3 include_once("../../globals.php");
4 include_once("$srcdir/api.inc");
5 formHeader("Form: Forms_Cardiology");
6 $obj = formFetch("form_Forms_Cardiology", $_GET["id"]); //#Use the formFetch function from api.inc to get values for existing form.
8 function chkdata_Txt(&$obj, $var) {
9 return htmlentities($obj{"$var"});
11 function chkdata_Date(&$obj, $var) {
12 return htmlentities($obj{"$var"});
14 function chkdata_CB(&$obj, $nam, $var) {
15 if (preg_match("/$var/",$obj{$nam})) {return "checked";} else {return "";}
17 function chkdata_Radio(&$obj, $nam, $var) {
18 if (strpos($obj{$nam},$var) !== false) {return "checked";}
20 function chkdata_PopOrScroll(&$obj, $nam, $var) {
21 if (preg_match("/$var/",$obj{$nam})) {return "selected";} else {return "";}
26 <link rel
=stylesheet href
="<?php echo $css_header;?>" type
="text/css">
28 <body
<?php
echo $top_bg_line;?
> topmargin
=0 rightmargin
=0 leftmargin
=2 bottommargin
=0 marginwidth
=2 marginheight
=0>
29 <style type
="text/css">@import
url(../../../library
/dynarch_calendar
.css
);</style
>
30 <script type
="text/javascript" src
="../../../library/dialog.js"></script
>
31 <script type
="text/javascript" src
="../../../library/textformat.js"></script
>
32 <script type
="text/javascript" src
="../../../library/dynarch_calendar.js"></script
>
33 <script type
="text/javascript" src
="../../../library/dynarch_calendar_en.js"></script
>
34 <script type
="text/javascript" src
="../../../library/dynarch_calendar_setup.js"></script
>
35 <script language
='JavaScript'> var mypcc
= '1'; </script
>
37 <form method
=post action
="<?php echo $rootdir?>/forms/Forms_Cardiology/save.php?mode=update&id=<?php echo $_GET["id
"];?>" name
="my_form" onSubmit
="return top.restoreSession()">
38 <h1
> Forms_Cardiology
</h1
>
40 <input type
="submit" name
="submit form" value
="submit form" />
42 <table width
="100%" cellpadding
="0" cellspacing
="0">
46 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
48 <table width
="100%" cellpadding
="0" cellspacing
="0">
52 <td
class='text' colspan
="5" align
="center" style
="border: 1px #000000 solid; height: 15px;">
56 PATIENT INFORMATION
- PLEASE
PRINT
61 <tr
><td
class='text' colspan
="5"><b
> <?php
xl("FULL LEGAL NAME(FIRST NAME)",'e') ?
> </b
></td
></tr
>
65 <td
class='text' style
="border: 1px #000000 solid;">
69 <tr
><td
class='text' > first name
</td
> <td
class='text' ><input type
="text" name
="_first_name" value
="<?php $result = chkdata_Txt($obj,"_first_name
"); echo $result;?>"></td
></tr
>
74 <td
class='text' style
="border: 1px #000000 solid;">
78 <tr
><td
class='text' > middle name
</td
> <td
class='text' ><input type
="text" name
="_middle_name" value
="<?php $result = chkdata_Txt($obj,"_middle_name
"); echo $result;?>"></td
></tr
>
83 <td
class='text' style
="border: 1px #000000 solid;">
87 <tr
><td
class='text' > last name
</td
> <td
class='text' ><input type
="text" name
="_last_name" value
="<?php $result = chkdata_Txt($obj,"_last_name
"); echo $result;?>"></td
></tr
>
92 <td
class='text' colspan
="2" style
="border: 1px #000000 solid;">
96 <tr
><td
class='text' > nick name
</td
> <td
class='text' ><input type
="text" name
="_nick_name" value
="<?php $result = chkdata_Txt($obj,"_nick_name
"); echo $result;?>"></td
></tr
>
110 <td
class='text' colspan
="2" style
="border: 1px #000000 solid;">
114 <tr
><td
class='text' > street address number
</td
> <td
class='text' ><input type
="text" name
="_street_address_number" value
="<?php $result = chkdata_Txt($obj,"_street_address_number
"); echo $result;?>"></td
></tr
>
119 <td
class='text' style
="border: 1px #000000 solid;">
123 <tr
><td
class='text' > street name
</td
> <td
class='text' ><input type
="text" name
="_street_name" value
="<?php $result = chkdata_Txt($obj,"_street_name
"); echo $result;?>"></td
></tr
>
128 <td
class='text' style
="border: 1px #000000 solid;">
132 <tr
><td
class='text' > street name apt
</td
> <td
class='text' ><input type
="text" name
="_street_name_apt" value
="<?php $result = chkdata_Txt($obj,"_street_name_apt
"); echo $result;?>"></td
></tr
>
137 <td
class='text' style
="border: 1px #000000 solid;">
141 <tr
><td
class='text' > street name space
</td
> <td
class='text' ><input type
="text" name
="_street_name_space" value
="<?php $result = chkdata_Txt($obj,"_street_name_space
