contrib/forms/physical_examination/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 include_once("$srcdir/forms.inc");
   5 include_once("$srcdir/calendar.inc");
   6 $frmn = 'form_physical_examination';
   7 $ftitle = 'Physical examination';
   8 $old = sqlStatement("select form_id, formdir from forms where (form_name='${ftitle}') and (pid=$pid) order by date desc limit 1");
   9 if ($old) {
  10   $dt = sqlFetchArray($old);
  11   $fid = $dt{'form_id'};
  12   if ($fid && ($fid != 0) && ($fid != '')){
  13   $fdir = $dt{'formdir'};
  14   unset($dt);
  15   $dt = formFetch($frmn, $fid);
  16   $newid = formSubmit($frmn, array_slice($dt,7), $id, $userauthorized);
  17   addForm($encounter, $ftitle, $newid, $fdir, $pid, $userauthorized);
  18   $id = $newid;
  19   formJump("${rootdir}/patient_file/encounter/view_form.php?formname=${fdir}&id=${newid}");
  20   exit;
  21   }
  22   }
  23 ?>
  24 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  25 "http://www.w3.org/TR/html4/loose.dtd">
  26
  27 <html>
  28 <head>
  29 <?php html_header_show();?>
  30 <title>Physical examination</title>
  31 <link rel="stylesheet" href="<?php echo $css_header;?>" type="text/css">
  32 <link rel="stylesheet" href="../../acog.css" type="text/css">
  33 <script language="JavaScript" src="../../acog.js" type="text/JavaScript"></script>
  34 <script language="JavaScript" type="text/JavaScript">
  35 window.onload = initialize;
  36 </script>
  37 </head>
  38
  39 <body class="body_top">
  40
  41 <?php
  42 $tip1 = <<<EOL
  43 The <b>Physical Examination</b> section
  44 should be completed by the physician each time a
  45 physical examination is provided. The form offers prompts to
  46 aid in documenting the services that are provided. This form
  47 is based on the 1997 CMS (formerly, HCFA) guidelines for
  48 the female genitourinary system examination and can be
  49 used to document any level of examination.<br><br>
  50
  51 The female genitourinary examination template includes 9 organ systems/body areas with 3 shaded boxes and 6 unshaded boxes. The shading only becomes important when a comprehensive
  52 examination is performed. For all other levels of examination, the total number of bulleted elements documented in the medical record will determine the level that can be
  53 reported.<br><br>
  54 <table border=1>
  55 <tr><td>LEVEL OF EXAMINATION</td><td>PERFORM AND DOCUMENT</td></tr>
  56 <tr><td>PROBLEM FOCUSED</td><td>15 ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  57 <tr><td>EXPANDED PROBLEM FOCUSED</td><td>611 ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  58 <tr><td>DETAILED</td><td>12 OR MORE ELEMENTS IDENTIFIED BY A BULLET</td></tr>
  59 <tr><td>COMPREHENSIVE</td><td>ALL ELEMENTS IDENTIFIED BY A BULLET IN CONSTITUTIONAL AND GASTROINTESTINAL,
  60 ANY 7 BULLETS IN GYNECOLOGIC, AT LEAST 1 BULLET IN ALL OTHER SYSTEMS</td></tr>
  61 </table>
  62 EOL;
  63 $tip1 = strtr($tip1, "\n\r", "  ");
  64 ?>
  65 <div class="srvChapter">Physical examination <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>
  66 <?php
  67    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  68    if ($fres){
  69      $patient = sqlFetchArray($fres);
  70    }
  71 ?>
  72 <form action="<?php echo $rootdir;?>/forms/physical_examination/save.php?mode=new" method="post" enctype="multipart/form-data" name="my_form">
  73 <?php include("../../acog_menu.inc"); ?>
  74 <div style="border: solid 2px black; background-color: white;">
  75 <table width="100%"  border="0" cellspacing="0" cellpadding="3">
  76   <tr>
  77     <td align="left" valign="top" style="border-bottom: 2px solid black;"><table width="100%"  border="0" cellspacing="0" cellpadding="5">
  78       <tr align="left" valign="bottom" class="fibody">
  79         <td width="40%" class="bordR">Patient name <br>
  80           <input name="pname" type="text" class="fullin" id="pname" value="<?php
  81           echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};
  82           ?>"></td>
  83         <td width="20%" class="bordR">birth date
  84           <br>
  85           <input name="pbdate" type="text" class="fullin" id="pbdate" value="<?php
  86           echo $patient{'DOB'};
  87           ?>" size="12"> </td>
  88         <td width="20%" class="bordR">ID No<br>
  89           <input name="pe_id" type="text" class="fullin" id="pe_id" size="12" value="<?php
