1 <?
function physician_history_report( $pid, $encounter, $cols, $id) {
2 include_once("../../globals.php");
3 include_once("$srcdir/api.inc");
4 include_once("$srcdir/forms.inc");
5 include_once("$srcdir/calendar.inc");
7 $fres=sqlStatement("select * from patient_data where pid='".$pid."'");
9 $patient = sqlFetchArray($fres);
12 $fres=sqlStatement("select * from form_physician_history where id='".$id."'");
14 $fdata = sqlFetchArray($fres);
17 <table width
="70%" border
="0" cellspacing
="0" cellpadding
="4" style
="">
19 <td width
="120" align
="left" valign
="top" class="srvCaption">Patient name
:</td
>
20 <td align
="left" valign
="top" class="fibody5"><?
echo $patient{'fname'}.' '.$patient{'mname'}.' '.$patient{'lname'};?
></td
>
23 <td width
="120" align
="left" valign
="top" class="srvCaption">Birth date
: </td
>
24 <td align
="left" valign
="top" class="fibody5"><?
echo $patient{'DOB'}; ?
></td
>
27 <td width
="120" align
="left" valign
="top" class="srvCaption">ID No
:</td
>
28 <td align
="left" valign
="top" class="fibody5"><?
echo $patient{'id'}; ?
></td
>
31 <td width
="120" align
="left" valign
="top" class="srvCaption">Date
</td
>
32 <td align
="left" valign
="top" class="fibody5"><?
echo $fdata['date']; ?
></td
>
35 <div
class="srvChapter">Physician history
</div
>
36 <div style
="border: solid 2px black; background-color:#FFFFFF;">
37 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="0">
39 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
40 <tr align
="left" valign
="baseline">
41 <td width
="25%" class="fibody2" id
="bordR"><?
echo (($fdata{'established'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
43 <td width
="25%" class="fibody2" id
="bordR"><?
echo (($fdata{'established'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
44 Established patient
</td
>
45 <td width
="20%" class="fibody2" id
="bordR"><?
echo (($fdata{'consultation'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
47 <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
>
49 <tr align
="left" valign
="top">
50 <td colspan
="2" class="fibody2" id
="bordR">Primary care physician
:<br
>
51 <?
echo $fdata{'primary_care'}; ?
></td
>
52 <td colspan
="2" class="fibody2">Who sent patient
:<br
>
53 <?
echo $fdata{'who_sent'}; ?
></td
>
55 <tr align
="left" valign
="top">
56 <td colspan
="2" class="fibody2" id
="bordR"> Other
physician(s
):<br
> <?
echo $fdata{'other_physician'}; ?
> </td
>
57 <td colspan
="2" class="fibody2"> 
;</td
>
62 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
63 <tr align
="left" valign
="baseline">
64 <td width
="50%" class="ficaption2" id
="bordR">Chief
complaint (CC
) (<small
>Required
for all visits except preventive
</small
>):</td
>
65 <td width
="50%" class="ficaption2">Current prescription medications
: </td
>
67 <tr align
="left" valign
="baseline">
68 <td width
="50%" class="fibody5" id
="bordR"><?
echo $fdata{'chief_complaint'}; ?
>  
;</td
>
69 <td width
="50%" class="fibody5"><?
echo $fdata{'current_prescription'}; ?
>  
;</td
>
71 <tr align
="left" valign
="baseline">
72 <td width
="50%" valign
="top" class="ficaption2" id
="bordR">History of present
ilness (HPI
): <br
> </td
>
73 <td width
="50%" valign
="top" class="ficaption2">Current nonpresription
, complementary
, and alternative medications
: </td
>
75 <tr align
="left" valign
="baseline">
76 <td width
="50%" valign
="top" class="fibody5" id
="bordR"><?
echo $fdata{'hpi'}; ?
> 
;</td
>
77 <td width
="50%" valign
="top" class="fibody5"><?
echo $fdata{'current_nonprescription'}; ?
> 
;</td
>
82 <td
class="fibody2"> 
;</td
>
85 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
86 <tr align
="left" valign
="top">
87 <td width
="200" class="ficaption2">Changes since last visit
</td
>
88 <td width
="40" align
="center" class="ficaption2">yes
</td
>
89 <td width
="40" align
="center" class="ficaption2" id
="bordR">no
</td
>
90 <td colspan
="2" align
="center" class="ficaption2">Notes
</td
>
92 <tr align
="left" valign
="top">
93 <td width
="200" class="fibody2">Illnesses
</td
>
94 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_ill'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
95 <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
>
96 <td colspan
="2" rowspan
="7" valign
="top" class="fibody5"><?
echo $fdata{'ph_lvch_notes'}; ?
