contrib/forms/physician_history/printable.php

   1 <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
   2 "http://www.w3.org/TR/html4/loose.dtd">
   3 <?php
   4 include_once("../../globals.php");
   5 include_once("$srcdir/api.inc");
   6 include_once("$srcdir/forms.inc");
   7 include_once("$srcdir/calendar.inc");
   8 ?>
   9
  10 <html>
  11 <head>
  12 <? html_header_show();?>
  13 <title>Physician history</title>
  14
  15 <?
  16    $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
  17    if ($fres){
  18      $patient = sqlFetchArray($fres);
  19    }
  20
  21    $fres=sqlStatement("select * from form_physician_history where id='".$id."'");
  22    if ($fres){
  23      $fdata = sqlFetchArray($fres);
  24    }
  25 ?>
  26 <? include("../../acog_printable_v.css"); ?>
  27 </head>
  28
  29 <body>
  30 <table width="70%"  border="0" cellspacing="0" cellpadding="4" style="">
  31   <tr>
  32     <td width="120" align="left" valign="top" class="srvCaption">Patient name:</td>
  33     <td align="left" valign="top" class="fibody5"><?  echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};?></td>
  34   </tr>
  35   <tr>
  36     <td width="120" align="left" valign="top" class="srvCaption">Birth date: </td>
  37     <td align="left" valign="top" class="fibody5"><?          echo $patient{'DOB'};          ?></td>
  38   </tr>
  39   <tr>
  40     <td width="120" align="left" valign="top" class="srvCaption">ID No:</td>
  41     <td align="left" valign="top" class="fibody5"><?          echo $patient{'id'};          ?></td>
  42   </tr>
  43   <tr>
  44     <td width="120" align="left" valign="top" class="srvCaption">Date</td>
  45     <td align="left" valign="top" class="fibody5"><?        echo $fdata['date'];        ?></td>
  46   </tr>
  47 </table>
  48 <div class="srvChapter">Physician history</div>
  49 <div style="border: solid 2px black; background-color:#FFFFFF;">
  50 <table width="100%"  border="0" cellspacing="0" cellpadding="0">
  51   <tr>
  52     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  53       <tr align="left" valign="baseline">
  54         <td width="25%" class="fibody2" id="bordR"><? echo (($fdata{'established'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  55           New patient </td>
  56         <td width="25%" class="fibody2" id="bordR"><? echo (($fdata{'established'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  57           Established patient </td>
  58         <td width="20%"   class="fibody2" id="bordR"><? echo (($fdata{'consultation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
  59           Consultation</td>
  60         <td width="30%" valign="top" class="fibody2"><? echo (($fdata{'report_sent'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?> Report sent <? echo $fdata{'report_sent_date'}; ?></td>
  61         </tr>
  62       <tr align="left" valign="top">
  63         <td colspan="2" class="fibody2" id="bordR">Primary care physician:<br>
  64           <? echo $fdata{'primary_care'}; ?></td>
  65         <td colspan="2" class="fibody2">Who sent patient:<br>
  66           <? echo $fdata{'who_sent'}; ?></td>
  67       </tr>
  68       <tr align="left" valign="top">
  69         <td colspan="2" class="fibody2" id="bordR"> Other physician(s):<br> <? echo $fdata{'other_physician'}; ?> </td>
  70         <td colspan="2" class="fibody2">&nbsp;</td>
  71       </tr>
  72     </table></td>
  73   </tr>
  74   <tr>
  75     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  76       <tr align="left" valign="baseline">
  77         <td width="50%" class="ficaption2" id="bordR">Chief complaint (CC) (<small>Required for all visits except preventive</small>):</td>
  78         <td width="50%" class="ficaption2">Current prescription medications:          </td>
  79       </tr>
  80       <tr align="left" valign="baseline">
  81         <td width="50%"   class="fibody5" id="bordR"><? echo $fdata{'chief_complaint'}; ?> &nbsp;</td>
  82         <td width="50%"   class="fibody5"><? echo $fdata{'current_prescription'}; ?> &nbsp;</td>
  83       </tr>
  84       <tr align="left" valign="baseline">
  85         <td width="50%" valign="top" class="ficaption2" id="bordR">History of present ilness (HPI): <br> </td>
  86         <td width="50%" valign="top" class="ficaption2">Current nonpresription, complementary, and alternative medications:          </td>
  87       </tr>
  88       <tr align="left" valign="baseline">
  89         <td width="50%" valign="top"   class="fibody5" id="bordR"><? echo $fdata{'hpi'}; ?>&nbsp;</td>
  90         <td width="50%" valign="top"   class="fibody5"><? echo $fdata{'current_nonprescription'}; ?>&nbsp;</td>
  91       </tr>
  92     </table></td>
  93   </tr>
  94   <tr>
  95     <td class="fibody2">&nbsp;</td>
  96   </tr>
  97   <tr>
  98     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
  99       <tr align="left" valign="top">
 100         <td width="200" class="ficaption2">Changes since last visit </td>
 101         <td width="40" align="center" class="ficaption2">yes</td>
 102         <td width="40" align="center" class="ficaption2" id="bordR">no</td>
 103         <td colspan="2" align="center" class="ficaption2">Notes</td>
 104         </tr>
 105       <tr align="left" valign="top">
 106         <td width="200" class="fibody2">Illnesses</td>
 107         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_ill'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 108         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_ill'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 109         <td colspan="2" rowspan="7" valign="top" class="fibody5"><? echo $fdata{'ph_lvch_notes'}; ?>&nbsp;</td>
 110         </tr>
 111       <tr align="left" valign="top">
 112         <td width="200" class="fibody2">Surgery</td>