  90           echo $patient{'id'};
  91           ?>"></td>
  92         <td width="20%">date<br>
  93         <input name="pe_date" type="text" class="fullin" id="pe_date" value="<?php
  94         echo date('Y-m-d');
  95         ?>" size="12"></td>
  96       </tr>
  97     </table></td>
  98   </tr>
  99   <tr>
 100     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Constitutional</h2>
 101       <li>Vital signs (record <u><strong>&gt;</strong></u> 3 vital signs)</li>
 102       <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 103         <tr align="left" valign="top" class="fibody">
 104           <td width="14%" nowrap>Height<br>
 105             <input name="height" type="text" class="fullin" id="height"></td>
 106           <td width="14%" nowrap>Weight<br>
 107             <input name="weight" type="text" class="fullin" id="weight"></td>
 108           <td width="14%" nowrap>BMI<br>
 109             <input name="bmi" type="text" class="fullin" id="bmi"></td>
 110           <td nowrap>Blood pressure (sitting) <br>
 111             <input name="blood_pressure" type="text" class="fullin" id="blood_pressure"></td>
 112           <td width="14%" nowrap>Temperature<br>
 113             <input name="temperature" type="text" class="fullin" id="temperature"></td>
 114           <td width="14%" nowrap>Pulse<br>
 115             <input name="pulse" type="text" class="fullin" id="pulse"></td>
 116           <td width="14%" nowrap>Respiration<br>
 117             <input name="respiration" type="text" class="fullin" id="respiration"></td>
 118         </tr>
 119       </table>
 120       <li>General appearance (Note all that apply):</li>      <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 121         <tr class="fibody">
 122           <td width="150" nowrap><input name="general_well_developed" type="radio" value="0" checked>
 123             Well-developed
 124 </td>
 125           <td width="90" nowrap><input name="general_well_developed" type="radio" value="1">
 126             Other
 127 </td>
 128           <td width="100" nowrap>&nbsp;</td>
 129           <td>&nbsp;</td>
 130           <td width="120"><input name="general_no_deformities" type="radio" value="0" checked>
 131             No deformities
 132 </td>
 133           <td width="100"><input name="general_no_deformities" type="radio" value="1">
 134             Other
 135 </td>
 136           <td>&nbsp;</td>
 137         </tr>
 138         <tr class="fibody">
 139           <td width="150" nowrap><input name="general_well_nourished" type="radio" value="0" checked>
 140             Well-nourished
 141 </td>
 142           <td width="90" nowrap><input name="general_well_nourished" type="radio" value="1">
 143             Other
 144 </td>
 145           <td width="100" nowrap>&nbsp;</td>
 146           <td>&nbsp;</td>
 147           <td width="120"><input name="general_well_groomed" type="radio" value="0" checked>
 148             Well-groomed
 149 </td>
 150           <td width="100"><input name="general_well_groomed" type="radio" value="1">
 151             Other
 152 </td>
 153           <td>&nbsp;</td>
 154         </tr>
 155         <tr class="fibody">
 156           <td width="150" nowrap><input name="general_normal_habitus" type="radio" value="0" checked>
 157             Normal habitus</td>
 158           <td width="90" nowrap><input name="general_normal_habitus" type="radio" value="2">
 159             Obese</td>
 160           <td width="100" nowrap><input name="general_normal_habitus" type="radio" value="1">
 161             Other</td>
 162           <td>&nbsp;</td>
 163           <td width="120">&nbsp;</td>
 164           <td width="100">&nbsp;</td>
 165           <td>&nbsp;</td>
 166         </tr>
 167       </table>      </td>
 168   </tr>
 169   <tr>
 170     <td align="left" valign="top"><h2>Neck</h2>
 171       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 172         <tr align="left" valign="bottom" class="fibody">
 173           <td width="150" nowrap><li>Neck</li></td>
 174           <td width="90" nowrap>            <input name="neck_neck" type="radio" value="0">
 175       Normal</td>
 176           <td width="100" nowrap><input name="neck_neck" type="radio" value="1">
 177             ABNormal</td>
 178           <td><input name="neck_neck_data" type="text" class="fullin" id="neck_neck_data"></td>