> 
;</td
>
98 <tr align
="left" valign
="top">
99 <td width
="200" class="fibody2">Surgery
</td
>
100 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_surg'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
101 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_surg'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
103 <tr align
="left" valign
="top">
104 <td width
="200" class="fibody2">New medications
</td
>
105 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_newmed'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
106 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_newmed'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
108 <tr align
="left" valign
="top">
109 <td width
="200" class="fibody2">Change in family history
</td
>
110 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_famhist'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
111 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_famhist'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
113 <tr align
="left" valign
="top">
114 <td width
="200" class="fibody2">New allergies
</td
>
115 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_newallerg'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
116 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_newallerg'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
118 <tr align
="left" valign
="top">
119 <td width
="200" class="fibody2">Change in gynecologic history
</td
>
120 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_gynhist'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
121 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_gynhist'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
123 <tr align
="left" valign
="top">
124 <td width
="200" class="fibody2">Change in obstetric history
</td
>
125 <td width
="40" align
="center" class="fibody2"><?
echo (($fdata{'ph_lvch_obsthist'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
126 <td width
="40" align
="center" class="fibody2" id
="bordR"><?
echo (($fdata{'ph_lvch_obsthist'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
></td
>
131 <td
class="fibody2"> 
;</td
>
134 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
135 <tr align
="left" valign
="top">
136 <td width
="225" class="fibody2"><a name
="allergies"></a
>Allergies (describe reaction
):
137 <?
echo (($fdata{'ph_allergies_none'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
139 <td
class="fibody5"><?
echo $fdata{'ph_allergies_data'}; ?
></td
>
144 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
145 <tr align
="left" valign
="top">
146 <td width
="70%" class="fibody2" id
="bordR">Last cervical cancer screening
:
147 <?
echo (($fdata{'cancer_scr_cytology'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
149 <?
echo $fdata{'cancer_scr_cytology_date'}; ?
>
150 <?
echo (($fdata{'cancer_scr_hpv'} == 'checkbox')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
152 <?
echo $fdata{'cancer_scr_hpv_date'}; ?
></td
>
153 <td width
="30%" class="fibody5"><?
echo $fdata{'cancer_scr_notes'}; ?
></td
>
155 <tr align
="left" valign
="top">
156 <td width
="70%" class="fibody2" id
="bordR">last mammogram
:
157 <?
echo $fdata{'last_mammogram'}; ?
></td
>
158 <td
class="fibody5"><?
echo $fdata{'last_mammogram_notes'}; ?
></td
>
160 <tr align
="left" valign
="top">
161 <td width
="70%" class="fibody2" id
="bordR">Last colorectal screening
:
162 <?
echo $fdata{'last_colorectal'}; ?
></td
>
163 <td
class="fibody5"><?
echo $fdata{'last_colorectal_notes'}; ?
></td
>
170 <h2 align
="center"><a name
="gh"></a
>Gynecologic
history (PH
)</h2
>
171 <div style
="border: solid 2px black; background-color:#FFFFFF;">
172 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
173 <tr align
="left" valign
="top">
174 <td colspan
="4"><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
175 <tr align
="left" valign
="top">
176 <td
class="fibody2">Imp
</td
>
177 <td
class="fibody2"><?
echo $fdata{'gh_imp'}; ?
></td
>
178 <td
class="fibody2">Age at menarche
</td
>
179 <td
class="fibody2"><?
echo $fdata{'gh_age_at_menarche'}; ?
></td
>
180 <td
class="fibody2">Length of flow
</td
>
181 <td
class="fibody2"><?
echo $fdata{'gh_length_of_flow'}; ?
></td
>
182 <td
class="fibody2">Interval between periods
</td
>
183 <td
class="fibody2"><?
echo $fdata{'gh_interval_periods'}; ?
></td
>
184 <td
class="fibody2">Recent changes
</td
>
185 <td
class="fibody2"><?
echo $fdata{'gh_recent_changes'}; ?
></td
>
189 <tr align
="left" valign
="top">
190 <td colspan
="4" class="fibody2">Sexually active
:
191 <?
echo (($fdata{'gh_sexually_active'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
193 <?
echo (($fdata{'gh_sexually_active'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
194 No
 
; 
; 
; 
; 
; 
; 
; 
; 
;Ever had sex
:
195 <?
echo (($fdata{'gh_had_sex'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
197 <?
echo (($fdata{'gh_had_sex'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
198 No
 
; 
; 
; 
; 
; 
; 
; 
; 
;Number of
partners (Lifetime
)
199 <?
echo $fdata{'gh_partners'}; ?
></td
>
201 <tr align
="left" valign
="top">
202 <td colspan
="4" class="fibody2">Partners are
:
203 <?
echo (($fdata{'gh_partners_are'} == 'men')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
205 <?
echo (($fdata{'gh_partners_are'} == 'women')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
207 <?
echo (($fdata{'ph_gh_partners_are'} == 'both')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
210 <tr align
="left" valign
="top">
211 <td width
="202" nowrap
class="fibody2">Current method of contraception
: </td
>
212 <td width
="30%" class="fibody5"><?
echo $fdata{'gh_method_contraception'}; ?
> 
;</td
>
213 <td width
="161" nowrap
class="fibody2">Past contraceptive history
:</td
>
214 <td width
="34%" class="fibody5"><?
echo $fdata{'gh_contraceptive_history'}; ?