 113         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_surg'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 114         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_surg'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 115       </tr>
 116       <tr align="left" valign="top">
 117         <td width="200" class="fibody2">New medications </td>
 118         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_newmed'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 119         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_newmed'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 120       </tr>
 121       <tr align="left" valign="top">
 122         <td width="200" class="fibody2">Change in family history </td>
 123         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_famhist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 124         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_famhist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 125       </tr>
 126       <tr align="left" valign="top">
 127         <td width="200" class="fibody2">New allergies </td>
 128         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_newallerg'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 129         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_newallerg'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 130       </tr>
 131       <tr align="left" valign="top">
 132         <td width="200" class="fibody2">Change in gynecologic history </td>
 133         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_gynhist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 134         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_gynhist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 135       </tr>
 136       <tr align="left" valign="top">
 137         <td width="200" class="fibody2">Change in obstetric history </td>
 138         <td width="40" align="center" class="fibody2"><? echo (($fdata{'ph_lvch_obsthist'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 139         <td width="40" align="center" class="fibody2" id="bordR"><? echo (($fdata{'ph_lvch_obsthist'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?></td>
 140       </tr>
 141     </table></td>
 142   </tr>
 143   <tr>
 144     <td class="fibody2">&nbsp;</td>
 145   </tr>
 146   <tr>
 147     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 148       <tr align="left" valign="top">
 149         <td width="225" class="fibody2"><a name="allergies"></a>Allergies (describe reaction):
 150           <? echo (($fdata{'ph_allergies_none'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 151 none</td>
 152         <td class="fibody5"><? echo $fdata{'ph_allergies_data'}; ?></td>
 153       </tr>
 154     </table></td>
 155     </tr>
 156   <tr>
 157     <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 158       <tr align="left" valign="top">
 159         <td width="70%" class="fibody2" id="bordR">Last cervical cancer screening:
 160           <? echo (($fdata{'cancer_scr_cytology'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 161           Cytology
 162           <? echo $fdata{'cancer_scr_cytology_date'}; ?>
 163           <? echo (($fdata{'cancer_scr_hpv'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 164           HPV test
 165           <? echo $fdata{'cancer_scr_hpv_date'}; ?></td>
 166         <td width="30%" class="fibody5"><? echo $fdata{'cancer_scr_notes'}; ?></td>
 167       </tr>
 168       <tr align="left" valign="top">
 169         <td width="70%" class="fibody2" id="bordR">last mammogram:
 170           <? echo $fdata{'last_mammogram'}; ?></td>
 171         <td class="fibody5"><? echo $fdata{'last_mammogram_notes'}; ?></td>
 172       </tr>
 173       <tr align="left" valign="top">
 174         <td width="70%" class="fibody2" id="bordR">Last colorectal screening:
 175           <? echo $fdata{'last_colorectal'}; ?></td>
 176         <td class="fibody5"><? echo $fdata{'last_colorectal_notes'}; ?></td>
 177       </tr>
 178     </table></td>
 179   </tr>
 180 </table>
 181 </div>
 182 <p>&nbsp;</p>
 183 <h2 align="center"><a name="gh"></a>Gynecologic history (PH)</h2>
 184 <div style="border: solid 2px black; background-color:#FFFFFF;">
 185   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 186     <tr align="left" valign="top">
 187       <td colspan="4"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 188         <tr align="left" valign="top">
 189           <td   class="fibody2">Imp</td>
 190           <td   class="fibody2"><? echo $fdata{'gh_imp'}; ?></td>
 191           <td   class="fibody2">Age at menarche </td>
 192           <td   class="fibody2"><? echo $fdata{'gh_age_at_menarche'}; ?></td>
 193           <td   class="fibody2">Length of flow </td>
 194           <td   class="fibody2"><? echo $fdata{'gh_length_of_flow'}; ?></td>
 195           <td   class="fibody2">Interval between periods </td>
 196           <td   class="fibody2"><? echo $fdata{'gh_interval_periods'}; ?></td>
 197           <td   class="fibody2">Recent changes </td>
 198           <td   class="fibody2"><? echo $fdata{'gh_recent_changes'}; ?></td>
 199         </tr>
 200       </table></td>
 201     </tr>
 202     <tr align="left" valign="top">
 203       <td colspan="4"   class="fibody2">Sexually active:
 204         <? echo (($fdata{'gh_sexually_active'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 205         Yes
 206         <? echo (($fdata{'gh_sexually_active'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 207         No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Ever had sex:
 208         <? echo (($fdata{'gh_had_sex'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 209 Yes
 210 <? echo (($fdata{'gh_had_sex'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 211 No&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Number of partners (Lifetime)