 179           </tr>
 180         <tr align="left" valign="bottom" class="fibody">
 181           <td width="150" nowrap><li>Thyroid</li></td>
 182           <td width="90" nowrap>
 183             <input name="neck_thyroid" type="radio" value="0">
 184   Normal</td>
 185           <td width="100" nowrap><input name="neck_thyroid" type="radio" value="1">
 186 ABNormal</td>
 187           <td><input name="neck_thyroid_data" type="text" class="fullin" id="neck_thyroid_data"></td>
 188           </tr>
 189       </table>      </td>
 190   </tr>
 191   <tr>
 192     <td align="left" valign="top"><h2>Respiratory</h2>
 193       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 194         <tr align="left" valign="bottom" class="fibody">
 195           <td width="150" nowrap><li>Respiratory effort </li></td>
 196           <td nowrap>
 197             <input name="respiratory_effort" type="radio" value="0">
 198   Normal</td>
 199           <td nowrap><input name="respiratory_effort" type="radio" value="1">
 200   ABNormal</td>
 201           <td><input name="respiratory_effort_data" type="text" class="fullin" id="respiratory_effort_data"></td>
 202         </tr>
 203         <tr align="left" valign="bottom" class="fibody">
 204           <td width="150" nowrap><li>Auscultated lungs </li></td>
 205           <td width="90" nowrap><input name="auscultated_lungs" type="radio" value="0">
 206 Normal</td>
 207           <td width="100" nowrap><input name="auscultated_lungs" type="radio" value="1">
 208 ABNormal</td>
 209           <td><input name="auscultated_lungs_data" type="text" class="fullin" id="auscultated_lungs_data"></td>
 210         </tr>
 211       </table>      </td>
 212   </tr>
 213   <tr>
 214     <td align="left" valign="top"><h2>Cardiovascular</h2>
 215       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 216         <tr align="left" valign="bottom" class="fibody">
 217           <td width="150" nowrap><li>Auscultated heart </li></td>
 218           <td width="90" nowrap>&nbsp;</td>
 219           <td width="100" nowrap>&nbsp;</td>
 220           <td>&nbsp;</td>
 221         </tr>
 222         <tr align="left" valign="bottom" class="fibody">
 223           <td width="150" nowrap><blockquote> Sounds</blockquote></td>
 224           <td width="90" nowrap><input name="auscultated_heart_sounds" type="radio" value="0">
 225 Normal</td>
 226           <td width="100" nowrap><input name="auscultated_heart_sounds" type="radio" value="1">
 227 ABNormal</td>
 228           <td><input name="auscultated_heart_sounds_data" type="text" class="fullin" id="auscultated_heart_sounds_data"></td>
 229         </tr>
 230         <tr align="left" valign="bottom" class="fibody">
 231           <td nowrap><blockquote> Murmurs</blockquote></td>
 232           <td nowrap><input name="auscultated_heart_murmurs" type="radio" value="0">
 233 Normal</td>
 234           <td nowrap><input name="auscultated_heart_murmurs" type="radio" value="1">
 235 ABNormal</td>
 236           <td><input name="auscultated_heart_murmurs_data" type="text" class="fullin" id="auscultated_heart_murmurs_data"></td>
 237         </tr>
 238         <tr align="left" valign="bottom" class="fibody">
 239           <td nowrap><li>Perirheral vascular </li></td>
 240           <td nowrap><input name="peripheral_vascular" type="radio" value="0">
 241 Normal</td>
 242           <td nowrap><input name="peripheral_vascular" type="radio" value="1">
 243 ABNormal</td>
 244           <td><input name="peripheral_vascular_data" type="text" class="fullin" id="peripheral_vascular_data"></td>
 245         </tr>
 246       </table>      </td>
 247   </tr>
 248   <tr>
 249     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Gastrointestinal</h2>
 250       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 251         <tr align="left" valign="bottom" class="fibody">
 252           <td width="150" nowrap><li>Abdomen</li></td>
 253           <td width="90" nowrap><input name="gastr_abdomen" type="radio" value="0">
 254 Normal</td>
 255           <td width="100" nowrap><input name="gastr_abdomen" type="radio" value="1">
 256 ABNormal</td>
 257           <td><input name="gastr_abdomen_data" type="text" class="fullin" id="gastr_abdomen_data"></td>
 258         </tr>
 259         <tr align="left" valign="bottom" class="fibody">
 260           <td width="150" nowrap><li>Hernia</li></td>
