2 //================================================
4 //Z&H Healthcare Solutions, LLC.
7 //Initial New Patient Physical Exam
8 //================================================
9 include_once("../../globals.php");
10 include_once("$srcdir/api.inc");
11 formHeader("Form: Initial New Patient Physical Exam");
14 <?php
html_header_show();?
>
15 <link rel
="stylesheet" href
="<?php echo $css_header;?>" type
="text/css">
17 <body
class="body_top">
18 <form method
=post action
="<?php echo $rootdir;?>/forms/Initial_New_Patient_Physical_Exam/save.php?mode=new" name
="my_form" onSubmit
="return top.restoreSession()">
19 <table width
="100%" border
="0" cellspacing
="0" cellpadding
="0" >
21 <td align
="center" colspan
="5"><h3
> <?php
xl("015 Initial New Patient Physical Exam - ",'e') ?
> </h3
></td
>
26 <td align
="right"><b
class="text"> <?php
xl("EATING HABITS:",'e') ?
> </b
></td
>
27 <td align
="left"> 
;</td
>
28 <td align
="left"> 
;</td
>
29 <td align
="left"> 
;</td
>
30 <td align
="left"> 
;</td
>
38 <tr
><td colspan
="5" align
="center">
39 <table cellpadding
="0" cellspacing
="0" border
="0">
40 <tr
><td
><label
class="text"><?php
xl("% Sweeter",'e') ?
></label
></td
><td
> 
;<input type
="text" name
="sweeter" /></td
></tr
>
41 <tr
> <td
><label
class="text"><?php
xl("% Bloater",'e') ?
></label
></td
><td
> 
;<input type
="text" name
="bloater" /></td
></tr
>
42 <tr
> <td
><label
class="text"><?php
xl("% Grazer",'e') ?
></label
></td
><td
> 
;<input type
="text" name
="grazer" /></td
></tr
>
48 <td align
="left" colspan
="5"> 
;</td
>
52 <td align
="left" colspan
="5"><b
class="text"> <?php
xl("PHYSICAL EXAMINATION:",'e') ?
> </b
></td
>
55 <td align
="left" colspan
="5"> 
;</td
>
62 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("GENERAL:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="general[]" value
="Alert" /> <?php
xl("Alert",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="Oriented X3" /> <?php
xl("Oriented X3",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="Not in distress" /> <?php
xl("Not in distress",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="In distress" /> <?php
xl("In distress",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
><label
class="text"><input type
="checkbox" name
="general[]" value
="Well developed" /> <?php
xl("Well developed",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="Well nourished" /> <?php
xl("Well nourished",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="Petite" /> <?php
xl("Petite",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="general[]" value
="Obese" /> <?php
xl("Obese",'e') ?
> </label
></td
></tr
>
66 <td align
="left" colspan
="5"> 
;</td
>
69 <td align
="right"><b
class="text"> <?php
xl("HEENT:",'e') ?
> </b
></td
>
70 <td align
="left"> 
;</td
>
71 <td align
="left"> 
;</td
>
72 <td align
="left"> 
;</td
>
73 <td align
="left"> 
;</td
>
76 <td align
="left" colspan
="5"> 
;</td
>
83 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Head",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="head[]" value
="AT NC" /> <?php
xl("AT/NC",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="head[]" value
="Hirsutism Facial hairs" /> <?php
xl("Hirsutism/Facial hairs",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
89 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Eyes",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="eyes[]" value
="PERRLA" /> <?php
xl("PERRLA",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="eyes[]" value
="EOMI" /> <?php
xl("EOMI",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="eyes[]" value
="Anicteric" /> <?php
xl("Anicteric",'e') ?
> </label
></td
><td
> </td
></tr
><tr
><td
></td
><td
><label
class="text"><input type
="checkbox" name
="eyes[]" value
="Pink" /> <?php
xl("Pink",'e') ?
> </label
> </td
><td
> <label
class="text"><input type
="checkbox" name
="eyes[]" value
="Pale" /> <?php
xl("Pale",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="eyes[]" value
="Icteric" /> <?php
xl("Icteric",'e') ?
> </label
></td
><td
><label
class="text"><input type
="checkbox" name
="eyes[]" value
="Cataracts" /> <?php
xl("Cataracts",'e') ?
> </label
></td
></tr
>
95 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Ears",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="ears[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="ears[]" value
="TM w good light reflex" /> <?php
xl("TM w/ good light reflex",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
101 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Nose",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="nose[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="nose[]" value
="Patent" /> <?php
xl("Patent",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="nose[]" value
="No discharge" /> <?php
xl("No discharge",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="nose[]" value
="Discharge" /> <?php
xl("Discharge",'e') ?