 212 <? echo $fdata{'gh_partners'}; ?></td>
 213       </tr>
 214     <tr align="left" valign="top">
 215       <td colspan="4"   class="fibody2">Partners are:
 216         <? echo (($fdata{'gh_partners_are'} == 'men')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 217         men
 218         <? echo (($fdata{'gh_partners_are'} == 'women')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 219         women
 220         <? echo (($fdata{'ph_gh_partners_are'} == 'both')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 221         both</td>
 222       </tr>
 223     <tr align="left" valign="top">
 224       <td width="202" nowrap class="fibody2">Current method of contraception: </td>
 225       <td width="30%"   class="fibody5"><? echo $fdata{'gh_method_contraception'}; ?>&nbsp;</td>
 226       <td width="161" nowrap class="fibody2">Past contraceptive history:</td>
 227       <td width="34%"   class="fibody5"><? echo $fdata{'gh_contraceptive_history'}; ?>&nbsp;</td>
 228     </tr>
 229   </table>
 230 </div>
 231 <p>&nbsp;</p>
 232 <h2 align="center"><a name="oh"></a>Obstetric history (PH)</h2>
 233 <div style="border: solid 2px black; background-color:#FFFFFF; page-break-after: always;">
 234   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 235     <tr>
 236       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 237         <tr align="left" valign="top">
 238           <td width="30%"   class="fibody2" id="bordR">&nbsp;</td>
 239           <td width="50" align="center"   class="ficaption2" id="bordR">Number</td>
 240           <td width="30%" align="center"   class="fibody2" id="bordR">&nbsp;</td>
 241           <td width="50" align="center"   class="ficaption2" id="bordR">Number</td>
 242           <td width="30%" align="center"   class="fibody2" id="bordR">&nbsp;</td>
 243           <td width="50" align="center"   class="ficaption2">Number</td>
 244         </tr>
 245         <tr align="left" valign="top">
 246           <td width="30%"   class="fibody2" id="bordR">Pregnancies</td>
 247           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_pregnancies'}; ?></td>
 248           <td width="30%"   class="fibody2" id="bordR">abortions</td>
 249           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_abortions'}; ?></td>
 250           <td width="30%"   class="fibody2" id="bordR">miscarriages</td>
 251           <td width="50" align="center"   class="fibody2"><? echo $fdata{'oh_miscarriages'}; ?></td>
 252         </tr>
 253         <tr align="left" valign="top">
 254           <td width="30%"   class="fibody2" id="bordR">premature births(&lt;37 weeks) </td>
 255           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_premature_births'}; ?></td>
 256           <td width="30%"   class="fibody2" id="bordR">live births </td>
 257           <td width="50" align="center"   class="fibody2" id="bordR"><? echo $fdata{'oh_live_births'}; ?></td>
 258           <td width="30%"   class="fibody2" id="bordR">living children </td>
 259           <td width="50" align="center"   class="fibody2"><? echo $fdata{'oh_living_children'}; ?></td>
 260         </tr>
 261       </table></td>
 262     </tr>
 263     <tr>
 264       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 265         <tr align="center" valign="middle">
 266           <td class="ficaption2" id="bordR">No</td>
 267           <td class="ficaption2" id="bordR">birth date </td>
 268           <td class="ficaption2" id="bordR">weight at birth </td>
 269           <td class="ficaption2" id="bordR">baby's sex </td>
 270           <td class="ficaption2" id="bordR">weeks pregnant </td>
 271           <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
 272           <td class="ficaption2">physician's notes</td>
 273         </tr>
 274 <?
 275   $bi = 0;
 276   while ($bi<4) {
 277     $n = $bi+1;
 278     list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
 279     print <<<EOL
 280         <tr align="left" valign="top">
 281           <td   class="fibody2" id="bordR">$n.</td>
 282           <td   class="fibody2" id="bordR">${oh_ch_date}&nbsp;</td>
 283           <td   class="fibody2" id="bordR">${oh_ch_width}&nbsp;</td>
 284           <td   class="fibody2" id="bordR">${oh_ch_sex}&nbsp;</td>
 285           <td   class="fibody2" id="bordR">${oh_ch_weeks}&nbsp;</td>
 286           <td   class="fibody2" id="bordR">${oh_ch_delivery}&nbsp;</td>
 287           <td   class="fibody2">${oh_ch_notes}&nbsp;</td>
 288         </tr>
 289 EOL;
 290      $bi++;
 291   }
 292 ?>
 293       </table></td>
 294     </tr>
 295     <tr>
 296       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 297         <tr align="left" valign="top">
 298           <td width="23%" nowrap   class="fibody2">Any pregnancy complications? </td>
 299           <td class="fibody5"><? echo $fdata{'oh_complications'}; ?></td>
 300         </tr>
 301       </table></td>
 302     </tr>
 303     <tr>
 304       <td><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 305         <tr align="left" valign="top">
 306           <td colspan="2" class="fibody2"><? echo (($fdata{'oh_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 307             diabetes
 308               <? echo (($fdata{'oh_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 309               hypertension/high blood pressure
 310               <? echo (($fdata{'oh_preemclampsia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 311               preeclampsia/foxemia
 312               <? echo (($fdata{'oh_complic_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 313               other </td>
 314         </tr>
 315         <tr align="left" valign="top">
 316           <td width="472"   class="fibody2">any history of depression before or after pregnancy?