> 
;</td
>
219 <h2 align
="center"><a name
="oh"></a
>Obstetric
history (PH
)</h2
>
220 <div style
="border: solid 2px black; background-color:#FFFFFF; page-break-after: always;">
221 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="0">
223 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
224 <tr align
="left" valign
="top">
225 <td width
="30%" class="fibody2" id
="bordR"> 
;</td
>
226 <td width
="50" align
="center" class="ficaption2" id
="bordR">Number
</td
>
227 <td width
="30%" align
="center" class="fibody2" id
="bordR"> 
;</td
>
228 <td width
="50" align
="center" class="ficaption2" id
="bordR">Number
</td
>
229 <td width
="30%" align
="center" class="fibody2" id
="bordR"> 
;</td
>
230 <td width
="50" align
="center" class="ficaption2">Number
</td
>
232 <tr align
="left" valign
="top">
233 <td width
="30%" class="fibody2" id
="bordR">Pregnancies
</td
>
234 <td width
="50" align
="center" class="fibody2" id
="bordR"><?
echo $fdata{'oh_pregnancies'}; ?
></td
>
235 <td width
="30%" class="fibody2" id
="bordR">abortions
</td
>
236 <td width
="50" align
="center" class="fibody2" id
="bordR"><?
echo $fdata{'oh_abortions'}; ?
></td
>
237 <td width
="30%" class="fibody2" id
="bordR">miscarriages
</td
>
238 <td width
="50" align
="center" class="fibody2"><?
echo $fdata{'oh_miscarriages'}; ?
></td
>
240 <tr align
="left" valign
="top">
241 <td width
="30%" class="fibody2" id
="bordR">premature
births(<
;37 weeks
) </td
>
242 <td width
="50" align
="center" class="fibody2" id
="bordR"><?
echo $fdata{'oh_premature_births'}; ?
></td
>
243 <td width
="30%" class="fibody2" id
="bordR">live births
</td
>
244 <td width
="50" align
="center" class="fibody2" id
="bordR"><?
echo $fdata{'oh_live_births'}; ?
></td
>
245 <td width
="30%" class="fibody2" id
="bordR">living children
</td
>
246 <td width
="50" align
="center" class="fibody2"><?
echo $fdata{'oh_living_children'}; ?
></td
>
251 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
252 <tr align
="center" valign
="middle">
253 <td
class="ficaption2" id
="bordR">No
</td
>
254 <td
class="ficaption2" id
="bordR">birth date
</td
>
255 <td
class="ficaption2" id
="bordR">weight at birth
</td
>
256 <td
class="ficaption2" id
="bordR">baby
's sex </td>
257 <td class="ficaption2" id="bordR">weeks pregnant </td>
258 <td class="ficaption2" id="bordR">type of delivery (<small>vaginal, cesarian etc.</small>) </td>
259 <td class="ficaption2">physician's notes
</td
>
265 list ($oh_ch_date, $oh_ch_width, $oh_ch_sex, $oh_ch_weeks, $oh_ch_delivery, $oh_ch_notes) = explode('|~', $fdata["oh_ch_rec_".$bi] );
267 <tr align="left" valign="top">
268 <td class="fibody2" id="bordR">$n.</td>
269 <td class="fibody2" id="bordR">${oh_ch_date} </td>
270 <td class="fibody2" id="bordR">${oh_ch_width} </td>
271 <td class="fibody2" id="bordR">${oh_ch_sex} </td>
272 <td class="fibody2" id="bordR">${oh_ch_weeks} </td>
273 <td class="fibody2" id="bordR">${oh_ch_delivery} </td>
274 <td class="fibody2">${oh_ch_notes} </td>
283 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
284 <tr align
="left" valign
="top">
285 <td width
="23%" nowrap
class="fibody2">Any pregnancy complications?
</td
>
286 <td
class="fibody5"><?
echo $fdata{'oh_complications'}; ?
></td
>
291 <td
><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
292 <tr align
="left" valign
="top">
293 <td colspan
="2" class="fibody2"><?
echo (($fdata{'oh_diabetes'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
295 <?
echo (($fdata{'oh_hipertension'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
296 hypertension
/high blood pressure
297 <?
echo (($fdata{'oh_preemclampsia'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
299 <?
echo (($fdata{'oh_complic_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
302 <tr align
="left" valign
="top">
303 <td width
="472" class="fibody2">any history of depression before
or after pregnancy?
304 <?
echo (($fdata{'oh_depression'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
306 <?
echo (($fdata{'oh_depression'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
307 yes
, How treated
</td
>
308 <td
class="fibody5"><?
echo $fdata{'oh_depression_treated'}; ?
> 
;</td
>
315 <h2 align
="center"><a name
="ph"></a
>Past
history (PH
)</h2
>
316 <div style
="border: solid 2px black; background-color:#FFFFFF;">
317 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
319 <td
class="fibody2"><?
echo (($fdata{'ph_noncontrib'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
321 <?
echo (($fdata{'ph_nochange_since'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
322 no interval change since
323 <?
echo $fdata{'ph_nochange_since_date'}; ?
></td
>
326 <td
class="fibody5"><strong
>Surgeries
:</strong
>
327 <?
echo $fdata{'ph_surgeries'}; ?
