?>></td>
2977
2978         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_urination_now" value="3" <?php echo (($fros{'ros_frequent_urination_now'} == '3')?' checked ':''); ?>></td>
2979
2980         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_34"   value="<?php echo $fros{'ros_notes_34'}; ?>"></td>
2981
2982       </tr>
2983
2984       <tr valign="bottom">
2985
2986         <td align="left" class="fibody4"  id="bordR" >Incomplete emtying </td>
2987
2988         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="1" <?php echo (($fros{'ros_incomplete_emptying_now'} == '1')?' checked ':''); ?>></td>
2989
2990         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="2" <?php echo (($fros{'ros_incomplete_emptying_now'} == '2')?' checked ':''); ?>></td>
2991
2992         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_incomplete_emptying_now" value="3" <?php echo (($fros{'ros_incomplete_emptying_now'} == '3')?' checked ':''); ?>></td>
2993
2994         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_35"   value="<?php echo $fros{'ros_notes_35'}; ?>"></td>
2995
2996       </tr>
2997
2998       <tr valign="bottom">
2999
3000         <td align="left" class="fibody4"  id="bordR" >Involuntary/Unintended urine loss </td>
3001
3002         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="1" <?php echo (($fros{'ros_unint_urine_loss_now'} == '1')?' checked ':''); ?>></td>
3003
3004         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="2" <?php echo (($fros{'ros_unint_urine_loss_now'} == '2')?' checked ':''); ?>></td>
3005
3006         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_unint_urine_loss_now" value="3" <?php echo (($fros{'ros_unint_urine_loss_now'} == '3')?' checked ':''); ?>></td>
3007
3008         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_36"   value="<?php echo $fros{'ros_notes_36'}; ?>"></td>
3009
3010       </tr>
3011
3012       <tr valign="bottom">
3013
3014         <td align="left" class="fibody4"  id="bordR" >Urine loss when coughing or lifting </td>
3015
3016         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="1" <?php echo (($fros{'ros_lifting_urine_loss_now'} == '1')?' checked ':''); ?>></td>
3017
3018         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="2" <?php echo (($fros{'ros_lifting_urine_loss_now'} == '2')?' checked ':''); ?>></td>
3019
3020         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lifting_urine_loss_now" value="3" <?php echo (($fros{'ros_lifting_urine_loss_now'} == '3')?' checked ':''); ?>></td>
3021
3022         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_37"   value="<?php echo $fros{'ros_notes_37'}; ?>"></td>
3023
3024       </tr>
3025
3026       <tr valign="bottom">
3027
3028         <td align="left" class="fibody4"  id="bordR" >Abnormal bleeding</td>
3029
3030         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="1" <?php echo (($fros{'ros_abnormal_bleeding_now'} == '1')?' checked ':''); ?>></td>
3031
3032         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="2" <?php echo (($fros{'ros_abnormal_bleeding_now'} == '2')?' checked ':''); ?>></td>
3033
3034         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_bleeding_now" value="3" <?php echo (($fros{'ros_abnormal_bleeding_now'} == '3')?' checked ':''); ?>></td>
3035
3036         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_38"   value="<?php echo $fros{'ros_notes_38'}; ?>"></td>
3037
3038       </tr>
3039
3040       <tr valign="bottom">
3041
3042         <td align="left" class="fibody4"  id="bordR" >Painful periods </td>
3043
3044         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="1" <?php echo (($fros{'ros_painful_periods_now'} == '1')?' checked ':''); ?>></td>
3045
3046         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="2" <?php echo (($fros{'ros_painful_periods_now'} == '2')?' checked ':''); ?>></td>
3047
3048         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_periods_now" value="3" <?php echo (($fros{'ros_painful_periods_now'} == '3')?' checked ':''); ?>></td>
3049
3050         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_39"   value="<?php echo $fros{'ros_notes_39'}; ?>"></td>
3051
3052       </tr>
3053
3054       <tr valign="bottom">
3055
3056         <td align="left" class="fibody4"  id="bordR" >Premenstrual Syndrome (PMS) </td>
3057
3058         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="1" <?php echo (($fros{'ros_pms_now'} == '1')?' checked ':''); ?>></td>