 317             <? echo (($fdata{'oh_depression'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 318             no
 319             <? echo (($fdata{'oh_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 320             yes, How treated </td>
 321           <td class="fibody5"><? echo $fdata{'oh_depression_treated'}; ?>&nbsp;</td>
 322         </tr>
 323       </table></td>
 324     </tr>
 325   </table>
 326 </div>
 327 <p>&nbsp;</p>
 328 <h2 align="center"><a name="ph"></a>Past history (PH)</h2>
 329 <div style="border: solid 2px black; background-color:#FFFFFF;">
 330   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 331     <tr>
 332       <td class="fibody2"><? echo (($fdata{'ph_noncontrib'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 333         Noncontributory
 334         <? echo (($fdata{'ph_nochange_since'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 335         no interval change since
 336         <? echo $fdata{'ph_nochange_since_date'}; ?></td>
 337     </tr>
 338     <tr>
 339       <td class="fibody5"><strong>Surgeries:</strong>
 340         <? echo $fdata{'ph_surgeries'}; ?></td>
 341     </tr>
 342     <tr>
 343       <td class="fibody5"><strong>Illnesses (Physical and mental):</strong>
 344         <? echo $fdata{'ph_illnesses'}; ?></td>
 345     </tr>
 346     <tr>
 347       <td class="fibody5"><strong>Injuries:</strong>
 348         <? echo $fdata{'ph_injuries'}; ?></td>
 349     </tr>
 350     <tr>
 351       <td class="fibody5"><strong>Immunizations/Tuberculosis test: </strong>
 352         <? echo $fdata{'ph_immunizations_tuberculosis'}; ?></td>
 353     </tr>
 354   </table>
 355 </div>
 356 <p>&nbsp;</p>
 357 <h2 align="center"><a name="fh"></a>Family history (FH) </h2>
 358 <div style="border: solid 2px black; background-color:#FFFFFF;">
 359   <table width="100%"  border="0" cellspacing="0" cellpadding="2">
 360     <tr align="left" valign="top">
 361       <td colspan="3" class="fibody2"><? echo (($fdata{'fh_noncontrib'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 362 Noncontributory
 363   <? echo (($fdata{'fh_nochange_since'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 364 no interval change since
 365 <? echo $fdata{'fh_nochange_since_date'}; ?></td>
 366     </tr>
 367     <tr align="left" valign="top">
 368       <td colspan="3" class="fibody2">Mother:
 369         <? echo (($fdata{'fh_mother'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> deceased'); ?>
 370         <? if ($fdata{'fh_mother'} != '0') { echo (($fdata{'fh_mother'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 371         cause:
 372         <? echo $fdata{'fh_mother_dec_cause'}; ?>
 373         , age:
 374         <? echo $fdata{'fh_mother_dec_age'}; }?>
 375 &nbsp;&nbsp;&nbsp;        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Father:
 376         <? echo (($fdata{'fh_father'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> Living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> Deceased'); ?>
 377 <? if ($fdata{'fh_father'} != '0') {  ?>
 378 deceased &mdash;  cause:
 379 <? echo $fdata{'fh_father_dec_cause'}; ?>
 380 , age:
 381 <? echo $fdata{'fh_father_dec_age'}; }?></td>
 382     </tr>
 383     <tr align="left" valign="top">
 384       <td colspan="3" class="fibody2">Siblings: number living:
 385         <? echo $fdata{'fh_sibl_living'}; ?>
 386         &nbsp;&nbsp;Number deceased:
 387         <? echo $fdata{'fh_sibl_deceased'}; ?>
 388         &nbsp;&nbsp;Cause(s) / Age(s) :<br>
 389         <? echo $fdata{'fh_sibl_cause'}; ?></td>
 390     </tr>
 391     <tr align="left" valign="top">
 392       <td colspan="3" class="fibody2">Children: number living:
 393         <? echo $fdata{'fh_children_living'}; ?>
 394 &nbsp;&nbsp;Number deceased:
 395 <? echo $fdata{'fh_children_deceased'}; ?>
 396 &nbsp;&nbsp;Cause(s) / Age(s) :<br>
 397 <? echo $fdata{'fh_children_cause'}; ?></td>
 398     </tr>
 399     <tr align="left" valign="top">
 400       <td colspan="3" class="fibody2" style="border: none">(IF YES, indicate whom, and age of diagnosis) </td>
 401     </tr>
 402     <tr align="left" valign="top">
 403       <td width="33%" class="fibody2" id="bordR"><? echo (($fdata{'fhd_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 404         diabetes
 405         <? echo $fdata{'fhd_diabetes_who'}; ?></td>
 406       <td width="33%" class="fibody2" id="bordR"><? echo (($fdata{'fhd_heart'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 407         heart disease
 408         <? echo $fdata{'fhd_heart_who'}; ?></td>
 409       <td width="33%" class="fibody2"> <? echo (($fdata{'fhd_hyperlipidemia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 410         hyperlipidemia
 411         <? echo $fdata{'fhd_hyperlipidemia_who'}; ?></td>
 412     </tr>
 413     <tr align="left" valign="top">
 414       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_cancer'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 415         cancer
 416         <? echo $fdata{'fhd_cancer_who'}; ?></td>
 417       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_hipertension'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 418         Hypertension
 419         <? echo $fdata{'fhd_hipertension_who'}; ?></td>
 420       <td rowspan="2" valign="middle" class="fibody2"><? echo (($fdata{'fhd_deepvenous'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 421         deep venous tromboembolIsm / Pulmonary embolism
 422         <? echo $fdata{'fhd_deepvenous_who'}; ?></td>
 423     </tr>
 424     <tr align="left" valign="top">
 425       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_osteoporosis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 426         osteoporosis
 427         <? echo $fdata{'fhd_osteoporosis_who'}; ?></td>
 428       <td class="fibody2" id="bordR"><? echo (($fdata{'fhd_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 429         other illnesses
 430         <? echo $fdata{'fhd_other_who'}; ?></td>
 431       </tr>
 432   </table>
 433 </div>
 434 <p></p>
 435 <p>&nbsp;</p>
 436 <h2 align="center"><a name="sh"></a>Social history (SH) </h2>
 437 <div style="border: solid 2px black; background-color:#FFFFFF;">
 438   <table width="100%"  border="0" cellspacing="0" cellpadding="0">
 439     <tr>
 440       <td align="left" valign="top" class="fibody2"> <? echo (($fdata{'sh_noncontrib'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 441 Noncontributory
 442 <? echo (($fdata{'sh_nochange_since'} == 'checkbox')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 443 no interval change since
 444 <? echo $fdata{'sh_nochange_since_date'}; ?>&nbsp; </td>
 445     </tr>
 446     <tr>
 447       <td align="left" valign="top"><table width="100%"  border="0" cellspacing="0" cellpadding="2">
 448         <tr align="center" valign="top">
 449           <td width="190" class="ficaption2">&nbsp;</td>
 450           <td width="30" class="ficaption2">yes</td>
 451           <td width="30" class="ficaption2" id="bordR">no</td>