> </label
></td
></tr
>
107 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Throat",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="throat[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="throat[]" value
="Erythematous" /> <?php
xl("Erythematous",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
113 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Oral cavity",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="oral_cavity[]" value
="No lesions" /> <?php
xl("No lesions",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="oral_cavity[]" value
="Lesions" /> <?php
xl("Lesions",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="oral_cavity[]" value
="Friable gums" /> <?php
xl("Friable gums",'e') ?
> </label
></td
><td
> 
;</td
></tr
>
119 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Dentition",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="dentition[]" value
="Good" /> <?php
xl("Good",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="dentition[]" value
="Fair" /> <?php
xl("Fair",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="dentition[]" value
="Poor" /> <?php
xl("Poor",'e') ?
> </label
></td
><td
> 
;</td
></tr
>
124 <td align
="left" colspan
="5"> 
;</td
>
128 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("NECK:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="neck[]" value
="No lymphadenopathy" /> <?php
xl("No lymphadenopathy",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="No thyromegally" /> <?php
xl("No thyromegally",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="No Bruit" /> <?php
xl("No Bruit",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="FROM" /> <?php
xl("FROM",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="Lymphadenopathy" /> <?php
xl("Lymphadenopathy",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="Thyromegally" /> <?php
xl("Thyromegally",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="Right Bruit" /> <?php
xl("Right Bruit",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neck[]" value
="Left Bruit" /> <?php
xl("Left Bruit",'e') ?
> </label
></td
></tr
>
133 <td align
="left" colspan
="5"> 
;</td
>
137 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("HEART:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="heart[]" value
="NSR" /> <?php
xl("NSR",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="heart[]" value
="S1 S2" /> <?php
xl("S1/S2",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="heart[]" value
="No murmur" /> <?php
xl("No murmur",'e') ?
> </label
></td
><td
> </td
></tr
><tr
><td
></td
><td
><label
class="text"><input type
="checkbox" name
="heart[]" value
="Irregular rate" /> <?php
xl("Irregular rate",'e') ?
> </label
></td
><td
><label
class="text"><input type
="checkbox" name
="heart[]" value
="Irreg rhythm" /> <?php
xl("Irreg rhythm",'e') ?
> </label
> </td
><td
><label
class="text"><input type
="checkbox" name
="heart[]" value
="Murmur" /> <?php
xl("Murmur",'e') ?
> </label
> </td
><td
><label
class="text"><input type
="checkbox" name
="heart[]" value
="Gallop" /> <?php
xl("Gallop",'e') ?
> </label
></td
></tr
>
141 <td align
="left" colspan
="5"> 
;</td
>
146 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("LUNG:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="lung[]" value
="Clear to ascultation" /> <?php
xl("Clear to ascultation",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="No rales" /> <?php
xl("No rales",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="No wheezes" /> <?php
xl("No wheezes",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="No rhonchi" /> <?php
xl("No rhonchi",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="Distant" /> <?php
xl("Distant",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="Rales" /> <?php
xl("Rales",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="Wheezes" /> <?php
xl("Wheezes",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="lung[]" value
="Rhonchi" /> <?php
xl("Rhonchi",'e') ?
> </label
></td
></tr
>
150 <td align
="left" colspan
="5"> 
;</td
>
155 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("CHEST:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="chest[]" value
="No palpable tenderness" /> <?php
xl("No palpable tenderness",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="chest[]" value
="Palpable tenderness" /> <?php
xl("Palpable tenderness",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
157 <td align
="left" colspan
="5"> 
;</td
>
164 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("BREAST:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="breast[]" value
="Did not examine" /> <?php
xl("Did not examine",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
170 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Male",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="male[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="male[]" value
="Gynecomastia" /> <?php
xl("Gynecomastia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="male[]" value
="Palpable mass" /> <?php
xl("Palpable mass",'e') ?
> </label
></td
><td
> 
;</td
></tr
>
176 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Female",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="female[]" value
="Normal size" /> <?php
xl("Normal size",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Normal exam" /> <?php
xl("Normal exam",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Enlarged" /> <?php
xl("Enlarged",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Pendulous" /> <?php
xl("Pendulous",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Palpable mass" /> <?php
xl("Palpable mass",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Tender" /> <?php
xl("Tender",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Erythematous" /> <?php
xl("Erythematous",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="female[]" value
="Peau d orange" /> <?php
xl("Peau d'orange",'e') ?