3059
3060         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="2" <?php echo (($fros{'ros_pms_now'} == '2')?' checked ':''); ?>></td>
3061
3062         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pms_now" value="3" <?php echo (($fros{'ros_pms_now'} == '3')?' checked ':''); ?>></td>
3063
3064         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_40"   value="<?php echo $fros{'ros_notes_40'}; ?>"></td>
3065
3066       </tr>
3067
3068       <tr valign="bottom">
3069
3070         <td align="left" class="fibody4"  id="bordR" >Painful intercourse </td>
3071
3072         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="1" <?php echo (($fros{'ros_painful_intercourse_now'} == '1')?' checked ':''); ?>></td>
3073
3074         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="2" <?php echo (($fros{'ros_painful_intercourse_now'} == '2')?' checked ':''); ?>></td>
3075
3076         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_painful_intercourse_now" value="3" <?php echo (($fros{'ros_painful_intercourse_now'} == '3')?' checked ':''); ?>></td>
3077
3078         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_41"   value="<?php echo $fros{'ros_notes_41'}; ?>"></td>
3079
3080       </tr>
3081
3082       <tr valign="bottom">
3083
3084         <td align="left" class="fibody4"  id="bordR" >Abnormal vaginal discharge </td>
3085
3086         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="1" <?php echo (($fros{'ros_vaginal_discharge_now'} == '1')?' checked ':''); ?>></td>
3087
3088         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="2" <?php echo (($fros{'ros_vaginal_discharge_now'} == '2')?' checked ':''); ?>></td>
3089
3090         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_vaginal_discharge_now" value="3" <?php echo (($fros{'ros_vaginal_discharge_now'} == '3')?' checked ':''); ?>></td>
3091
3092         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_42"   value="<?php echo $fros{'ros_notes_42'}; ?>"></td>
3093
3094       </tr>
3095
3096       <tr valign="bottom">
3097
3098         <td align="left" class="ficaption2"  id="bordR" >8. Musculoskeletal </td>
3099
3100         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3101
3102         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3103
3104         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3105
3106         <td align="left" class="fibody2">&nbsp;</td>
3107
3108       </tr>
3109
3110       <tr valign="bottom">
3111
3112         <td align="left" class="fibody4"  id="bordR" >Muscle weakness </td>
3113
3114         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="1" <?php echo (($fros{'ros_muscle_weakness_now'} == '1')?' checked ':''); ?>></td>
3115
3116         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="2" <?php echo (($fros{'ros_muscle_weakness_now'} == '2')?' checked ':''); ?>></td>
3117
3118         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_weakness_now" value="3" <?php echo (($fros{'ros_muscle_weakness_now'} == '3')?' checked ':''); ?>></td>
3119
3120         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_43"   value="<?php echo $fros{'ros_notes_43'}; ?>"></td>
3121
3122       </tr>
3123
3124       <tr valign="bottom">
3125
3126         <td align="left" class="fibody4"  id="bordR" >Muscle or joint pain </td>
3127
3128         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="1" <?php echo (($fros{'ros_muscle_pain_now'} == '1')?' checked ':''); ?>></td>
3129
3130         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="2" <?php echo (($fros{'ros_muscle_pain_now'} == '2')?' checked ':''); ?>></td>
3131
3132         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_muscle_pain_now" value="3" <?php echo (($fros{'ros_muscle_pain_now'} == '3')?' checked ':''); ?>></td>
3133
3134         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_44"   value="<?php echo $fros{'ros_notes_44'}; ?>"></td>
3135
3136       </tr>
3137
3138       <tr valign="bottom">
3139
3140         <td align="left" class="ficaption2"  id="bordR" >9a. Skin </td>
3141
3142         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3143
3144         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3145
3146         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3147
3148         <td align="left" class="fibody2">&nbsp;</td>
3149
3150       </tr>
3151
3152       <tr valign="bottom">
