contrib/forms/cardiology_set/Forms3_Cardiology/view.php

   1 <!-- view.php -->
   2  <?php
   3  include_once("../../globals.php");
   4  include_once("$srcdir/api.inc");
   5  formHeader("Form: Forms3_Cardiology");
   6  $obj = formFetch("form_Forms3_Cardiology", $_GET["id"]);  //#Use the formFetch function from api.inc to get values for existing form.
   7
   8  function chkdata_Txt(&$obj, $var) {
   9          return htmlentities($obj{"$var"});
  10  }
  11  function chkdata_Date(&$obj, $var) {
  12          return htmlentities($obj{"$var"});
  13  }
  14  function chkdata_CB(&$obj, $nam, $var) {
  15         if (preg_match("/$var/",$obj{$nam})) {return "checked";} else {return "";}
  16  }
  17  function chkdata_Radio(&$obj, $nam, $var) {
  18         if (strpos($obj{$nam},$var) !== false) {return "checked";}
  19  }
  20   function chkdata_PopOrScroll(&$obj, $nam, $var) {
  21   if (preg_match("/$var/",$obj{$nam})) {return "selected";} else {return "";}
  22  }
  23
  24  ?>
  25  <html><head>
  26  <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  27  </head>
  28  <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  29  <form method=post action="<?php echo $rootdir?>/forms/Forms3_Cardiology/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form" onSubmit="return top.restoreSession()">
  30  <h1> Forms3_Cardiology </h1>
  31  <hr>
  32  <input type="submit" name="submit form" value="submit form" />
  33
  34  <table width="100%" cellpadding="0" cellspacing="0">
  35
  36      <tr>
  37
  38          <td class='text'  valign="top">
  39
  40              <table width="100%" cellpadding="0" cellspacing="0">
  41
  42                  <tr>
  43
  44                      <td class='text'  style="border: 1px #000000 solid;">
  45
  46  <table>
  47
  48  <tr><td class='text' > date</td> <td class='text' ><input type="text" name="_date" value="<?php $result = chkdata_Txt($obj,"_date"); echo $result;?>"></td></tr>
  49
  50  </table>
  51                      </td>
  52
  53                      <td class='text'   style="border: 1px #000000 solid;">
  54
  55  <table>
  56
  57  <tr><td class='text' > name</td> <td class='text' ><input type="text" name="_name" value="<?php $result = chkdata_Txt($obj,"_name"); echo $result;?>"></td></tr>
  58
  59  </table>
  60                      </td>
  61
  62
  63                  </tr>
  64
  65                 <tr>
  66
  67                         <td class='text'  colspan='2' style="border: 1px #000000 solid;">
  68
  69  <table>
  70
  71  <tr><td class='text' > chief complaint</td> <td class='text' ><input type="text" name="_chief_complaint" value="<?php $result = chkdata_Txt($obj,"_chief_complaint"); echo $result;?>"></td></tr>
  72
  73  </table>
  74                      </td></tr>
  75
  76              </table>
  77          </td>
  78      </tr>
  79
  80      <tr>
  81
  82          <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;">
  83
  84              <table width="100%" cellpadding="0" cellspacing="0">
  85
  86                  <tr>
  87
  88
  89
  90                      <td class='text'  colspan="2" style="border: 1px #000000 solid;">
  91
  92  <table>
  93
  94  <tr><td class='text' > wt</td> <td class='text' ><input type="text" name="_wt" value="<?php $result = chkdata_Txt($obj,"_wt"); echo $result;?>"></td></tr>
  95
  96  </table>
  97                      </td>
  98
  99                      <td class='text'  style="border: 1px #000000 solid;">
 100
 101  <table>
 102
 103  <tr><td class='text' > bp</td> <td class='text' ><input type="text" name="_bp" value="<?php $result = chkdata_Txt($obj,"_bp"); echo $result;?>"></td></tr>
 104
 105  </table>
 106                      </td>
 107
 108                       <td class='text'  style="border: 1px #000000 solid;">
 109
 110  <table>
 111
 112  <tr><td class='text' > p</td> <td class='text' ><input type="text" name="_p" value="<?php $result = chkdata_Txt($obj,"_p"); echo $result;?>"></td></tr>
 113
 114  </table>
 115                      </td>
 116
 117                      <td class='text'  style="border: 1px #000000 solid;">
 118
 119  <table>
 120
 121  <tr><td class='text' > t</td> <td class='text' ><input type="text" name="_t" value="<?php $result = chkdata_Txt($obj,"_t"); echo $result;?>"></td></tr>
 122
 123  </table>
 124                      </td>
 125
 126                 <td class='text'  style="border: 1px #000000 solid;">
 127
 128  <table>
 129
 130  <tr><td class='text' > r</td> <td class='text' ><input type="text" name="_r" value="<?php $result = chkdata_Txt($obj,"_r"); echo $result;?>"></td></tr>
 131
 132  </table>
 133                      </td>
 134
 135                 <td class='text'  style="border: 1px #000000 solid;">
 136
 137  <table>
 138
 139  <tr><td class='text' > ht</td> <td class='text' ><input type="text" name="_ht" value="<?php $result = chkdata_Txt($obj,"_ht"); echo $result;?>"></td></tr>
 140
 141  </table>
 142                      </td>
 143                  </tr>
 144