></td
>
330 <td
class="fibody5"><strong
>Illnesses (Physical
and mental
):</strong
>
331 <?
echo $fdata{'ph_illnesses'}; ?
></td
>
334 <td
class="fibody5"><strong
>Injuries
:</strong
>
335 <?
echo $fdata{'ph_injuries'}; ?
></td
>
338 <td
class="fibody5"><strong
>Immunizations
/Tuberculosis test
: </strong
>
339 <?
echo $fdata{'ph_immunizations_tuberculosis'}; ?
></td
>
344 <h2 align
="center"><a name
="fh"></a
>Family
history (FH
) </h2
>
345 <div style
="border: solid 2px black; background-color:#FFFFFF;">
346 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
347 <tr align
="left" valign
="top">
348 <td colspan
="3" class="fibody2"><?
echo (($fdata{'fh_noncontrib'} == 'checkbox')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
350 <?
echo (($fdata{'fh_nochange_since'} == 'checkbox')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
351 no interval change since
352 <?
echo $fdata{'fh_nochange_since_date'}; ?
></td
>
354 <tr align
="left" valign
="top">
355 <td colspan
="3" class="fibody2">Mother
:
356 <?
echo (($fdata{'fh_mother'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> deceased'); ?
>
357 <?
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"> '); ?
>
359 <?
echo $fdata{'fh_mother_dec_cause'}; ?
>
361 <?
echo $fdata{'fh_mother_dec_age'}; }?
>
362  
; 
; 
;  
; 
; 
; 
; 
;Father
:
363 <?
echo (($fdata{'fh_father'} == '0')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> Living':'<img src="../../pic/mrkcheck.png" width="12" height="11"> Deceased'); ?
>
364 <?
if ($fdata{'fh_father'} != '0') { ?
>
365 deceased
&mdash
; cause
:
366 <?
echo $fdata{'fh_father_dec_cause'}; ?
>
368 <?
echo $fdata{'fh_father_dec_age'}; }?
></td
>
370 <tr align
="left" valign
="top">
371 <td colspan
="3" class="fibody2">Siblings
: number living
:
372 <?
echo $fdata{'fh_sibl_living'}; ?
>
373  
; 
;Number deceased
:
374 <?
echo $fdata{'fh_sibl_deceased'}; ?
>
375  
; 
;Cause(s
) / Age(s
) :<br
>
376 <?
echo $fdata{'fh_sibl_cause'}; ?
></td
>
378 <tr align
="left" valign
="top">
379 <td colspan
="3" class="fibody2">Children
: number living
:
380 <?
echo $fdata{'fh_children_living'}; ?
>
381  
; 
;Number deceased
:
382 <?
echo $fdata{'fh_children_deceased'}; ?
>
383  
; 
;Cause(s
) / Age(s
) :<br
>
384 <?
echo $fdata{'fh_children_cause'}; ?
></td
>
386 <tr align
="left" valign
="top">
387 <td colspan
="3" class="fibody2" style
="border: none">(IF YES
, indicate whom
, and age of diagnosis
) </td
>
389 <tr align
="left" valign
="top">
390 <td width
="33%" class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_diabetes'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
392 <?
echo $fdata{'fhd_diabetes_who'}; ?
></td
>
393 <td width
="33%" class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_heart'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
395 <?
echo $fdata{'fhd_heart_who'}; ?
></td
>
396 <td width
="33%" class="fibody2"> <?
echo (($fdata{'fhd_hyperlipidemia'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
398 <?
echo $fdata{'fhd_hyperlipidemia_who'}; ?
></td
>
400 <tr align
="left" valign
="top">
401 <td
class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_cancer'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
403 <?
echo $fdata{'fhd_cancer_who'}; ?
></td
>
404 <td
class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_hipertension'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
406 <?
echo $fdata{'fhd_hipertension_who'}; ?
></td
>
407 <td rowspan
="2" valign
="middle" class="fibody2"><?
echo (($fdata{'fhd_deepvenous'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
408 deep venous tromboembolIsm
/ Pulmonary embolism
409 <?
echo $fdata{'fhd_deepvenous_who'}; ?
></td
>
411 <tr align
="left" valign
="top">
412 <td
class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_osteoporosis'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
414 <?
echo $fdata{'fhd_osteoporosis_who'}; ?
></td
>
415 <td
class="fibody2" id
="bordR"><?
echo (($fdata{'fhd_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
417 <?
echo $fdata{'fhd_other_who'}; ?
></td
>
423 <h2 align
="center"><a name
="sh"></a
>Social
history (SH
) </h2
>
424 <div style
="border: solid 2px black; background-color:#FFFFFF;">
425 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="0">
427 <td align
="left" valign
="top" class="fibody2"> <?
echo (($fdata{'sh_noncontrib'} == 'checkbox')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;
429 <?
echo (($fdata{'sh_nochange_since'} == 'checkbox')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;
430 no interval change since
431 <?
echo $fdata{'sh_nochange_since_date'}; ?