3153
3154         <td align="left" class="fibody4"  id="bordR" >Rash</td>
3155
3156         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="1" <?php echo (($fros{'ros_rash_now'} == '1')?' checked ':''); ?>></td>
3157
3158         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="2" <?php echo (($fros{'ros_rash_now'} == '2')?' checked ':''); ?>></td>
3159
3160         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_rash_now" value="3" <?php echo (($fros{'ros_rash_now'} == '3')?' checked ':''); ?>></td>
3161
3162         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_45"   value="<?php echo $fros{'ros_notes_45'}; ?>"></td>
3163
3164       </tr>
3165
3166       <tr valign="bottom">
3167
3168         <td align="left" class="fibody4"  id="bordR" >Sores</td>
3169
3170         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="1" <?php echo (($fros{'ros_sores_now'} == '1')?' checked ':''); ?>></td>
3171
3172         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="2" <?php echo (($fros{'ros_sores_now'} == '2')?' checked ':''); ?>></td>
3173
3174         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_sores_now" value="3" <?php echo (($fros{'ros_sores_now'} == '3')?' checked ':''); ?>></td>
3175
3176         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_46"   value="<?php echo $fros{'ros_notes_46'}; ?>"></td>
3177
3178       </tr>
3179
3180       <tr valign="bottom">
3181
3182         <td align="left" class="fibody4"  id="bordR" >Dry skin </td>
3183
3184         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="1" <?php echo (($fros{'ros_dry_skin_now'} == '1')?' checked ':''); ?>></td>
3185
3186         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="2" <?php echo (($fros{'ros_dry_skin_now'} == '2')?' checked ':''); ?>></td>
3187
3188         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dry_skin_now" value="3" <?php echo (($fros{'ros_dry_skin_now'} == '3')?' checked ':''); ?>></td>
3189
3190         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_47"   value="<?php echo $fros{'ros_notes_47'}; ?>"></td>
3191
3192       </tr>
3193
3194       <tr valign="bottom">
3195
3196         <td align="left" class="fibody4"  id="bordR" >Moles (growth or changes) </td>
3197
3198         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="1" <?php echo (($fros{'ros_moles_now'} == '1')?' checked ':''); ?>></td>
3199
3200         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="2" <?php echo (($fros{'ros_moles_now'} == '2')?' checked ':''); ?>></td>
3201
3202         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_moles_now" value="3" <?php echo (($fros{'ros_moles_now'} == '3')?' checked ':''); ?>></td>
3203
3204         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_48"   value="<?php echo $fros{'ros_notes_48'}; ?>"></td>
3205
3206       </tr>
3207
3208       <tr valign="bottom">
3209
3210         <td align="left" class="ficaption2"  id="bordR" >9b. Breasts </td>
3211
3212         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3213
3214         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3215
3216         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3217
3218         <td align="left" class="fibody2">&nbsp;</td>
3219
3220       </tr>
3221
3222       <tr valign="bottom">
3223
3224         <td align="left" class="fibody4"  id="bordR" >Pain in breast </td>
3225
3226         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="1" <?php echo (($fros{'ros_pain_breast_now'} == '1')?' checked ':''); ?>></td>
3227
3228         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="2" <?php echo (($fros{'ros_pain_breast_now'} == '2')?' checked ':''); ?>></td>
3229
3230         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_pain_breast_now" value="3" <?php echo (($fros{'ros_pain_breast_now'} == '3')?' checked ':''); ?>></td>
3231
3232         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_49"   value="<?php echo $fros{'ros_notes_49'}; ?>"></td>
3233
3234       </tr>
3235
3236       <tr valign="bottom">
3237
3238         <td align="left" class="fibody4"  id="bordR" >Nipple discharge </td>
3239
3240         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="1" <?php echo (($fros{'ros_nipple_discharge_now'} == '1')?' checked ':''); ?>></td>
3241
3242         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="2" <?php echo (($fros{'ros_nipple_discharge_now'} == '2')?' checked ':''); ?>></td>