 452           <td class="ficaption2" id="bordR">notes</td>
 453           <td width="190" class="ficaption2">&nbsp;</td>
 454           <td width="30" class="ficaption2">yes</td>
 455           <td width="30" class="ficaption2" id="bordR">no</td>
 456           <td class="ficaption2">notes</td>
 457         </tr>
 458         <tr align="left" valign="top">
 459           <td   class="fibody2">Tobacco use </td>
 460           <td class="fibody2"><? echo (($fdata{'sh_tobacco'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 461           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_tobacco'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 462           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_1'}; ?>&nbsp;</td>
 463           <td   class="fibody2">diet discussed </td>
 464           <td class="fibody2"><? echo (($fdata{'sh_diet'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 465           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_diet'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 466           <td class="fibody2">
 467             <? echo $fdata{'sh_notes_9'}; ?>&nbsp;</td>
 468         </tr>
 469         <tr align="left" valign="top">
 470           <td rowspan="2"   class="fibody2">Alcohol use<br>
 471             specify amount and type<br>
 472             <small style="font-size:6pt;">12 OZ beer = 5 oz wine = 1 1/2 oz liquor</small> </td>
 473           <td rowspan="2" class="fibody2"><? echo (($fdata{'sh_alcohol'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 474           <td rowspan="2" class="fibody2" id="bordR"><? echo (($fdata{'sh_alcohol'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 475           <td rowspan="2" class="fibody2" id="bordR"><? echo $fdata{'sh_notes_2'}; ?>&nbsp;</td>
 476           <td   class="fibody2">folic acid intake </td>
 477           <td class="fibody2"><? echo (($fdata{'sh_folic_acid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 478           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_folic_acid'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 479           <td class="fibody2"><? echo $fdata{'sh_notes_10'}; ?>&nbsp;</td>
 480         </tr>
 481         <tr align="left" valign="top">
 482           <td   class="fibody2">calcium intake </td>
 483           <td class="fibody2"><? echo (($fdata{'sh_calcium'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 484           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_calcium'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 485           <td class="fibody2"><? echo $fdata{'sh_notes_11'}; ?>&nbsp;</td>
 486         </tr>
 487         <tr align="left" valign="top">
 488           <td   class="fibody2">Illegal/Street drug use </td>
 489           <td class="fibody2"><? echo (($fdata{'sh_drugs'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 490           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_drugs'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 491           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_3'}; ?>&nbsp;</td>
 492           <td   class="fibody2">regular exercise </td>
 493           <td class="fibody2"><? echo (($fdata{'sh_reg_exercise'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 494           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_reg_exercise'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 495           <td class="fibody2"><? echo $fdata{'sh_notes_12'}; ?>&nbsp;</td>
 496         </tr>
 497         <tr align="left" valign="top">
 498           <td   class="fibody2">misuse of prescription drugs </td>
 499           <td class="fibody2"><? echo (($fdata{'sh_misuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 500           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_misuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 501           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_4'}; ?>&nbsp;</td>
 502           <td   class="fibody2">caffeine intake </td>
 503           <td class="fibody2"><? echo (($fdata{'sh_caffeine'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 504           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_caffeine'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 505           <td class="fibody2"><? echo $fdata{'sh_notes_13'}; ?>&nbsp;</td>
 506         </tr>
 507         <tr align="left" valign="top">
 508           <td   class="fibody2">intimate partner violence </td>
 509           <td class="fibody2"><? echo (($fdata{'sh_partner_violence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 510           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_partner_violence'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 511           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_5'}; ?>&nbsp;</td>
 512           <td   class="fibody2">advance directive (living will) </td>
 513           <td class="fibody2"><? echo (($fdata{'sh_advance'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 514           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_advance'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 515           <td class="fibody2"><? echo $fdata{'sh_notes_14'}; ?>&nbsp;</td>
 516         </tr>
 517         <tr align="left" valign="top">
 518           <td   class="fibody2">sexual abuse </td>
 519           <td class="fibody2"><? echo (($fdata{'sh_sexual_abuse'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 520           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_sexual_abuse'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 521           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_6'}; ?>&nbsp;</td>
 522           <td   class="fibody2">organ donation </td>
 523           <td class="fibody2"><? echo (($fdata{'sh_organ_donation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 524           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_organ_donation'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 525           <td class="fibody2"><? echo $fdata{'sh_notes_15'}; ?>&nbsp;</td>
 526         </tr>
 527         <tr align="left" valign="top">
 528           <td   class="fibody2">health hazards at home/work </td>
 529           <td class="fibody2"><? echo (($fdata{'sh_health_hazards'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 530           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_health_hazards'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 531           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_7'}; ?>&nbsp;</td>
 532           <td   class="fibody2">other</td>
 533           <td class="fibody2"><? echo (($fdata{'sh_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 534           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_other'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 535           <td class="fibody2"><? echo $fdata{'sh_notes_16'}; ?>&nbsp;</td>
 536         </tr>
 537         <tr align="left" valign="top">
 538           <td   class="fibody2">seat belt use </td>