> 
; </td
>
434 <td align
="left" valign
="top"><table width
="100%" border
="0" cellspacing
="0" cellpadding
="2">
435 <tr align
="center" valign
="top">
436 <td width
="190" class="ficaption2"> 
;</td
>
437 <td width
="30" class="ficaption2">yes
</td
>
438 <td width
="30" class="ficaption2" id
="bordR">no
</td
>
439 <td
class="ficaption2" id
="bordR">notes
</td
>
440 <td width
="190" class="ficaption2"> 
;</td
>
441 <td width
="30" class="ficaption2">yes
</td
>
442 <td width
="30" class="ficaption2" id
="bordR">no
</td
>
443 <td
class="ficaption2">notes
</td
>
445 <tr align
="left" valign
="top">
446 <td
class="fibody2">Tobacco
use </td
>
447 <td
class="fibody2"><?
echo (($fdata{'sh_tobacco'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
448 <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"> '); ?
> 
;</td
>
449 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_1'}; ?
> 
;</td
>
450 <td
class="fibody2">diet discussed
</td
>
451 <td
class="fibody2"><?
echo (($fdata{'sh_diet'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
452 <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"> '); ?
> 
;</td
>
454 <?
echo $fdata{'sh_notes_9'}; ?
> 
;</td
>
456 <tr align
="left" valign
="top">
457 <td rowspan
="2" class="fibody2">Alcohol
use<br
>
458 specify amount
and type
<br
>
459 <small style
="font-size:6pt;">12 OZ beer
= 5 oz wine
= 1 1/2 oz liquor
</small
> </td
>
460 <td rowspan
="2" class="fibody2"><?
echo (($fdata{'sh_alcohol'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
461 <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"> '); ?
> 
;</td
>
462 <td rowspan
="2" class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_2'}; ?
> 
;</td
>
463 <td
class="fibody2">folic acid intake
</td
>
464 <td
class="fibody2"><?
echo (($fdata{'sh_folic_acid'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
465 <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"> '); ?
> 
;</td
>
466 <td
class="fibody2"><?
echo $fdata{'sh_notes_10'}; ?
> 
;</td
>
468 <tr align
="left" valign
="top">
469 <td
class="fibody2">calcium intake
</td
>
470 <td
class="fibody2"><?
echo (($fdata{'sh_calcium'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
471 <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"> '); ?
> 
;</td
>
472 <td
class="fibody2"><?
echo $fdata{'sh_notes_11'}; ?
> 
;</td
>
474 <tr align
="left" valign
="top">
475 <td
class="fibody2">Illegal
/Street drug
use </td
>
476 <td
class="fibody2"><?
echo (($fdata{'sh_drugs'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
477 <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"> '); ?
> 
;</td
>
478 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_3'}; ?
> 
;</td
>
479 <td
class="fibody2">regular exercise
</td
>
480 <td
class="fibody2"><?
echo (($fdata{'sh_reg_exercise'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
481 <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"> '); ?
> 
;</td
>
482 <td
class="fibody2"><?
echo $fdata{'sh_notes_12'}; ?
> 
;</td
>
484 <tr align
="left" valign
="top">
485 <td
class="fibody2">misuse of prescription drugs
</td
>
486 <td
class="fibody2"><?
echo (($fdata{'sh_misuse'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
487 <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"> '); ?
> 
;</td
>
488 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_4'}; ?
> 
;</td
>
489 <td
class="fibody2">caffeine intake
</td
>
490 <td
class="fibody2"><?
echo (($fdata{'sh_caffeine'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
491 <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"> '); ?
> 
;</td
>
492 <td
class="fibody2"><?
echo $fdata{'sh_notes_13'}; ?
> 
;</td
>
494 <tr align
="left" valign
="top">
495 <td
class="fibody2">intimate partner violence
</td
>
496 <td
class="fibody2"><?
echo (($fdata{'sh_partner_violence'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
497 <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"> '); ?
> 
;</td
>
498 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_5'}; ?
> 
;</td
>
499 <td
class="fibody2">advance
directive (living will
) </td
>
500 <td
class="fibody2"><?
echo (($fdata{'sh_advance'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
501 <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"> '); ?
> 
;</td
>
502 <td
class="fibody2"><?
echo $fdata{'sh_notes_14'}; ?
> 
;</td
>
504 <tr align
="left" valign
="top">
505 <td
class="fibody2">sexual abuse
</td
>
506 <td
class="fibody2"><?
echo (($fdata{'sh_sexual_abuse'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
507 <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"> '); ?
> 
;</td
>
508 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_6'}; ?
> 
;</td
>
509 <td
class="fibody2">organ donation
</td
>
510 <td
class="fibody2"><?
echo (($fdata{'sh_organ_donation'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
511 <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"> '); ?
> 
;</td
>
512 <td
class="fibody2"><?
echo $fdata{'sh_notes_15'}; ?
> 
;</td
>
514 <tr align
="left" valign
="top">
515 <td
class="fibody2">health hazards at home
/work
</td
>
516 <td
class="fibody2"><?
echo (($fdata{'sh_health_hazards'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
517 <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"> '); ?
> 
;</td
>
518 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_7'}; ?