 145
 146
 147              </table>
 148          </td>
 149      </tr>
 150
 151
 152
 153
 154
 155
 156
 157
 158
 159      <tr>
 160
 161           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;">
 162
 163              <table width="100%" cellpadding="0" cellspacing="0">
 164
 165                  <tr>
 166
 167                      <td class='text'  colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;">
 168
 169                          <h3>
 170
 171                              HPI
 172
 173                          </h3>
 174                      </td>
 175                  </tr>
 176
 177                  <tr>
 178
 179
 180
 181                      <td class='text'   style="border: 1px #000000 solid;">
 182
 183  <table>
 184
 185  <tr><td class='text' > location</td> <td class='text' ><input type="text" name="_location" value="<?php $result = chkdata_Txt($obj,"_location"); echo $result;?>"></td></tr>
 186
 187  </table>
 188                      </td>
 189
 190                      <td class='text'  style="border: 1px #000000 solid;">
 191
 192  <table>
 193
 194  <tr><td class='text' > quality</td> <td class='text' ><input type="text" name="_quality" value="<?php $result = chkdata_Txt($obj,"_quality"); echo $result;?>"></td></tr>
 195
 196  </table>
 197                      </td>
 198
 199                       <td class='text'  style="border: 1px #000000 solid;">
 200
 201  <table>
 202
 203  <tr><td class='text' > severity</td> <td class='text' ><input type="text" name="_severity" value="<?php $result = chkdata_Txt($obj,"_severity"); echo $result;?>"></td></tr>
 204
 205  </table>
 206                      </td>
 207
 208                      <td class='text'  style="border: 1px #000000 solid;">
 209
 210  <table>
 211
 212  <tr><td class='text' > duration</td> <td class='text' ><input type="text" name="_duration" value="<?php $result = chkdata_Txt($obj,"_duration"); echo $result;?>"></td></tr>
 213
 214  </table>
 215                      </td>
 216
 217                      <td class='text'  style="border: 1px #000000 solid;">&nbsp;
 218
 219
 220                      </td>
 221                  </tr>
 222
 223  <tr>
 224
 225  <td class='text'  style="border: 1px #000000 solid;">
 226
 227  <table>
 228
 229  <tr><td class='text' > timing</td> <td class='text' ><input type="text" name="_timing" value="<?php $result = chkdata_Txt($obj,"_timing"); echo $result;?>"></td></tr>
 230
 231  </table>
 232                      </td>
 233
 234                 <td class='text'  style="border: 1px #000000 solid;">
 235
 236  <table>
 237
 238  <tr><td class='text' > context</td> <td class='text' ><input type="text" name="_context" value="<?php $result = chkdata_Txt($obj,"_context"); echo $result;?>"></td></tr>
 239
 240  </table>
 241                      </td>
 242
 243                 <td class='text'  style="border: 1px #000000 solid;">
 244
 245  <table>
 246
 247  <tr><td class='text' > modifying factors</td> <td class='text' ><input type="text" name="_modifying_factors" value="<?php $result = chkdata_Txt($obj,"_modifying_factors"); echo $result;?>"></td></tr>
 248
 249  </table>
 250                      </td>
 251
 252                 <td class='text'  style="border: 1px #000000 solid;">
 253
 254  <table>
 255
 256  <tr><td class='text' > signs symptoms</td> <td class='text' ><input type="text" name="_signs_symptoms" value="<?php $result = chkdata_Txt($obj,"_signs_symptoms"); echo $result;?>"></td></tr>
 257
 258  </table>
 259                      </td>
 260
 261                 <td class='text'  style="border: 1px #000000 solid;">
 262
 263  <table>
 264
 265  <tr><td class='text' > status of chronic illness</td> <td class='text' ><input type="text" name="_status_of_chronic_illness" value="<?php $result = chkdata_Txt($obj,"_status_of_chronic_illness"); echo $result;?>"></td></tr>
 266
 267  </table>
 268                      </td></tr>
 269
 270
 271
 272
 273
 274              </table>
 275          </td>
 276      </tr>
 277
 278
 279
 280       <tr>
 281
 282           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;">
 283
 284              <table width="100%" cellpadding="0" cellspacing="0">
 285
 286                  <tr>
 287
 288                      <td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;">
 289
 290                              ROS
 291
 292
 293                      </td>
 294
 295         <td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;">
 296
 297
 298
 299                              +
 300
 301
 302                      </td>
 303
 304         <td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;">
 305
 306
 307
 308                              -
 309
 310
 311                      </td>
 312                  </tr>
 313
 314                  <tr>
 315
 316                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 317
 318                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 319                          Systemic</td>
 320