3243
3244         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_nipple_discharge_now" value="3" <?php echo (($fros{'ros_nipple_discharge_now'} == '3')?' checked ':''); ?>></td>
3245
3246         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_50"   value="<?php echo $fros{'ros_notes_50'}; ?>"></td>
3247
3248       </tr>
3249
3250       <tr valign="bottom">
3251
3252         <td align="left" class="fibody4"  id="bordR" >Lumps</td>
3253
3254         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="1" <?php echo (($fros{'ros_lumps_now'} == '1')?' checked ':''); ?>></td>
3255
3256         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="2" <?php echo (($fros{'ros_lumps_now'} == '2')?' checked ':''); ?>></td>
3257
3258         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_lumps_now" value="3" <?php echo (($fros{'ros_lumps_now'} == '3')?' checked ':''); ?>></td>
3259
3260         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_51"   value="<?php echo $fros{'ros_notes_51'}; ?>"></td>
3261
3262       </tr>
3263
3264       <tr valign="bottom">
3265
3266         <td align="left" class="ficaption2"  id="bordR" >10. Neurologic </td>
3267
3268         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3269
3270         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3271
3272         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3273
3274         <td align="left" class="fibody2">&nbsp;</td>
3275
3276       </tr>
3277
3278       <tr valign="bottom">
3279
3280         <td align="left" class="fibody4"  id="bordR" >Dizziness</td>
3281
3282         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="1" <?php echo (($fros{'ros_dizziness_now'} == '1')?' checked ':''); ?>></td>
3283
3284         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="2" <?php echo (($fros{'ros_dizziness_now'} == '2')?' checked ':''); ?>></td>
3285
3286         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_dizziness_now" value="3" <?php echo (($fros{'ros_dizziness_now'} == '3')?' checked ':''); ?>></td>
3287
3288         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_52"   value="<?php echo $fros{'ros_notes_52'}; ?>"></td>
3289
3290       </tr>
3291
3292       <tr valign="bottom">
3293
3294         <td align="left" class="fibody4"  id="bordR" >Seizures</td>
3295
3296         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="1" <?php echo (($fros{'ros_seizures_now'} == '1')?' checked ':''); ?>></td>
3297
3298         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="2" <?php echo (($fros{'ros_seizures_now'} == '2')?' checked ':''); ?>></td>
3299
3300         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_seizures_now" value="3" <?php echo (($fros{'ros_seizures_now'} == '3')?' checked ':''); ?>></td>
3301
3302         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_53"   value="<?php echo $fros{'ros_notes_53'}; ?>"></td>
3303
3304       </tr>
3305
3306       <tr valign="bottom">
3307
3308         <td align="left" class="fibody4"  id="bordR" >Numbness</td>
3309
3310         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="1" <?php echo (($fros{'ros_numbness_now'} == '1')?' checked ':''); ?>></td>
3311
3312         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="2" <?php echo (($fros{'ros_numbness_now'} == '2')?' checked ':''); ?>></td>
3313
3314         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_numbness_now" value="3" <?php echo (($fros{'ros_numbness_now'} == '3')?' checked ':''); ?>></td>
3315
3316         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_54"   value="<?php echo $fros{'ros_notes_54'}; ?>"></td>
3317
3318       </tr>
3319
3320       <tr valign="bottom">
3321
3322         <td align="left" class="fibody4"  id="bordR" >Trouble walking </td>
3323
3324         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="1" <?php echo (($fros{'ros_trouble_walking_now'} == '1')?' checked ':''); ?>></td>
3325
3326         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="2" <?php echo (($fros{'ros_trouble_walking_now'} == '2')?' checked ':''); ?>></td>
3327
3328         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_trouble_walking_now" value="3" <?php echo (($fros{'ros_trouble_walking_now'} == '3')?' checked ':''); ?>></td>
3329
3330         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_55"   value="<?php echo $fros{'ros_notes_55'}; ?>"></td>
3331
3332       </tr>
3333