 261           <td width="90" nowrap><input name="gastr_hernia" type="radio" value="0">
 262       none</td>
 263           <td width="100" nowrap><input name="gastr_hernia" type="radio" value="1">
 264       present</td>
 265           <td><input name="gastr_hernia_data" type="text" class="fullin" id="gastr_hernia_data"></td>
 266         </tr>
 267         <tr align="left" valign="bottom" class="fibody">
 268           <td nowrap><li>Liver/Spleen</li></td>
 269           <td nowrap>&nbsp;</td>
 270           <td nowrap>&nbsp;</td>
 271           <td>&nbsp;</td>
 272         </tr>
 273         <tr align="left" valign="bottom" class="fibody">
 274           <td nowrap><blockquote> Liver </blockquote></td>
 275           <td nowrap><input name="gastr_liver" type="radio" value="0">
 276     Normal</td>
 277           <td nowrap><input name="gastr_liver" type="radio" value="1">
 278     ABNormal</td>
 279           <td><input name="gastr_liver_data" type="text" class="fullin" id="gastr_liver_data"></td>
 280         </tr>
 281         <tr align="left" valign="bottom" class="fibody">
 282           <td nowrap><blockquote> Spleen </blockquote></td>
 283           <td nowrap><input name="gastr_spleen" type="radio" value="0">
 284     Normal</td>
 285           <td nowrap><input name="gastr_spleen" type="radio" value="1">
 286     ABNormal</td>
 287           <td><input name="gastr_spleen_data" type="text" class="fullin" id="gastr_spleen_data"></td>
 288         </tr>
 289         <tr align="left" valign="bottom" class="fibody">
 290           <td nowrap><li><a name="sg"></a>Stool guaIac, if indic.</li></td>
 291           <td nowrap><input name="gastr_stool_guaiac" type="radio" value="0">
 292     positive</td>
 293           <td nowrap><input name="gastr_stool_guaiac" type="radio" value="1">
 294     negative</td>
 295           <td><input name="gastr_stool_guaiac_data" type="text" class="fullin" id="gastr_stool_guaiac_data"></td>
 296         </tr>
 297       </table>      </td>
 298   </tr>
 299   <tr>
 300     <td align="left" valign="top"><h2>Lymphatic</h2>
 301       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 302         <tr align="left" valign="bottom" class="fibody">
 303           <td colspan="4" nowrap><li>Palpation of nodes (Choose all, that are applicable) </li></td>
 304           </tr>
 305         <tr align="left" valign="bottom" class="fibody">
 306           <td width="150" nowrap><blockquote> Neck </blockquote></td>
 307           <td width="90" nowrap><input name="lymph_neck" type="radio" value="0">
 308       Normal</td>
 309           <td width="100" nowrap><input name="lymph_neck" type="radio" value="1">
 310       ABNormal</td>
 311           <td><input name="lymph_neck_data" type="text" class="fullin" id="lymph_neck_data"></td>
 312         </tr>
 313         <tr align="left" valign="bottom" class="fibody">
 314           <td nowrap><blockquote> Axilla </blockquote></td>
 315           <td nowrap><input name="lymph_axilla" type="radio" value="0">
 316       Normal</td>
 317           <td nowrap><input name="lymph_axilla" type="radio" value="1">
 318       ABNormal</td>
 319           <td><input name="lymph_axilla_data" type="text" class="fullin" id="lymph_axilla_data"></td>
 320         </tr>
 321         <tr align="left" valign="bottom" class="fibody">
 322           <td nowrap><blockquote> Groin </blockquote></td>
 323           <td nowrap><input name="lymph_groin" type="radio" value="0">
 324     Normal</td>
 325           <td nowrap><input name="lymph_groin" type="radio" value="1">
 326     ABNormal</td>
 327           <td><input name="lymph_groin_data" type="text" class="fullin" id="lymph_groin_data"></td>
 328         </tr>
 329         <tr align="left" valign="bottom" class="fibody">
 330           <td nowrap><blockquote> Other site </blockquote></td>
 331           <td nowrap><input name="lymph_other" type="radio" value="0">
 332     Normal</td>
 333           <td nowrap><input name="lymph_other" type="radio" value="1">
 334     ABNormal</td>
 335           <td><input name="lymph_other_data" type="text" class="fullin" id="lymph_other_data"></td>
 336         </tr>
 337       </table>      </td>
 338   </tr>
 339   <tr>
 340     <td align="left" valign="top"><h2>Skin</h2>
 341       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 342         <tr align="left" valign="bottom" class="fibody">