 321                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 322
 323                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 324
 325  <table>
 326
 327  <tr><td class='text' > systemic positive</td> <td class='text' ><input type="text" name="_systemic_positive" value="<?php $result = chkdata_Txt($obj,"_systemic_positive"); echo $result;?>"></td></tr>
 328
 329  </table>
 330                      </td>
 331
 332                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 333
 334                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 335
 336  <table>
 337
 338  <tr><td class='text' > systemic negative</td> <td class='text' ><input type="text" name="_systemic_negative" value="<?php $result = chkdata_Txt($obj,"_systemic_negative"); echo $result;?>"></td></tr>
 339
 340  </table>
 341                      </td>
 342                  </tr>
 343
 344                  <tr>
 345
 346                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 347
 348                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 349                          ENT</td>
 350
 351                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 352
 353                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 354
 355  <table>
 356
 357  <tr><td class='text' > ent positive</td> <td class='text' ><input type="text" name="_ent_positive" value="<?php $result = chkdata_Txt($obj,"_ent_positive"); echo $result;?>"></td></tr>
 358
 359  </table>
 360                      </td>
 361
 362                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 363
 364                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 365
 366  <table>
 367
 368  <tr><td class='text' > ent negative</td> <td class='text' ><input type="text" name="_ent_negative" value="<?php $result = chkdata_Txt($obj,"_ent_negative"); echo $result;?>"></td></tr>
 369
 370  </table>
 371                      </td>
 372                  </tr>
 373
 374                  <tr>
 375
 376                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 377
 378                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 379                          Eyes</td>
 380
 381                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 382
 383                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 384
 385  <table>
 386
 387  <tr><td class='text' > eyes positive</td> <td class='text' ><input type="text" name="_eyes_positive" value="<?php $result = chkdata_Txt($obj,"_eyes_positive"); echo $result;?>"></td></tr>
 388
 389  </table>
 390                      </td>
 391
 392                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 393
 394                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 395
 396  <table>
 397
 398  <tr><td class='text' > eyes negative</td> <td class='text' ><input type="text" name="_eyes_negative" value="<?php $result = chkdata_Txt($obj,"_eyes_negative"); echo $result;?>"></td></tr>
 399
 400  </table>
 401                      </td>
 402                  </tr>
 403
 404                  <tr>
 405
 406                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 407
 408                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 409                          Lymph</td>
 410
 411                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 412
 413                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 414
 415  <table>
 416
 417  <tr><td class='text' > lymph positive</td> <td class='text' ><input type="text" name="_lymph_positive" value="<?php $result = chkdata_Txt($obj,"_lymph_positive"); echo $result;?>"></td></tr>
 418
 419  </table>
 420                      </td>
 421
 422                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 423
 424                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 425
 426  <table>
 427
 428  <tr><td class='text' > lymph negative</td> <td class='text' ><input type="text" name="_lymph_negative" value="<?php $result = chkdata_Txt($obj,"_lymph_negative"); echo $result;?>"></td></tr>
 429
 430  </table>
 431                      </td>
 432                  </tr>
 433
 434                  <tr>
 435
 436                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 437
 438                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 439                          Resp</td>
 440
 441                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 442
 443                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 444
 445  <table>
 446
 447  <tr><td class='text' > resp positive</td> <td class='text' ><input type="text" name="_resp_positive" value="<?php $result = chkdata_Txt($obj,"_resp_positive"); echo $result;?>"></td></tr>
 448
 449  </table>
 450                      </td>
 451
 452                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 453
 454                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 455