 539           <td class="fibody2"><? echo (($fdata{'sh_seat_belt'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 540           <td class="fibody2" id="bordR"><? echo (($fdata{'sh_seat_belt'} == '0')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;</td>
 541           <td class="fibody2" id="bordR"><? echo $fdata{'sh_notes_8'}; ?>&nbsp;</td>
 542           <td   class="fibody2"><? echo (($fdata{'sh_nochanges_since2'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>&nbsp;
 543             no changes since              <? echo $fdata{'sh_nochanges_since2_date'}; ?>&nbsp; </td>
 544           <td class="fibody2">&nbsp;</td>
 545           <td class="fibody2">&nbsp;</td>
 546           <td class="fibody2">&nbsp;</td>
 547         </tr>
 548       </table></td>
 549     </tr>
 550   </table>
 551 </div>
 552 <p>&nbsp;  </p>
 553 <h2 align="center"><a name="ros"></a>Review of systems (ROS)</h2>
 554 <div style="border: solid 2px black; background-color:#FFFFFF;">
 555 <table width="100%"  border="0" cellspacing="0" cellpadding="2" class="fitable">
 556   <tr>
 557     <td width="190" align="left" valign="top" class="ficaption">1. Constitutional </td>
 558     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 559       <tr align="left" valign="baseline">
 560         <td width="20%" nowrap><? echo (($fdata{'ros_const_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 561         Negative</td>
 562         <td width="20%" nowrap><? echo (($fdata{'ros_const_weight_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 563           weight loss</td>
 564         <td width="20%" nowrap><? echo (($fdata{'ros_const_weight_gain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 565           weight gain
 566 </td>
 567         <td>&nbsp;</td>
 568         <td width="20%">&nbsp;</td>
 569       </tr>
 570       <tr align="left" valign="baseline">
 571         <td width="20%" nowrap><? echo (($fdata{'ros_const_fever'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 572           fever</td>
 573         <td width="20%" nowrap><? echo (($fdata{'ros_const_fatigue'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 574           fatigue</td>
 575         <td nowrap><? echo (($fdata{'ros_const_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 576           other</td>
 577         <td align="right" nowrap>tallest height&nbsp; </td>
 578         <td><? echo $fdata{'ros_const_tallest_height'}; ?></td>
 579       </tr>
 580     </table></td>
 581   </tr>
 582   <tr>
 583     <td width="190" align="left" valign="top" class="ficaption">2. Eyes </td>
 584     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 585       <tr align="left" valign="baseline">
 586         <td width="20%" nowrap><? echo (($fdata{'ros_eyes_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 587       Negative</td>
 588         <td colspan="2" nowrap><? echo (($fdata{'ros_eyes_vision_change'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 589       Vision change </td>
 590         <td colspan="2" nowrap><? echo (($fdata{'ros_eyes_glasses'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 591 Glasses/contacts</td>
 592         </tr>
 593       <tr align="left" valign="baseline">
 594         <td width="20%" nowrap><? echo (($fdata{'ros_eyes_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 595       Other</td>
 596         <td width="20%" nowrap>&nbsp;</td>
 597         <td width="20%" nowrap>&nbsp;</td>
 598         <td align="right" nowrap>&nbsp; </td>
 599         <td width="20%">&nbsp;</td>
 600       </tr>
 601     </table></td>
 602   </tr>
 603   <tr>
 604     <td width="190" align="left" valign="top" class="ficaption">3. Ear, nose and throat </td>
 605     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 606       <tr align="left" valign="baseline">
 607         <td width="20%" nowrap><? echo (($fdata{'ros_ear_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 608       Negative</td>
 609         <td width="20%" nowrap><? echo (($fdata{'ros_ear_ulcers'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 610       Ulcers</td>
 611         <td width="20%" nowrap><? echo (($fdata{'ros_ear_sinusitis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 612       sinusitis</td>
 613         <td width="20%">&nbsp;</td>
 614         <td width="20%">&nbsp;</td>
 615       </tr>
 616       <tr align="left" valign="baseline">
 617         <td nowrap><? echo (($fdata{'ros_ear_headache'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 618       Headache</td>
 619         <td nowrap><? echo (($fdata{'ros_ear_hearing_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 620       Hearing loss </td>
 621         <td nowrap><? echo (($fdata{'ros_ear_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 622       other</td>
 623         <td width="20%" align="right" nowrap>&nbsp;</td>
 624         <td>&nbsp;</td>
 625       </tr>
 626     </table></td>
 627   </tr>
 628   <tr>
 629     <td width="190" align="left" valign="top" class="ficaption">4. Cardiovascular </td>
 630     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 631       <tr align="left" valign="baseline">
 632         <td width="20%" nowrap><? echo (($fdata{'ros_cv_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 633       Negative</td>
 634         <td width="20%" nowrap><? echo (($fdata{'ros_cv_orthopnea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 635       Orthopnea</td>
 636         <td width="20%" nowrap><? echo (($fdata{'ros_cv_chest_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 637       Chest pain </td>
 638         <td colspan="2" rowspan="2"><? echo (($fdata{'ros_cv_difficulty_breathing'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 639           Difficulty breathing on exertion
 640 </td>
 641         </tr>
 642       <tr align="left" valign="baseline">
 643         <td nowrap><? echo (($fdata{'ros_cv_edema'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 644       Edema</td>
 645         <td nowrap><? echo (($fdata{'ros_cv_palpitation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 646       Palpitation</td>
 647         <td nowrap><? echo (($fdata{'ros_cv_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 648       other</td>
 649         </tr>
 650     </table></td>
 651   </tr>
 652   <tr>
 653     <td width="190" align="left" valign="top" class="ficaption">5. Respiratory </td>
 654     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 655       <tr align="left" valign="baseline">
 656         <td width="20%" nowrap><? echo (($fdata{'ros_resp_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 657       Negative</td>
 658         <td width="20%" nowrap><? echo (($fdata{'ros_resp_wheezing'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 659       Wheezing</td>
 660         <td width="20%" nowrap><? echo (($fdata{'ros_hemoptysis'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 661       Hemoptysis</td>
 662         <td width="20%">&nbsp;</td>
 663         <td width="20%">&nbsp;</td>
 664       </tr>
 665       <tr align="left" valign="baseline">