> </label
></td
></tr
>
182 <tr
><td align
="right" width
="150"> 
;</td
> <td colspan
="4"><input type
="text" name
="note" size
="80" /></td
></tr
>
187 <td align
="left" colspan
="5"> 
;</td
>
191 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("ABDOMEN:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="abdomen[]" value
="NABS" /> <?php
xl("NABS",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Soft" /> <?php
xl("Soft",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Non tender" /> <?php
xl("Non-tender",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Non distended" /> <?php
xl("Non-distended",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Obese" /> <?php
xl("Obese",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Hepatomegaly" /> <?php
xl("Hepatomegaly",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Ascites" /> <?php
xl("Ascites",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Tender" /> <?php
xl("Tender",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Distended" /> <?php
xl("Distended",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Guarding" /> <?php
xl("Guarding",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="Rebound tenderness" /> <?php
xl("Rebound tenderness",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="abdomen[]" value
="CVA tenderness" /> <?php
xl("CVA tenderness",'e') ?
> </label
></td
></tr
>
197 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Scar",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="scar[]" value
="Upper midline" /> <?php
xl("Upper midline",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Lower midline" /> <?php
xl("Lower midline",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Rt subcostal" /> <?php
xl("Rt subcostal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Lt subcostal" /> <?php
xl("Lt subcostal",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Rt inguinal" /> <?php
xl("Rt inguinal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Lt inguinal" /> <?php
xl("Lt inguinal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Paramedian" /> <?php
xl("Paramedian",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Pfanennsteil" /> <?php
xl("Pfanennsteil",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
><label
class="text"><input type
="checkbox" name
="scar[]" value
="Upper Transverse" /> <?php
xl("Upper Transverse",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Lower Transverse" /> <?php
xl("Lower Transverse",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="Laparoscopic" /> <?php
xl("Laparoscopic",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="scar[]" value
="McBurney s" /> <?php
xl("McBurney's",'e') ?
> </label
></td
></tr
>
201 <td align
="left" colspan
="5"> 
;</td
>
206 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("UMBILIUS:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="umbilius[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="umbilius[]" value
="Hernia" /> <?php
xl("Hernia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="umbilius[]" value
="Lymphadenopathy" /> <?php
xl("Lymphadenopathy",'e') ?
> </label
></td
><td
> 
;</td
></tr
>
210 <td align
="left" colspan
="5"> 
;</td
>
215 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("GROINS:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="groins[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="groins[]" value
="Rt hernia" /> <?php
xl("Rt hernia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="groins[]" value
="Lt hernia" /> <?php
xl("Lt hernia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="groins[]" value
="Rash" /> <?php
xl("Rash",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="groins[]" value
="Lymphadenopathy" /> <?php
xl("Lymphadenopathy",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
219 <td align
="left" colspan
="5"> 
;</td
>
224 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("EXTREMITIES:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="extremities[]" value
="Warm" /> <?php
xl("Warm",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Dry" /> <?php
xl("Dry",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="No edema" /> <?php
xl("No edema",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="No calf tenderness" /> <?php
xl("No calf tenderness",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Pitting edema" /> <?php
xl("Pitting edema",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Stasis dermatitis" /> <?php
xl("Stasis dermatitis",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Varicosities" /> <?php
xl("Varicosities",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Calf tenderness" /> <?php
xl("Calf tenderness",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Acanthosis Nigricans" /> <?php
xl("Acanthosis Nigricans",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Spider Angiomas" /> <?php
xl("Spider Angiomas",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Palmar Erythema" /> <?php
xl("Palmar Erythema",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="extremities[]" value
="Hirsutism" /> <?php
xl("Hirsutism",'e') ?
> </label
></td
></tr
>
228 <td align
="left" colspan
="5"> 
;</td
>
231 <td align
="right"><b
class="text"> <?php
xl("VASCULAR:",'e') ?