3334       <tr valign="bottom">
3335
3336         <td align="left" class="fibody4"  id="bordR" >Memory problems </td>
3337
3338         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="1" <?php echo (($fros{'ros_memory_problems_now'} == '1')?' checked ':''); ?>></td>
3339
3340         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="2" <?php echo (($fros{'ros_memory_problems_now'} == '2')?' checked ':''); ?>></td>
3341
3342         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_memory_problems_now" value="3" <?php echo (($fros{'ros_memory_problems_now'} == '3')?' checked ':''); ?>></td>
3343
3344         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_56"   value="<?php echo $fros{'ros_notes_56'}; ?>"></td>
3345
3346       </tr>
3347
3348       <tr valign="bottom">
3349
3350         <td align="left" class="fibody4"  id="bordR" >Frequent headaches </td>
3351
3352         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="1" <?php echo (($fros{'ros_freq_headaches_now'} == '1')?' checked ':''); ?>></td>
3353
3354         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="2" <?php echo (($fros{'ros_freq_headaches_now'} == '2')?' checked ':''); ?>></td>
3355
3356         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_freq_headaches_now" value="3" <?php echo (($fros{'ros_freq_headaches_now'} == '3')?' checked ':''); ?>></td>
3357
3358         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_57"   value="<?php echo $fros{'ros_notes_57'}; ?>"></td>
3359
3360       </tr>
3361
3362       <tr valign="bottom">
3363
3364         <td align="left" class="ficaption2"  id="bordR" >11. Psychiatric </td>
3365
3366         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3367
3368         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3369
3370         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3371
3372         <td align="left" class="fibody2">&nbsp;</td>
3373
3374       </tr>
3375
3376       <tr valign="bottom">
3377
3378         <td align="left" class="fibody4"  id="bordR" >Depression or frequent crying </td>
3379
3380         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="1" <?php echo (($fros{'ros_depression_now'} == '1')?' checked ':''); ?>></td>
3381
3382         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="2" <?php echo (($fros{'ros_depression_now'} == '2')?' checked ':''); ?>></td>
3383
3384         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_depression_now" value="3" <?php echo (($fros{'ros_depression_now'} == '3')?' checked ':''); ?>></td>
3385
3386         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_58"   value="<?php echo $fros{'ros_notes_58'}; ?>"></td>
3387
3388       </tr>
3389
3390       <tr valign="bottom">
3391
3392         <td align="left" class="fibody4"  id="bordR" >Anxiety</td>
3393
3394         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="1" <?php echo (($fros{'ros_anxiety_now'} == '1')?' checked ':''); ?>></td>
3395
3396         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="2" <?php echo (($fros{'ros_anxiety_now'} == '2')?' checked ':''); ?>></td>
3397
3398         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_anxiety_now" value="3" <?php echo (($fros{'ros_anxiety_now'} == '3')?' checked ':''); ?>></td>
3399
3400         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_59"   value="<?php echo $fros{'ros_notes_59'}; ?>"></td>
3401
3402       </tr>
3403
3404       <tr valign="bottom">
3405
3406         <td align="left" class="ficaption2"  id="bordR" >12. Endocrine </td>
3407
3408         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3409
3410         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3411
3412         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3413
3414         <td align="left" class="fibody2">&nbsp;</td>
3415
3416       </tr>
3417
3418       <tr valign="bottom">
3419
3420         <td align="left" class="fibody4"  id="bordR" >Hair loss </td>
3421
3422         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="1" <?php echo (($fros{'ros_hair_loss_now'} == '1')?' checked ':''); ?>></td>
3423
3424         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="2" <?php echo (($fros{'ros_hair_loss_now'} == '2')?' checked ':''); ?>></td>
3425
3426         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hair_loss_now" value="3" <?php echo (($fros{'ros_hair_loss_now'} == '3')?' checked ':''); ?>></td>
3427