 666         <td colspan="2" nowrap><? echo (($fdata{'ros_resp_shortness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 667       Shortness of breath </td>
 668         <td nowrap><? echo (($fdata{'ros_resp_cough'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 669       Cough</td>
 670         <td colspan="2" align="left" nowrap><? echo (($fdata{'ros_resp_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 671           Other
 672 </td>
 673         </tr>
 674     </table></td>
 675   </tr>
 676   <tr>
 677     <td width="190" align="left" valign="top" class="ficaption">6. Gastrointestinal </td>
 678     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 679       <tr align="left" valign="baseline">
 680         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 681       Negative</td>
 682         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_diarrhea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 683       Diarrhea</td>
 684         <td width="20%" nowrap><? echo (($fdata{'ros_gastr_bloody_stool'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 685       Bloody stool </td>
 686         <td colspan="2"><? echo (($fdata{'ros_gastr_nausea'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 687           Nausea/Vomiting/Indigestion
 688 </td>
 689         </tr>
 690       <tr align="left" valign="baseline">
 691         <td nowrap><? echo (($fdata{'ros_gastr_constipation'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 692       Constipation</td>
 693         <td nowrap><? echo (($fdata{'ros_gastr_flatulence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 694       Flatulence</td>
 695         <td nowrap><? echo (($fdata{'ros_gastr_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 696       pain</td>
 697         <td align="left" nowrap><? echo (($fdata{'ros_gastr_fecal'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 698           Fecal incontinence</td>
 699         <td nowrap><? echo (($fdata{'ros_gastr_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 700           Other</td>
 701       </tr>
 702     </table></td>
 703   </tr>
 704   <tr>
 705     <td width="190" align="left" valign="top" class="ficaption">7. Genitourinary </td>
 706     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 707       <tr align="left" valign="baseline">
 708         <td width="20%" nowrap><? echo (($fdata{'ros_genit_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 709       Negative</td>
 710         <td width="20%" nowrap><? echo (($fdata{'ros_genit_hematuria'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 711       Hematuria</td>
 712         <td nowrap><? echo (($fdata{'ros_genit_dysuria'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 713       Dysuria</td>
 714         <td align="left" nowrap><? echo (($fdata{'ros_genit_urgency'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 715           Urgency</td>
 716         <td align="left" nowrap>&nbsp;</td>
 717       </tr>
 718       <tr align="left" valign="baseline">
 719         <td width="20%" nowrap><? echo (($fdata{'ros_genit_frequency'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 720       Frequency</td>
 721         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_incomplete_emptying'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 722       Incomplete emptying </td>
 723         <td align="left" nowrap><? echo (($fdata{'ros_genit_incontinence'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 724           Incontinence</td>
 725         <td align="left" nowrap>&nbsp;</td>
 726       </tr>
 727       <tr align="left" valign="baseline">
 728         <td width="20%" nowrap><? echo (($fdata{'ros_genit_dyspareunia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 729   Dyspareunia</td>
 730         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_abnormal_periods'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 731           Abnormal or painful periods </td>
 732         <td nowrap><? echo (($fdata{'ros_genit_pms'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 733   PMS</td>
 734         <td align="left" nowrap>&nbsp;</td>
 735       </tr>
 736       <tr align="left" valign="baseline">
 737         <td colspan="2" nowrap><? echo (($fdata{'ros_genit_abnormal_bleeding'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 738   Abnormal vaginal bleeding </td>
 739         <td nowrap><? echo (($fdata{'ros_genit_abnormal_discharge'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 740   Abnormal vaginal discharge </td>
 741         <td nowrap><? echo (($fdata{'ros_genit_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 742   other</td>
 743         <td align="left" nowrap>&nbsp;</td>
 744       </tr>
 745     </table></td>
 746   </tr>
 747   <tr>
 748     <td width="190" align="left" valign="top" class="ficaption">8. Musculoskeletal </td>
 749     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 750       <tr align="left" valign="baseline">
 751         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 752       Negative</td>
 753         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_weakness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 754       Muscle weakness </td>
 755         <td nowrap>&nbsp;</td>
 756         <td width="10%">&nbsp;</td>
 757         <td width="10%">&nbsp;</td>
 758       </tr>
 759       <tr align="left" valign="baseline">
 760         <td nowrap><? echo (($fdata{'ros_muscul_pain'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 761       Muscle or joint pain </td>
 762         <td width="40%" nowrap><? echo (($fdata{'ros_muscul_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 763 other</td>
 764         <td nowrap>&nbsp;</td>
 765         <td width="10%" align="left" nowrap>&nbsp;</td>
 766         <td width="10%">&nbsp;</td>
 767       </tr>
 768     </table></td>
 769   </tr>
 770   <tr>
 771     <td width="190" align="left" valign="top" class="ficaption">9a. Skin </td>
 772     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 773       <tr align="left" valign="baseline">
 774         <td width="20%" nowrap><? echo (($fdata{'ros_skin_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 775       Negative</td>
 776         <td width="20%" nowrap><? echo (($fdata{'ros_skin_rash'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 777       Rash</td>
 778         <td width="20%" nowrap><? echo (($fdata{'ros_skin_ulcers'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 779       Ulcers</td>
 780         <td width="20%">&nbsp;</td>
 781         <td width="20%">&nbsp;</td>
 782       </tr>
 783       <tr align="left" valign="baseline">
 784         <td nowrap><? echo (($fdata{'ros_skin_dry'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 785       Dry skin </td>
 786         <td colspan="2" nowrap><? echo (($fdata{'ros_skin_pigmented'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 787       Pigmented lesions </td>