 456  <table>
 457
 458  <tr><td class='text' > resp negative</td> <td class='text' ><input type="text" name="_resp_negative" value="<?php $result = chkdata_Txt($obj,"_resp_negative"); echo $result;?>"></td></tr>
 459
 460  </table>
 461                      </td>
 462                  </tr>
 463
 464                  <tr>
 465
 466                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 467
 468                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 469                          CV</td>
 470
 471                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 472
 473                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 474
 475  <table>
 476
 477  <tr><td class='text' > cv positive</td> <td class='text' ><input type="text" name="_cv_positive" value="<?php $result = chkdata_Txt($obj,"_cv_positive"); echo $result;?>"></td></tr>
 478
 479  </table>
 480                      </td>
 481
 482                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 483
 484                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 485
 486  <table>
 487
 488  <tr><td class='text' > cv negative</td> <td class='text' ><input type="text" name="_cv_negative" value="<?php $result = chkdata_Txt($obj,"_cv_negative"); echo $result;?>"></td></tr>
 489
 490  </table>
 491                      </td>
 492                  </tr>
 493
 494                  <tr>
 495
 496                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 497
 498                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 499                          GI</td>
 500
 501                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 502
 503                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 504
 505  <table>
 506
 507  <tr><td class='text' > gi positive</td> <td class='text' ><input type="text" name="_gi_positive" value="<?php $result = chkdata_Txt($obj,"_gi_positive"); echo $result;?>"></td></tr>
 508
 509  </table>
 510                      </td>
 511
 512                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 513
 514                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 515
 516  <table>
 517
 518  <tr><td class='text' > gi negative</td> <td class='text' ><input type="text" name="_gi_negative" value="<?php $result = chkdata_Txt($obj,"_gi_negative"); echo $result;?>"></td></tr>
 519
 520  </table>
 521                      </td>
 522                  </tr>
 523
 524                  <tr>
 525
 526                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 527
 528                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 529                          GU</td>
 530
 531                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 532
 533                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 534
 535  <table>
 536
 537  <tr><td class='text' > gu positive</td> <td class='text' ><input type="text" name="_gu_positive" value="<?php $result = chkdata_Txt($obj,"_gu_positive"); echo $result;?>"></td></tr>
 538
 539  </table>
 540                      </td>
 541
 542                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 543
 544                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 545
 546  <table>
 547
 548  <tr><td class='text' > gu negative</td> <td class='text' ><input type="text" name="_gu_negative" value="<?php $result = chkdata_Txt($obj,"_gu_negative"); echo $result;?>"></td></tr>
 549
 550  </table>
 551                      </td>
 552                  </tr>
 553
 554                  <tr>
 555
 556                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 557
 558                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 559                          Skin</td>
 560
 561                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 562
 563                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 564
 565  <table>
 566
 567  <tr><td class='text' > skin positive</td> <td class='text' ><input type="text" name="_skin_positive" value="<?php $result = chkdata_Txt($obj,"_skin_positive"); echo $result;?>"></td></tr>
 568
 569  </table>
 570                      </td>
 571
 572                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 573
 574                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 575
 576  <table>
 577
 578  <tr><td class='text' > skin negative</td> <td class='text' ><input type="text" name="_skin_negative" value="<?php $result = chkdata_Txt($obj,"_skin_negative"); echo $result;?>"></td></tr>
 579
 580  </table>
 581                      </td>
 582                  </tr>
 583
 584                  <tr>
 585
 586                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 587
 588                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 589                          MS</td>
 590
 591                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 592
 593                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 594