3428         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_60"   value="<?php echo $fros{'ros_notes_60'}; ?>"></td>
3429
3430       </tr>
3431
3432       <tr valign="bottom">
3433
3434         <td align="left" class="fibody4"  id="bordR" >Heat/cold intolerance </td>
3435
3436         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="1" <?php echo (($fros{'ros_heat_cold_intolerance_now'} == '1')?' checked ':''); ?>></td>
3437
3438         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="2" <?php echo (($fros{'ros_heat_cold_intolerance_now'} == '2')?' checked ':''); ?>></td>
3439
3440         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_heat_cold_intolerance_now" value="3" <?php echo (($fros{'ros_heat_cold_intolerance_now'} == '3')?' checked ':''); ?>></td>
3441
3442         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_61"   value="<?php echo $fros{'ros_notes_61'}; ?>"></td>
3443
3444       </tr>
3445
3446       <tr valign="bottom">
3447
3448         <td align="left" class="fibody4"  id="bordR" >Abnormal thirst </td>
3449
3450         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="1" <?php echo (($fros{'ros_abnormal_thirst_now'} == '1')?' checked ':''); ?>></td>
3451
3452         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="2" <?php echo (($fros{'ros_abnormal_thirst_now'} == '2')?' checked ':''); ?>></td>
3453
3454         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_abnormal_thirst_now" value="3" <?php echo (($fros{'ros_abnormal_thirst_now'} == '3')?' checked ':''); ?>></td>
3455
3456         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_62"   value="<?php echo $fros{'ros_notes_62'}; ?>"></td>
3457
3458       </tr>
3459
3460       <tr valign="bottom">
3461
3462         <td align="left" class="fibody4"  id="bordR" >Hot flashes </td>
3463
3464         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="1" <?php echo (($fros{'ros_hot_flashes_now'} == '1')?' checked ':''); ?>></td>
3465
3466         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="2" <?php echo (($fros{'ros_hot_flashes_now'} == '2')?' checked ':''); ?>></td>
3467
3468         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_hot_flashes_now" value="3" <?php echo (($fros{'ros_hot_flashes_now'} == '3')?' checked ':''); ?>></td>
3469
3470         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_63"   value="<?php echo $fros{'ros_notes_63'}; ?>"></td>
3471
3472       </tr>
3473
3474       <tr valign="bottom">
3475
3476         <td align="left" class="ficaption2"  id="bordR" >13. Hematologic/Lymphatic </td>
3477
3478         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3479
3480         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3481
3482         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3483
3484         <td align="left" class="fibody2">&nbsp;</td>
3485
3486       </tr>
3487
3488       <tr valign="bottom">
3489
3490         <td align="left" class="fibody4"  id="bordR" >Frequent bruises </td>
3491
3492         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="1" <?php echo (($fros{'ros_frequent_bruises_now'} == '1')?' checked ':''); ?>></td>
3493
3494         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="2" <?php echo (($fros{'ros_frequent_bruises_now'} == '2')?' checked ':''); ?>></td>
3495
3496         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_frequent_bruises_now" value="3" <?php echo (($fros{'ros_frequent_bruises_now'} == '3')?' checked ':''); ?>></td>
3497
3498         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_64"   value="<?php echo $fros{'ros_notes_64'}; ?>"></td>
3499
3500       </tr>
3501
3502       <tr valign="bottom">
3503
3504         <td align="left" class="fibody4"  id="bordR" >Cuts do not stop bleeding </td>
3505
3506         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="1" <?php echo (($fros{'ros_cuts_bleeding_now'} == '1')?' checked ':''); ?>></td>
3507
3508         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="2" <?php echo (($fros{'ros_cuts_bleeding_now'} == '2')?' checked ':''); ?>></td>
3509
3510         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_cuts_bleeding_now" value="3" <?php echo (($fros{'ros_cuts_bleeding_now'} == '3')?' checked ':''); ?>></td>
3511
3512         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_65"   value="<?php echo $fros{'ros_notes_65'}; ?>"></td>
3513
3514       </tr>
3515
3516       <tr valign="bottom">
3517