> </b
></td
>
232 <td align
="left"> 
;</td
>
233 <td align
="left"> 
;</td
>
234 <td align
="left"> 
;</td
>
235 <td align
="left"> 
;</td
>
242 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Peripheral pulses",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="peripheral_pulses[]" value
="Did not examine" /> <?php
xl("Did not examine",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="peripheral_pulses[]" value
="2 pulses" /> <?php
xl("2+ pulses",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
248 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Right",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="right_peripheral_pulses[]" value
="Radial" /> <?php
xl("Radial",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_peripheral_pulses[]" value
="Inguinal" /> <?php
xl("Inguinal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_peripheral_pulses[]" value
="Popliteal" /> <?php
xl("Popliteal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_peripheral_pulses[]" value
="DP" /> <?php
xl("DP",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_peripheral_pulses[]" value
="PT" /> <?php
xl("PT",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
254 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Left",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="left_peripheral_pulses[]" value
="Radial" /> <?php
xl("Radial",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_peripheral_pulses[]" value
="Inguinal" /> <?php
xl("Inguinal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_peripheral_pulses[]" value
="Popliteal" /> <?php
xl("Popliteal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_peripheral_pulses[]" value
="DP" /> <?php
xl("DP",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_peripheral_pulses[]" value
="PT" /> <?php
xl("PT",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
258 <td align
="left" colspan
="5"> 
;</td
>
263 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("NEUROLOGICAL:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="neurological[]" value
="Did not examine" /> <?php
xl("Did not examine",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="neurological[]" value
="Grossly normal" /> <?php
xl("Grossly normal",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
></tr
>
269 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Right",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="right_neurological[]" value
="Normal strength DTR s" /> <?php
xl("Normal strength & DTR's",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_neurological[]" value
="Abn grip strength" /> <?php
xl("Abn grip strength",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_neurological[]" value
="Abn arm strength" /> <?php
xl("Abn arm strength",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_neurological[]" value
="Abn leg strength" /> <?php
xl("Abn leg strength",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="right_neurological[]" value
="Abn DTR s" /> <?php
xl("Abn DTR's",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
275 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("Left",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="left_neurological[]" value
="Normal strength DTR s" /> <?php
xl("Normal strength & DTR's",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_neurological[]" value
="Abn grip strength" /> <?php
xl("Abn grip strength",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_neurological[]" value
="Abn arm strength" /> <?php
xl("Abn arm strength",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_neurological[]" value
="Abn leg strength" /> <?php
xl("Abn leg strength",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="left_neurological[]" value
="Abn DTR s" /> <?php
xl("Abn DTR's",'e') ?
> </label
></td
><td
> 
;</td
><td
> 
;</td
><td
> 
;</td
></tr
>
278 <td align
="left" colspan
="5"> 
;</td
>
284 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("RECTUM:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="rectum[]" value
="Did not examine" /> <?php
xl("Did not examine",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="rectum[]" value
="Normal" /> <?php
xl("Normal",'e') ?
> </label
></td
><td
> </td
><td
> </td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="rectum[]" value
="Palpable mass" /> <?php
xl("Palpable mass",'e') ?
> </label
></td
><td
><label
class="text"><input type
="checkbox" name
="rectum[]" value
="Enlarged prostate" /> <?php
xl("Enlarged prostate",'e') ?
> </label
> </td
><td
><label
class="text"><input type
="checkbox" name
="rectum[]" value
="Hemorrhoids" /> <?php
xl("Hemorrhoids",'e') ?
> </label
></td
><td
><label
class="text"><input type
="checkbox" name
="rectum[]" value
="Fissure Fistula" /> <?php
xl("Fissure/Fistula",'e') ?
> </label
></td
></tr
>
287 <td align
="left" colspan
="5"> 
;</td
>
293 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("PELVIC:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="pelvic[]" value
="Did not examine" /> <?php
xl("Did not examine",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="pelvic[]" value
="Nomal" /> <?php
xl("Nomal",'e') ?
> </label
></td
><td
> </td
><td
> </td
></tr
><tr
><td
></td
><td
><label
class="text"><input type
="checkbox" name
="pelvic[]" value
="CM tenderness" /> <?php
xl("CM tenderness",'e') ?
> </label
> </td
><td
><label
class="text"><input type
="checkbox" name
="pelvic[]" value
="Rt adnexal mass" /> <?php
xl("Rt adnexal mass",'e') ?
> </label
></td
><td
><label
class="text"><input type
="checkbox" name
="pelvic[]" value
="Lt adnexal mass" /> <?php
xl("Lt adnexal mass",'e') ?