 788         <td align="left" nowrap><? echo (($fdata{'ros_skin_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 789 other</td>
 790         <td>&nbsp;</td>
 791       </tr>
 792     </table></td>
 793   </tr>
 794   <tr>
 795     <td width="190" align="left" valign="top" class="ficaption">9b. Breast </td>
 796     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 797       <tr align="left" valign="baseline">
 798         <td width="20%" nowrap><? echo (($fdata{'ros_breast_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 799       Negative</td>
 800         <td width="20%" nowrap><? echo (($fdata{'ros_breast_mastalgia'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 801       Mastalgia</td>
 802         <td width="20%" nowrap>&nbsp;</td>
 803         <td width="20%">&nbsp;</td>
 804         <td width="20%">&nbsp;</td>
 805       </tr>
 806       <tr align="left" valign="baseline">
 807         <td nowrap><? echo (($fdata{'ros_breast_discharge'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 808       Discharge</td>
 809         <td nowrap><? echo (($fdata{'ros_breast_masses'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 810       Masses</td>
 811         <td nowrap><? echo (($fdata{'ros_breast_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 812       other</td>
 813         <td align="right" nowrap>&nbsp;</td>
 814         <td width="20%">&nbsp;</td>
 815       </tr>
 816     </table></td>
 817   </tr>
 818   <tr>
 819     <td width="190" align="left" valign="top" class="ficaption">10. Neurologic </td>
 820     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="2">
 821       <tr align="left" valign="baseline">
 822         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 823       Negative</td>
 824         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_syncope'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 825       Syncope</td>
 826         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_seizures'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 827       Seizures</td>
 828         <td width="20%" nowrap><? echo (($fdata{'ros_neuro_numbness'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 829           Numbness</td>
 830         <td width="20%">&nbsp;</td>
 831       </tr>
 832       <tr align="left" valign="baseline">
 833         <td colspan="2" nowrap><? echo (($fdata{'ros_neuro_trouble_walking'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 834       Trouble walking </td>
 835         <td colspan="2" nowrap><? echo (($fdata{'ros_neuro_memory'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 836 Severe memory problems </td>
 837         <td><? echo (($fdata{'ros_neuro_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 838 other</td>
 839       </tr>
 840     </table></td>
 841   </tr>
 842   <tr>
 843     <td width="190" align="left" valign="top" class="ficaption">11. Psychiatric</td>
 844     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 845       <tr align="left" valign="baseline">
 846         <td nowrap><? echo (($fdata{'ros_psych_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 847       Negative</td>
 848         <td width="20%" nowrap><? echo (($fdata{'ros_psych_depression'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 849       Depression</td>
 850         <td width="20%" nowrap><? echo (($fdata{'ros_psych_crying'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 851       Crying</td>
 852         <td width="20%">&nbsp;</td>
 853         <td width="20%">&nbsp;</td>
 854       </tr>
 855       <tr align="left" valign="baseline">
 856         <td colspan="2" nowrap><? echo (($fdata{'ros_psych_anxiety'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 857       Severe anxiety </td>
 858         <td width="20%" nowrap><? echo (($fdata{'ros_psych_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 859 Other</td>
 860         <td align="right" nowrap>&nbsp;</td>
 861         <td>&nbsp;</td>
 862       </tr>
 863     </table></td>
 864   </tr>
 865   <tr>
 866     <td width="190" align="left" valign="top" class="ficaption">12. Endocrine </td>
 867     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 868       <tr align="left" valign="baseline">
 869         <td width="20%" nowrap><? echo (($fdata{'ros_endo_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 870       Negative</td>
 871         <td width="20%" nowrap><? echo (($fdata{'ros_endo_diabetes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 872         Diabetes</td>
 873         <td nowrap><? echo (($fdata{'ros_endo_hipothyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 874       Hypothyroid</td>
 875         <td nowrap><? echo (($fdata{'ros_endo_hiperthyroid'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 876 Hyperthyroid</td>
 877       </tr>
 878       <tr align="left" valign="baseline">
 879         <td nowrap><? echo (($fdata{'ros_endo_flashes'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 880       Hot flashes </td>
 881         <td nowrap><? echo (($fdata{'ros_endo_hair_loss'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 882       Hair loss </td>
 883         <td nowrap><? echo (($fdata{'ros_endo_intolerance'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 884       Heat/cold intolerance </td>
 885         <td><? echo (($fdata{'ros_endo_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 886           Other
 887 </td>
 888       </tr>
 889     </table></td>
 890   </tr>
 891   <tr>
 892     <td width="190" align="left" valign="top" class="ficaption">13. Hematologic/Lymphatic</td>
 893     <td align="left" valign="top" class="fibody"><table width="100%"  border="0" cellpadding="0" cellspacing="1">
 894       <tr align="left" valign="baseline">
 895         <td width="20%" nowrap><? echo (($fdata{'ros_hemato_negative'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 896       Negative</td>
 897         <td width="20%" nowrap><? echo (($fdata{'ros_hemato_bruises'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 898       Bruises</td>
 899         <td width="20%" nowrap>&nbsp;</td>
 900         <td width="20%">&nbsp;</td>
 901         <td width="20%">&nbsp;</td>
 902       </tr>
 903       <tr align="left" valign="baseline">
 904         <td nowrap><? echo (($fdata{'ros_hemato_bleeding'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 905       Bleeding</td>
 906         <td nowrap><? echo (($fdata{'ros_hemato_adenopathy'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 907       Adenopathy</td>
 908         <td nowrap><? echo (($fdata{'ros_hemato_other'} == '1')?'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?>
 909       other</td>
 910         <td align="right" nowrap>&nbsp;</td>
 911         <td>&nbsp;</td>
 912       </tr>
 913     </table></td>
 914   </tr>
 915   <tr>
 916     <td width="190" align="left" valign="top" class="ficaption">14. Allergic/Immunologic </td>
 917     <td align="center" valign="middle" class="fibody"><a href="#allergies">See above (Page 1 of PH) </a></td>
 918   </tr>
 919 </table>
 920 </div>
 921 </body>
 922 </html>