3518         <td align="left" class="fibody4"  id="bordR" >Enlarged Lymph nodes (glands) </td>
3519
3520         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="1" <?php echo (($fros{'ros_enlarged_nodes_now'} == '1')?' checked ':''); ?>></td>
3521
3522         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="2" <?php echo (($fros{'ros_enlarged_nodes_now'} == '2')?' checked ':''); ?>></td>
3523
3524         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_enlarged_nodes_now" value="3" <?php echo (($fros{'ros_enlarged_nodes_now'} == '3')?' checked ':''); ?>></td>
3525
3526         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_66"   value="<?php echo $fros{'ros_notes_66'}; ?>"></td>
3527
3528       </tr>
3529
3530       <tr valign="bottom">
3531
3532         <td align="left" class="ficaption2"  id="bordR" >14. Allergic/immunologic </td>
3533
3534         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3535
3536         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3537
3538         <td align="center" class="fibody2"  id="bordR" >&nbsp;</td>
3539
3540         <td align="left" class="fibody2">&nbsp;</td>
3541
3542       </tr>
3543
3544       <tr valign="bottom">
3545
3546         <td align="left" class="fibody4"  id="bordR" >Medication allergies </td>
3547
3548         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="1" <?php echo (($fros{'ros_med_allergy_now'} == '1')?' checked ':''); ?>></td>
3549
3550         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="2" <?php echo (($fros{'ros_med_allergy_now'} == '2')?' checked ':''); ?>></td>
3551
3552         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_med_allergy_now" value="3" <?php echo (($fros{'ros_med_allergy_now'} == '3')?' checked ':''); ?>></td>
3553
3554         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_68"   value="<?php echo $fros{'ros_notes_68'}; ?>"></td>
3555
3556       </tr>
3557
3558       <tr valign="bottom">
3559
3560         <td align="left" class="fibody4"  id="bordR" >If any, please list allergy and type of reaction: </td>
3561
3562         <td colspan="4" align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_med_allergy_reaction"   value="<?php echo $fros{'ros_med_allergy_reaction'}; ?>"></td>
3563
3564       </tr>
3565
3566       <tr valign="bottom">
3567
3568         <td align="left" class="fibody4"  id="bordR" >Latex allergy </td>
3569
3570         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="1" <?php echo (($fros{'ros_latex_allergy_now'} == '1')?' checked ':''); ?>></td>
3571
3572         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="2" <?php echo (($fros{'ros_latex_allergy_now'} == '2')?' checked ':''); ?>></td>
3573
3574         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_latex_allergy_now" value="3" <?php echo (($fros{'ros_latex_allergy_now'} == '3')?' checked ':''); ?>></td>
3575
3576         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_69"   value="<?php echo $fros{'ros_notes_69'}; ?>"></td>
3577
3578       </tr>
3579
3580       <tr valign="bottom">
3581
3582         <td align="left" class="fibody4"  id="bordR" >Other allergies </td>
3583
3584         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="1" <?php echo (($fros{'ros_other_allergy_now'} == '1')?' checked ':''); ?>></td>
3585
3586         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="2" <?php echo (($fros{'ros_other_allergy_now'} == '2')?' checked ':''); ?>></td>
3587
3588         <td align="center" class="fibody2"  id="bordR" ><input  type="radio" name="ros_other_allergy_now" value="3" <?php echo (($fros{'ros_other_allergy_now'} == '3')?' checked ':''); ?>></td>
3589
3590         <td align="left" class="fibody2"><input  type="text" class="fullin2"   name="ros_notes_70"   value="<?php echo $fros{'ros_notes_70'}; ?>"></td>
3591
3592       </tr>
3593
3594       <tr valign="bottom">
3595
3596         <td align="left" class="fibody4"  id="bordR" >Please list allergy and type of reaction: </td>
3597
3598         <td colspan="4" align="left" class="fibody2"><input type="text" class="fullin2"   name="ros_other_allergy_reaction_"   value="<?php echo $fros{'ros_other_allergy_reaction_'}; ?>"></td>
3599
3600       </tr>
3601
3602     </table>
3603
3604   </div>
3605
3606   <p align="center">&nbsp;</p>
3607
3608   <div style="border: solid 2px black; background-color: white;">
3609
3610     <table width="100%"  border="0" cellspacing="0" cellpadding="2">