> </label
></td
><td
> 
;</td
></tr
>
297 <td align
="left" colspan
="5"> 
;</td
>
300 <td align
="left" colspan
="5"> 
;</td
>
305 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("ASSESSMENT:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="assessment[]" value
="Morbid obesity" /> <?php
xl("Morbid obesity",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="DVT" /> <?php
xl("DVT",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hernia Inguinal" /> <?php
xl("Hernia, Inguinal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Lower Back Pain" /> <?php
xl("Lower Back Pain",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Asthma" /> <?php
xl("Asthma",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Failed prev wt loss surgery" /> <?php
xl("Failed prev wt loss surgery",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hernia Internal" /> <?php
xl("Hernia, Internal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Osteoarthritis" /> <?php
xl("Osteoarthritis",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="CHF" /> <?php
xl("CHF",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Fatty Liver" /> <?php
xl("Fatty Liver",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hypercholesterolemia" /> <?php
xl("Hypercholesterolemia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Panniculitis" /> <?php
xl("Panniculitis",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Coronary Artery Dz" /> <?php
xl("Coronary Artery Dz",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Gallbladder Dz" /> <?php
xl("Gallbladder Dz",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hernia Umbilical" /> <?php
xl("Hernia, Umbilical",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="PVD" /> <?php
xl("PVD",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="COPD" /> <?php
xl("COPD",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="GERD" /> <?php
xl("GERD",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hypertension" /> <?php
xl("Hypertension",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Sleep Apnea" /> <?php
xl("Sleep Apnea",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Depression" /> <?php
xl("Depression",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hernia Hiatal" /> <?php
xl("Hernia, Hiatal",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hypertriglyceridemia" /> <?php
xl("Hypertriglyceridemia",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Urinary Incontinence" /> <?php
xl("Urinary Incontinence",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Diabetes" /> <?php
xl("Diabetes",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hernia Incisional" /> <?php
xl("Hernia, Incisional",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Hypothyroidism" /> <?php
xl("Hypothyroidism",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="assessment[]" value
="Venous Stasis Dz" /> <?php
xl("Venous Stasis Dz",'e') ?
> </label
></td
></tr
>
309 <td align
="left" colspan
="5"> 
;</td
>
314 <tr
><td align
="right" width
="150"> 
;</td
> <td colspan
="4"><textarea name
="note2" rows
="4" cols
="60"></textarea
></td
></tr
>
316 <td align
="left" colspan
="5"> 
;</td
>
324 <tr
><td align
="right" width
="150"> <b
class="text"><?php
xl("RECOMMENDATIONS:",'e') ?
></b
> </td
> <td
><label
class="text"><input type
="checkbox" name
="recommendations[]" value
="VBG Vertical Banded Gastroplasty" /> <?php
xl("VBG (Vertical Banded Gastroplasty)",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="PRYGBP Proximal Roux en Y Gastric Bypass" /> <?php
xl("PRYGBP (Proximal Roux-en-Y Gastric Bypass)",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="SG Sleeve Gastrectomy" /> <?php
xl("SG (Sleeve Gastrectomy)",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="MRYGBP Medial Roux en Y Gastric Bypass" /> <?php
xl("MRYGBP (Medial Roux-en-Y Gastric Bypass)",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="ABG Adjustable Banded Gastroplasty" /> <?php
xl("ABG (Adjustable Banded Gastroplasty)",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="DRYGBP Distal Roux en Y Gastric Bypass" /> <?php
xl("DRYGBP (Distal Roux-en-Y Gastric Bypass)",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Gastric Restrictive Procedure other than VBG ABG" /> <?php
xl("Gastric Restrictive Procedure other than VBG/ ABG",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Duodenal Switch Procedure" /> <?php
xl("Duodenal Switch Procedure",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Revision of Gastric Restrictive Procedure" /> <?php
xl("Revision of Gastric Restrictive Procedure",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="BPD Biliopancreatic Diversion" /> <?php
xl("BPD (Biliopancreatic Diversion)",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Lysis of Adhesions" /> <?php
xl("Lysis of Adhesions",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Liver Biopsy" /> <?php
xl("Liver Biopsy",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Hiatal Hernia Repair w Fundoplication" /> <?php
xl("Hiatal Hernia Repair w/ Fundoplication",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Hiatal Hernia Repair w o Fundoplication" /> <?php
xl("Hiatal Hernia Repair w/o Fundoplication",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Vagotomy Pyloraplasty" /> <?php
xl("Vagotomy & Pyloraplasty",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Abdominoplasty" /> <?php
xl("Abdominoplasty",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Appendectomy possible" /> <?php
xl("Appendectomy (possible)",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Cholecystectomy possible" /> <?php
xl("Cholecystectomy (possible)",'e') ?
> </label
></td
></tr
><tr
><td
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="EGD Esophagogastroduodenoscopy" /> <?php
xl("EGD (Esophagogastroduodenoscopy)",'e') ?
> </label
></td
><td
> <label
class="text"><input type
="checkbox" name
="recommendations[]" value
="Colonoscopy" /> <?php
xl("Colonoscopy",'e') ?
> </label
></td
></tr
>
330 <td align
="left" colspan
="2"> 
;</td
>
333 <tr
><td align
="right" width
="150"> 
;</td
> <td
><textarea name
="note3" rows
="4" cols
="60"></textarea
></td
></tr
>
336 <input type
="submit" name
="submit form" value
="submit form" />