 343           <td width="150" nowrap><li>inspected/palpated</li></td>
 344           <td width="90" nowrap><input name="skin_inspected" type="radio" value="0">
 345       Normal</td>
 346           <td width="100" nowrap><input name="skin_inspected" type="radio" value="1">
 347       ABNormal</td>
 348           <td><input name="skin_inspected_data" type="text" class="fullin" id="skin_inspected_data"></td>
 349         </tr>
 350       </table>      </td>
 351   </tr>
 352   <tr>
 353     <td align="left" valign="top"><h2>Neurologic/psychiatric</h2>
 354       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 355         <tr align="left" valign="bottom" class="fibody">
 356           <td width="150" nowrap><li>Orientation</li></td>
 357           <td width="90" nowrap><input name="neur_orient_time" type="checkbox" id="neur_orient_time" value="1" checked>
 358       Time</td>
 359           <td width="100" nowrap><input name="neur_orient_place" type="checkbox" id="neur_orient_place" value="1" checked>
 360       Place</td>
 361           <td width="100"><input name="neur_orient_person" type="checkbox" id="neur_orient_person" value="1" checked>
 362             Person
 363 </td>
 364           <td width="100"><input name="neur_orient_comments" type="checkbox" id="neur_orient_comments" value="1" checked>
 365             Comments
 366 </td>
 367           <td>&nbsp;</td>
 368           </tr>
 369         <tr align="left" valign="bottom" class="fibody">
 370           <td width="150" nowrap><li>Mood and affect </li></td>
 371           <td width="90" nowrap><input name="neur_mood_normal" type="checkbox" id="neur_mood_normal" value="1" checked>
 372       Normal</td>
 373           <td width="100" nowrap><input name="neur_mood_depressed" type="checkbox" id="neur_mood_depressed" value="1">
 374       Depressed</td>
 375           <td width="100"><input name="neur_mood_anxious" type="checkbox" id="neur_mood_anxious" value="1">
 376             Anxious
 377 </td>
 378           <td width="100"><input name="neur_mood_agitated" type="checkbox" id="neur_mood_agitated" value="1">
 379             Agitated
 380 </td>
 381           <td><input name="neur_mood_other" type="checkbox" id="neur_mood_other" value="1">
 382             Other
 383 </td>
 384           </tr>
 385       </table>      </td>
 386   </tr>
 387   <tr>
 388     <td align="left" valign="top" bgcolor="#EDEDED"><h2>Gynecologic (at least 7) </h2>
 389       <table width="100%"  border="0" cellspacing="0" cellpadding="1">
 390         <tr align="left" valign="bottom" class="fibody">
 391           <td width="150" nowrap><li>Breasts</li></td>
 392           <td width="90" nowrap><input name="gynec_breasts" type="radio" value="0">
 393       Normal</td>
 394           <td width="100" nowrap><input name="gynec_breasts" type="radio" value="1">
 395       ABNormal</td>
 396           <td><input name="gynec_breasts_data" type="text" class="fullin" id="gynec_breasts_data"></td>
 397           <td width="231" rowspan="12" align="center" valign="middle">
 398           <img src="<?php
 399           echo "$rootdir/forms/$formname/";
 400           ?>genit01.gif" width="231" height="222"></td>
 401         </tr>
 402         <tr align="left" valign="bottom" class="fibody">
 403           <td nowrap><li>External genitalia </li></td>
 404           <td nowrap><input name="gynec_ext_genitalia" type="radio" value="0">
 405   Normal</td>
 406           <td nowrap><input name="gynec_ext_genitalia" type="radio" value="1">
 407   ABNormal</td>
 408           <td><input name="gynec_ext_genitalia_data" type="text" class="fullin" id="gynec_ext_genitalia_data"></td>
 409           </tr>
 410         <tr align="left" valign="bottom" class="fibody">
 411           <td nowrap><li>Urethral meatus </li></td>
 412           <td nowrap><input name="gynec_urethral_meatus" type="radio" value="0">
 413   Normal</td>
 414           <td nowrap><input name="gynec_urethral_meatus" type="radio" value="1">
 415   ABNormal</td>
 416           <td><input name="gynec_urethral_meatus_data" type="text" class="fullin" id="gynec_urethral_meatus_data"></td>
 417           </tr>
 418         <tr align="left" valign="bottom" class="fibody">
 419           <td width="150" nowrap><li>Urethra</li></td>
 420           <td width="90" nowrap><input name="gynec_urethra" type="radio" value="0">