3611
3612       <tr valign="bottom">
3613
3614         <td colspan="2" align="left" class="fibody2">Form completed by
3615
3616           <input name="pih_completed_by" type="radio" value="patient"  <?php echo (($fdata{'pih_completed_by'} == 'patient')?' checked ':''); ?>>
3617
3618         patient
3619
3620         <input name="pih_completed_by" type="radio" value="nurse" <?php echo (($fdata{'pih_completed_by'} == 'nurse')?' checked ':''); ?>>
3621
3622         office nurse
3623
3624        <input name="pih_completed_by" type="radio" value="physician" <?php echo (($fdata{'pih_completed_by'} == 'physician')?' checked ':''); ?>>
3625
3626         physician
3627
3628         <input name="pih_completed_by" type="radio" value="other" <?php echo (($fdata{'pih_completed_by'} == 'other')?' checked ':''); ?>>
3629
3630         other:
3631
3632         <input name="pih_completed_by_other" type="text" class="fullin"  style="width: 40%" value="<?php echo $fdata{'pih_completed_by_other'}; ?>"></td>
3633
3634       </tr>
3635
3636       <tr valign="bottom">
3637
3638         <td height="46" colspan="2" align="left" class="fibody2">Signature of patient:</td>
3639
3640       </tr>
3641
3642       <tr valign="bottom">
3643
3644         <td width="39%" height="46" align="left" class="fibody3" id="bordR">Date reviewed by physician with patient
3645
3646         <input name="pih_date_reviewed_1" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_1'}; ?>"></td>
3647
3648         <td width="61%" height="46" align="left" class="fibody3">Physician signature: </td>
3649
3650       </tr>
3651
3652       <tr valign="bottom">
3653
3654         <td colspan="2" align="left" class="ficaption3" style="border-top: 2px solid black; border-bottom: 2px solid black;">Annual review of history </td>
3655
3656       </tr>
3657
3658       <tr valign="bottom">
3659
3660         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3661
3662           <input name="pih_date_reviewed_2" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_2'}; ?>">
3663
3664         </span></td>
3665
3666         <td height="46" align="left" class="fibody2">Physician signature: </td>
3667
3668       </tr>
3669
3670       <tr valign="bottom">
3671
3672         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3673
3674           <input name="pih_date_reviewed_3" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_3'}; ?>">
3675
3676         </span> </td>
3677
3678         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3679
3680       </tr>
3681
3682       <tr valign="bottom">
3683
3684         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3685
3686           <input name="pih_date_reviewed_4" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_4'}; ?>">
3687
3688         </span> </td>
3689
3690         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3691
3692       </tr>
3693
3694       <tr valign="bottom">
3695
3696         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3697
3698           <input name="pih_date_reviewed_5" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_5'}; ?>">
3699
3700         </span> </td>
3701
3702         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3703
3704       </tr>
3705
3706       <tr valign="bottom">
3707
3708         <td height="46" align="left" class="fibody2" id="bordR">Date reviewed: <span class="fibody3">
3709
3710           <input name="pih_date_reviewed_6" type="text" class="fullin"  style="width:70px" value="<?php echo $fdata{'pih_date_reviewed_6'}; ?>">
3711
3712         </span> </td>
3713
3714         <td height="46" align="left" class="fibody2">Physician signature:  </td>
3715
3716       </tr>
3717
3718     </table>
3719
3720   </div>
3721
3722   <p align="center">&nbsp;</p>
3723
3724 <table width="100%" border="0">
3725
3726   <tr><td align="left" width="120"> <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a> </td>
3727
3728   <td align="left" nowrap> <a href="<?php echo $rootdir; ?>/patient_file/encounter/print_form.php?id=<?php echo $id; ?>&formname=<?php echo $formname; ?>"
3729
3730    target="_blank" class="link_submit" onclick="top.restoreSession()">[Printable form]</a> </td>
3731
3732   <td align="right"> <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
3733
3734    onclick="top.restoreSession()">[Don't Save]</a> </td></tr>
3735
3736 </table>
3737
3738 </form>
3739
3740 <?php
3741
3742 formFooter();
3743
3744 ?>
3745
3746 </body>
3747
3748 </html>