> 
;</td
>
519 <td
class="fibody2">other
</td
>
520 <td
class="fibody2"><?
echo (($fdata{'sh_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
521 <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"> '); ?
> 
;</td
>
522 <td
class="fibody2"><?
echo $fdata{'sh_notes_16'}; ?
> 
;</td
>
524 <tr align
="left" valign
="top">
525 <td
class="fibody2">seat belt
use </td
>
526 <td
class="fibody2"><?
echo (($fdata{'sh_seat_belt'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;</td
>
527 <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"> '); ?
> 
;</td
>
528 <td
class="fibody2" id
="bordR"><?
echo $fdata{'sh_notes_8'}; ?
> 
;</td
>
529 <td
class="fibody2"><?
echo (($fdata{'sh_nochanges_since2'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
> 
;
530 no changes since
<?
echo $fdata{'sh_nochanges_since2_date'}; ?
> 
; </td
>
531 <td
class="fibody2"> 
;</td
>
532 <td
class="fibody2"> 
;</td
>
533 <td
class="fibody2"> 
;</td
>
540 <h2 align
="center"><a name
="ros"></a
>Review of
systems (ROS
)</h2
>
541 <div style
="border: solid 2px black; background-color:#FFFFFF;">
542 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="2" class="fitable">
544 <td width
="190" align
="left" valign
="top" class="ficaption">1. Constitutional
</td
>
545 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
546 <tr align
="left" valign
="baseline">
547 <td width
="20%" nowrap
><?
echo (($fdata{'ros_const_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
549 <td width
="20%" nowrap
><?
echo (($fdata{'ros_const_weight_loss'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
551 <td width
="20%" nowrap
><?
echo (($fdata{'ros_const_weight_gain'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
555 <td width
="20%"> 
;</td
>
557 <tr align
="left" valign
="baseline">
558 <td width
="20%" nowrap
><?
echo (($fdata{'ros_const_fever'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
560 <td width
="20%" nowrap
><?
echo (($fdata{'ros_const_fatigue'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
562 <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"> '); ?
>
564 <td align
="right" nowrap
>tallest height
 
; </td
>
565 <td
><?
echo $fdata{'ros_const_tallest_height'}; ?
></td
>
570 <td width
="190" align
="left" valign
="top" class="ficaption">2. Eyes
</td
>
571 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
572 <tr align
="left" valign
="baseline">
573 <td width
="20%" nowrap
><?
echo (($fdata{'ros_eyes_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
575 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_eyes_vision_change'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
577 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_eyes_glasses'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
578 Glasses
/contacts
</td
>
580 <tr align
="left" valign
="baseline">
581 <td width
="20%" nowrap
><?
echo (($fdata{'ros_eyes_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
583 <td width
="20%" nowrap
> 
;</td
>
584 <td width
="20%" nowrap
> 
;</td
>
585 <td align
="right" nowrap
> 
; </td
>
586 <td width
="20%"> 
;</td
>
591 <td width
="190" align
="left" valign
="top" class="ficaption">3. Ear
, nose
and throat
</td
>
592 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
593 <tr align
="left" valign
="baseline">
594 <td width
="20%" nowrap
><?
echo (($fdata{'ros_ear_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
596 <td width
="20%" nowrap
><?
echo (($fdata{'ros_ear_ulcers'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
598 <td width
="20%" nowrap
><?
echo (($fdata{'ros_ear_sinusitis'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
600 <td width
="20%"> 
;</td
>
601 <td width
="20%"> 
;</td
>
603 <tr align
="left" valign
="baseline">
604 <td nowrap
><?
echo (($fdata{'ros_ear_headache'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
606 <td nowrap
><?
echo (($fdata{'ros_ear_hearing_loss'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
608 <td nowrap
><?
echo (($fdata{'ros_ear_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
610 <td width
="20%" align
="right" nowrap
> 
;</td
>
616 <td width
="190" align
="left" valign
="top" class="ficaption">4. Cardiovascular
</td
>
617 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
618 <tr align
="left" valign
="baseline">
619 <td width
="20%" nowrap
><?
echo (($fdata{'ros_cv_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
621 <td width
="20%" nowrap
><?
echo (($fdata{'ros_cv_orthopnea'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
623 <td width
="20%" nowrap
><?
echo (($fdata{'ros_cv_chest_pain'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
625 <td colspan
="2" rowspan
="2"><?
echo (($fdata{'ros_cv_difficulty_breathing'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
626 Difficulty breathing on exertion
629 <tr align
="left" valign
="baseline">
630 <td nowrap
><?
echo (($fdata{'ros_cv_edema'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
632 <td nowrap
><?
echo (($fdata{'ros_cv_palpitation'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
634 <td nowrap
><?
echo (($fdata{'ros_cv_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
640 <td width
="190" align
="left" valign
="top" class="ficaption">5. Respiratory
</td
>
641 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
642 <tr align
="left" valign
="baseline">
643 <td width
="20%" nowrap
><?
echo (($fdata{'ros_resp_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
645 <td width
="20%" nowrap
><?