 595  <table>
 596
 597  <tr><td class='text' > ms positive</td> <td class='text' ><input type="text" name="_ms_positive" value="<?php $result = chkdata_Txt($obj,"_ms_positive"); echo $result;?>"></td></tr>
 598
 599  </table>
 600                      </td>
 601
 602                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 603
 604                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 605
 606  <table>
 607
 608  <tr><td class='text' > ms negative</td> <td class='text' ><input type="text" name="_ms_negative" value="<?php $result = chkdata_Txt($obj,"_ms_negative"); echo $result;?>"></td></tr>
 609
 610  </table>
 611                      </td>
 612                  </tr>
 613
 614                  <tr>
 615
 616                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 617
 618                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 619                          Psych</td>
 620
 621                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 622
 623                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 624
 625  <table>
 626
 627  <tr><td class='text' > psych positive</td> <td class='text' ><input type="text" name="_psych_positive" value="<?php $result = chkdata_Txt($obj,"_psych_positive"); echo $result;?>"></td></tr>
 628
 629  </table>
 630                      </td>
 631
 632                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 633
 634                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 635
 636  <table>
 637
 638  <tr><td class='text' > psych negative</td> <td class='text' ><input type="text" name="_psych_negative" value="<?php $result = chkdata_Txt($obj,"_psych_negative"); echo $result;?>"></td></tr>
 639
 640  </table>
 641                      </td>
 642                  </tr>
 643
 644                  <tr>
 645
 646                      <td class='text'   align="left" colspan="3" style="border-right: #000000 1px solid; border-top: #000000 1px solid;
 647
 648                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px">
 649
 650  <table>
 651
 652  <tr><td class='text' > all other ros negative </td> <td class='text' ><textarea name="_all_other_ros_negative_"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"_all_other_ros_negative_"); echo $result;?></textarea></td></tr>
 653
 654  </table>
 655                      </td>
 656                  </tr>
 657
 658
 659
 660
 661
 662
 663
 664              </table>
 665          </td>
 666      </tr>
 667
 668
 669
 670
 671
 672        <tr>
 673
 674           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;">
 675
 676              <table width="100%" cellpadding="0" cellspacing="0">
 677
 678                  <tr>
 679
 680                      <td class='text'  colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
 681
 682  <table>
 683
 684  <tr><td class='text' > past famiy social history</td> <td class='text' ><textarea name="_past_famiy_social_history"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"_past_famiy_social_history"); echo $result;?></textarea></td></tr>
 685
 686  </table>
 687                      </td>
 688                  </tr>
 689
 690
 691
 692                   <tr>
 693
 694
 695
 696                      <td class='text'  style="border: 1px #000000 solid; height: 27px;">
 697
 698  <table>
 699
 700  <tr><td class='text' > ph no change since</td> <td class='text' ><input type="text" name="_ph_no_change_since" value="<?php $result = chkdata_Txt($obj,"_ph_no_change_since"); echo $result;?>"></td></tr>
 701
 702  </table>
 703                      </td>
 704
 705                      <td class='text'  style="border: 1px #000000 solid; height: 27px;">
 706
 707  <table>
 708
 709  <tr><td class='text' > fh no change since</td> <td class='text' ><input type="text" name="_fh_no_change_since" value="<?php $result = chkdata_Txt($obj,"_fh_no_change_since"); echo $result;?>"></td></tr>
 710
 711  </table>
 712                      </td>
 713
 714                       <td class='text'  style="border: 1px #000000 solid; height: 27px;">
 715
 716  <table>
 717
 718  <tr><td class='text' > sh no change since</td> <td class='text' ><input type="text" name="_sh_no_change_since" value="<?php $result = chkdata_Txt($obj,"_sh_no_change_since"); echo $result;?>"></td></tr>
 719
 720  </table>
 721                      </td>
 722                  </tr>
 723
 724  <tr><td class='text'  colspan='3'>
 725
 726  <table>
 727
 728  <tr><td class='text' > <?php xl("Examination",'e') ?> </td> <td class='text' ><textarea name="examination"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"examination"); echo $result;?></textarea></td></tr>
 729
 730  </table>
 731  </td></tr>
 732
 733
 734
 735              </table>
 736          </td>
 737      </tr>
 738
 739  </table>
 740  <table></table><input type="submit" name="submit form" value="submit form" />
 741
 742  </form>
 743  <?php
 744  formFooter();
 745  ?>