 421   Normal</td>
 422           <td width="100" nowrap><input name="gynec_urethra" type="radio" value="1">
 423   ABNormal</td>
 424           <td><input name="gynec_urethra_data" type="text" class="fullin" id="gynec_urethra_data"></td>
 425           </tr>
 426         <tr align="left" valign="bottom" class="fibody">
 427           <td nowrap><li>Bladder</li></td>
 428           <td nowrap><input name="gynec_bladder" type="radio" value="0">
 429   Normal</td>
 430           <td nowrap><input name="gynec_bladder" type="radio" value="1">
 431   ABNormal</td>
 432           <td><input name="gynec_bladder_data" type="text" class="fullin" id="gynec_bladder_data"></td>
 433           </tr>
 434         <tr align="left" valign="bottom" class="fibody">
 435           <td nowrap><li>Vagina/Pelvic support</li></td>
 436           <td nowrap><input name="gynec_vagina_support" type="radio" value="0">
 437   Normal</td>
 438           <td nowrap><input name="gynec_vagina_support" type="radio" value="1">
 439   ABNormal</td>
 440           <td><input name="gynec_vagina_support_data" type="text" class="fullin" id="gynec_vagina_support_data"></td>
 441           </tr>
 442         <tr align="left" valign="bottom" class="fibody">
 443           <td width="150" nowrap><li>Cervix</li></td>
 444           <td width="90" nowrap><input name="gynec_cervix" type="radio" value="0">
 445   Normal</td>
 446           <td width="100" nowrap><input name="gynec_cervix" type="radio" value="1">
 447   ABNormal</td>
 448           <td><input name="gynec_cervix_data" type="text" class="fullin" id="gynec_cervix_data"></td>
 449           </tr>
 450         <tr align="left" valign="bottom" class="fibody">
 451           <td nowrap><li>Uterus</li></td>
 452           <td nowrap><input name="gynec_uterus" type="radio" value="0">
 453   Normal</td>
 454           <td nowrap><input name="gynec_uterus" type="radio" value="1">
 455   ABNormal</td>
 456           <td><input name="gynec_uterus_data" type="text" class="fullin" id="gynec_uterus_data"></td>
 457           </tr>
 458         <tr align="left" valign="bottom" class="fibody">
 459           <td nowrap><li>Adnexa/Parametria</li></td>
 460           <td nowrap><input name="gynec_adnexa" type="radio" value="0">
 461   Normal</td>
 462           <td nowrap><input name="gynec_adnexa" type="radio" value="1">
 463   ABNormal</td>
 464           <td><input name="gynec_adnexa_data" type="text" class="fullin" id="gynec_adnexa_data"></td>
 465           </tr>
 466         <tr align="left" valign="bottom" class="fibody">
 467           <td width="150" nowrap><li>Anus/Perineum</li></td>
 468           <td width="90" nowrap><input name="gynec_anus" type="radio" value="0">
 469   Normal</td>
 470           <td width="100" nowrap><input name="gynec_anus" type="radio" value="1">
 471   ABNormal</td>
 472           <td><input name="gynec_anus_data" type="text" class="fullin" id="gynec_anus_data"></td>
 473           </tr>
 474         <tr align="left" valign="bottom" class="fibody">
 475           <td nowrap><li>Rectal</li></td>
 476           <td nowrap><input name="gynec_rectal" type="radio" value="0">
 477   Normal</td>
 478           <td nowrap><input name="gynec_rectal" type="radio" value="1">
 479   ABNormal</td>
 480           <td><input name="gynec_rectal_data" type="text" class="fullin" id="gynec_rectal_data"></td>
 481           </tr>
 482         <tr align="left" valign="bottom" class="fibody">
 483           <td colspan="4" nowrap><br>
 484             (See also &quot;<a href="#sg">Stool guaiac</a>&quot; above ) </td>
 485           </tr>
 486       </table>      </td>
 487   </tr>
 488   <tr class="fibody">
 489     <td align="left" valign="top" style="border-bottom:2px solid black;border-top:2px solid black;">Total number of bulleted elements examined
 490       <input name="tot_num_examined" type="text" id="tot_num_examined"></td>
 491   </tr>
 492 </table>
 493 <br>
 494 <table width="100%" border="0">
 495 <tr><td align="left">
 496 <a href="javascript:top.restoreSession();document.my_form.submit();" class="link_submit">[Save Data]</a>
 497 </td><td align="right">
 498 <a href="<?php echo $GLOBALS['form_exit_url']; ?>" class="link_submit"
 499  onclick="top.restoreSession()">[Don't Save]</a>
 500 </td></tr></table></div>
 501   </form>
 502 <?php
 503 formFooter();
 504 ?>
 505 </body>
 506 </html>