echo (($fdata{'ros_resp_wheezing'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
647 <td width
="20%" nowrap
><?
echo (($fdata{'ros_hemoptysis'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
649 <td width
="20%"> 
;</td
>
650 <td width
="20%"> 
;</td
>
652 <tr align
="left" valign
="baseline">
653 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_resp_shortness'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
654 Shortness of breath
</td
>
655 <td nowrap
><?
echo (($fdata{'ros_resp_cough'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
657 <td colspan
="2" align
="left" nowrap
><?
echo (($fdata{'ros_resp_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
664 <td width
="190" align
="left" valign
="top" class="ficaption">6. Gastrointestinal
</td
>
665 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
666 <tr align
="left" valign
="baseline">
667 <td width
="20%" nowrap
><?
echo (($fdata{'ros_gastr_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
669 <td width
="20%" nowrap
><?
echo (($fdata{'ros_gastr_diarrhea'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
671 <td width
="20%" nowrap
><?
echo (($fdata{'ros_gastr_bloody_stool'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
673 <td colspan
="2"><?
echo (($fdata{'ros_gastr_nausea'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
674 Nausea
/Vomiting
/Indigestion
677 <tr align
="left" valign
="baseline">
678 <td nowrap
><?
echo (($fdata{'ros_gastr_constipation'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
680 <td nowrap
><?
echo (($fdata{'ros_gastr_flatulence'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
682 <td nowrap
><?
echo (($fdata{'ros_gastr_pain'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
684 <td align
="left" nowrap
><?
echo (($fdata{'ros_gastr_fecal'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
685 Fecal incontinence
</td
>
686 <td nowrap
><?
echo (($fdata{'ros_gastr_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
692 <td width
="190" align
="left" valign
="top" class="ficaption">7. Genitourinary
</td
>
693 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
694 <tr align
="left" valign
="baseline">
695 <td width
="20%" nowrap
><?
echo (($fdata{'ros_genit_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
697 <td width
="20%" nowrap
><?
echo (($fdata{'ros_genit_hematuria'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
699 <td nowrap
><?
echo (($fdata{'ros_genit_dysuria'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
701 <td align
="left" nowrap
><?
echo (($fdata{'ros_genit_urgency'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
703 <td align
="left" nowrap
> 
;</td
>
705 <tr align
="left" valign
="baseline">
706 <td width
="20%" nowrap
><?
echo (($fdata{'ros_genit_frequency'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
708 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_genit_incomplete_emptying'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
709 Incomplete emptying
</td
>
710 <td align
="left" nowrap
><?
echo (($fdata{'ros_genit_incontinence'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
712 <td align
="left" nowrap
> 
;</td
>
714 <tr align
="left" valign
="baseline">
715 <td width
="20%" nowrap
><?
echo (($fdata{'ros_genit_dyspareunia'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
717 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_genit_abnormal_periods'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
718 Abnormal
or painful periods
</td
>
719 <td nowrap
><?
echo (($fdata{'ros_genit_pms'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
721 <td align
="left" nowrap
> 
;</td
>
723 <tr align
="left" valign
="baseline">
724 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_genit_abnormal_bleeding'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
725 Abnormal vaginal bleeding
</td
>
726 <td nowrap
><?
echo (($fdata{'ros_genit_abnormal_discharge'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
727 Abnormal vaginal discharge
</td
>
728 <td nowrap
><?
echo (($fdata{'ros_genit_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
730 <td align
="left" nowrap
> 
;</td
>
735 <td width
="190" align
="left" valign
="top" class="ficaption">8. Musculoskeletal
</td
>
736 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="2">
737 <tr align
="left" valign
="baseline">
738 <td width
="40%" nowrap
><?
echo (($fdata{'ros_muscul_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
740 <td width
="40%" nowrap
><?
echo (($fdata{'ros_muscul_weakness'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
741 Muscle weakness
</td
>
742 <td nowrap
> 
;</td
>
743 <td width
="10%"> 
;</td
>
744 <td width
="10%"> 
;</td
>
746 <tr align
="left" valign
="baseline">
747 <td nowrap
><?
echo (($fdata{'ros_muscul_pain'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
748 Muscle
or joint pain
</td
>
749 <td width
="40%" nowrap
><?
echo (($fdata{'ros_muscul_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
751 <td nowrap
> 
;</td
>
752 <td width
="10%" align
="left" nowrap
> 
;</td
>
753 <td width
="10%"> 
;</td
>
758 <td width
="190" align
="left" valign
="top" class="ficaption">9a
. Skin
</td
>
759 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
760 <tr align
="left" valign
="baseline">
761 <td width
="20%" nowrap
><?
echo (($fdata{'ros_skin_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
763 <td width
="20%" nowrap
><?
echo (($fdata{'ros_skin_rash'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
765 <td width
="20%" nowrap
><?
echo (($fdata{'ros_skin_ulcers'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
767 <td width
="20%"> 
;</td
>
768 <td width
="20%"> 
;</td
>
770 <tr align
="left" valign
="baseline">
771 <td nowrap
><?
echo (($fdata{'ros_skin_dry'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
773 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_skin_pigmented'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
774 Pigmented lesions
</td
>
775 <td align
="left" nowrap
><?
echo (($fdata{'ros_skin_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
782 <td width
="190" align
="left" valign
="top" class="ficaption">9b
. Breast
</td
>
783 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
784 <tr align
="left" valign
="baseline">
785 <td width
="20%" nowrap
><?
echo (($fdata{'ros_breast_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
787 <td width
="20%" nowrap
><?
echo (($fdata{'ros_breast_mastalgia'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
789 <td width
="20%" nowrap
> 
;</td
>
790 <td width
="20%"> 
;</td
>
791 <td width
="20%"> 
;</td
>
793 <tr align
="left" valign
="baseline">
794 <td nowrap
><?
echo (($fdata{'ros_breast_discharge'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
796 <td nowrap
><?
echo (($fdata{'ros_breast_masses'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
798 <td nowrap
><?
echo (($fdata{'ros_breast_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
800 <td align
="right" nowrap
> 
;</td
>
801 <td width
="20%"> 
;</td
>
806 <td width
="190" align
="left" valign
="top" class="ficaption">10. Neurologic
</td
>
807 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="2">
808 <tr align
="left" valign
="baseline">
809 <td width
="20%" nowrap
><?
echo (($fdata{'ros_neuro_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
811 <td width
="20%" nowrap
><?
echo (($fdata{'ros_neuro_syncope'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
813 <td width
="20%" nowrap
><?
echo (($fdata{'ros_neuro_seizures'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
815 <td width
="20%" nowrap
><?
echo (($fdata{'ros_neuro_numbness'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
817 <td width
="20%"> 
;</td
>
819 <tr align
="left" valign
="baseline">
820 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_neuro_trouble_walking'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
821 Trouble walking
</td
>
822 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_neuro_memory'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
823 Severe memory problems
</td
>
824 <td
><?
echo (($fdata{'ros_neuro_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
830 <td width
="190" align
="left" valign
="top" class="ficaption">11. Psychiatric
</td
>
831 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
832 <tr align
="left" valign
="baseline">
833 <td nowrap
><?
echo (($fdata{'ros_psych_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
835 <td width
="20%" nowrap
><?
echo (($fdata{'ros_psych_depression'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
837 <td width
="20%" nowrap
><?
echo (($fdata{'ros_psych_crying'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
839 <td width
="20%"> 
;</td
>
840 <td width
="20%"> 
;</td
>
842 <tr align
="left" valign
="baseline">
843 <td colspan
="2" nowrap
><?
echo (($fdata{'ros_psych_anxiety'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
845 <td width
="20%" nowrap
><?
echo (($fdata{'ros_psych_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
847 <td align
="right" nowrap
> 
;</td
>
853 <td width
="190" align
="left" valign
="top" class="ficaption">12. Endocrine
</td
>
854 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
855 <tr align
="left" valign
="baseline">
856 <td width
="20%" nowrap
><?
echo (($fdata{'ros_endo_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
858 <td width
="20%" nowrap
><?
echo (($fdata{'ros_endo_diabetes'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
860 <td nowrap
><?
echo (($fdata{'ros_endo_hipothyroid'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
862 <td nowrap
><?
echo (($fdata{'ros_endo_hiperthyroid'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
865 <tr align
="left" valign
="baseline">
866 <td nowrap
><?
echo (($fdata{'ros_endo_flashes'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
868 <td nowrap
><?
echo (($fdata{'ros_endo_hair_loss'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
870 <td nowrap
><?
echo (($fdata{'ros_endo_intolerance'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
871 Heat
/cold intolerance
</td
>
872 <td
><?
echo (($fdata{'ros_endo_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
879 <td width
="190" align
="left" valign
="top" class="ficaption">13. Hematologic
/Lymphatic
</td
>
880 <td align
="left" valign
="top" class="fibody"><table width
="100%" border
="0" cellpadding
="0" cellspacing
="1">
881 <tr align
="left" valign
="baseline">
882 <td width
="20%" nowrap
><?
echo (($fdata{'ros_hemato_negative'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
884 <td width
="20%" nowrap
><?
echo (($fdata{'ros_hemato_bruises'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
886 <td width
="20%" nowrap
> 
;</td
>
887 <td width
="20%"> 
;</td
>
888 <td width
="20%"> 
;</td
>
890 <tr align
="left" valign
="baseline">
891 <td nowrap
><?
echo (($fdata{'ros_hemato_bleeding'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
893 <td nowrap
><?
echo (($fdata{'ros_hemato_adenopathy'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
895 <td nowrap
><?
echo (($fdata{'ros_hemato_other'} == '1')?
'<img src="../../pic/mrkcheck.png" width="12" height="11"> ':'<img src="../../pic/mrkempty.png" width="12" height="11"> '); ?
>
897 <td align
="right" nowrap
> 
;</td
>
903 <td width
="190" align
="left" valign
="top" class="ficaption">14. Allergic
/Immunologic
</td
>
904 <td align
="center" valign
="middle" class="fibody"><a href
="#allergies">See
above (Page
1 of PH
) </a
></td
>