"); echo $result;?>"></td
></tr
>
151 <td
class='text' colspan
="2" style
="border: 1px #000000 solid;">
155 <tr
><td
class='text' > po box address number
</td
> <td
class='text' ><input type
="text" name
="_po_box_address_number" value
="<?php $result = chkdata_Txt($obj,"_po_box_address_number
"); echo $result;?>"></td
></tr
>
160 <td
class='text' style
="border: 1px #000000 solid;">
164 <tr
><td
class='text' > po box street
</td
> <td
class='text' ><input type
="text" name
="_po_box_street" value
="<?php $result = chkdata_Txt($obj,"_po_box_street
"); echo $result;?>"></td
></tr
>
169 <td
class='text' style
="border: 1px #000000 solid;">
173 <tr
><td
class='text' > po box apt
</td
> <td
class='text' ><input type
="text" name
="_po_box_apt" value
="<?php $result = chkdata_Txt($obj,"_po_box_apt
"); echo $result;?>"></td
></tr
>
178 <td
class='text' style
="border: 1px #000000 solid;">
182 <tr
><td
class='text' > po box space
</td
> <td
class='text' ><input type
="text" name
="_po_box_space" value
="<?php $result = chkdata_Txt($obj,"_po_box_space
"); echo $result;?>"></td
></tr
>
194 <td
class='text' style
="border: 1px #000000 solid;">
198 <tr
><td
class='text' > city
</td
> <td
class='text' ><input type
="text" name
="_city" value
="<?php $result = chkdata_Txt($obj,"_city
"); echo $result;?>"></td
></tr
>
203 <td
class='text' style
="border: 1px #000000 solid;">
207 <tr
><td
class='text' > state
</td
> <td
class='text' ><input type
="text" name
="_state" value
="<?php $result = chkdata_Txt($obj,"_state
"); echo $result;?>"></td
></tr
>
212 <td
class='text' style
="border: 1px #000000 solid;">
216 <tr
><td
class='text' > zip code
</td
> <td
class='text' ><input type
="text" name
="_zip_code" value
="<?php $result = chkdata_Txt($obj,"_zip_code
"); echo $result;?>"></td
></tr
>
221 <td
class='text' style
="border: 1px #000000 solid;">
225 <tr
><td
class='text' > social security
</td
> <td
class='text' ><input type
="text" name
="_social_security" value
="<?php $result = chkdata_Txt($obj,"_social_security
"); echo $result;?>"></td
></tr
>
230 <td
class='text' style
="border: 1px #000000 solid;">
234 <tr
><td
class='text' > home phone
</td
> <td
class='text' ><input type
="text" name
="_home_phone" value
="<?php $result = chkdata_Txt($obj,"_home_phone
"); echo $result;?>"></td
></tr
>
246 <td
class='text' colspan
="4" style
="border: 1px #000000 solid; height: 10px;">
250 <tr
><td
class='text' > email address
</td
> <td
class='text' ><input type
="text" name
="_email_address" value
="<?php $result = chkdata_Txt($obj,"_email_address
"); echo $result;?>"></td
></tr
>
257 <td
class='text' style
="border: 1px #000000 solid; height: 10px;">
261 <tr
><td
class='text' > cell phone
</td
> <td
class='text' ><input type
="text" name
="_cell_phone" value
="<?php $result = chkdata_Txt($obj,"_cell_phone
"); echo $result;?>"></td
></tr
>
273 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
277 <tr
><td
class='text' >
278 <span
><?php
xl(' date of birth (yyyy-mm-dd): ','e') ?
></span
>
279 </td
><td
class='text' >
280 <input type
='text' size
='10' name
='_date_of_birth' id
='_date_of_birth' onkeyup
='datekeyup(this,mypcc)' onblur
='dateblur(this,mypcc)' title
='yyyy-mm-dd last date of this event' value
="<?php $result = chkdata_Date($obj,"_date_of_birth
"); echo $result;?>">
281 <img src
='../../../interface/pic/show_calendar.gif' align
='absbottom' width
='24' height
='22'
282 id
='img__date_of_birth' border
='0' alt
='[?]' style
='cursor:pointer'
283 title
='Click here to choose a date'>
285 Calendar
.setup({inputField
:'_date_of_birth', ifFormat
:'%Y-%m-%d', button
:'img__date_of_birth'});
292 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
296 <tr
><td
class='text' > age
</td
> <td
class='text' ><input type
="text" name
="_age" value
="<?php $result = chkdata_Txt($obj,"_age
"); echo $result;?>"></td
></tr
>
301 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
305 <tr
><td
class='text' > sex
</td
> <td
class='text' ><br
> <label
><input type
="checkbox" name
="_sex[]" value
="MALE" <?php
$result = chkdata_CB($obj,"_sex","MALE"); echo $result;?
> <?php
xl(">MALE",'e') ?
> </label
>
306 <br
> <label
><input type
="checkbox" name
="_sex[]" value
="FEMALE" <?php
$result = chkdata_CB($obj,"_sex","FEMALE"); echo $result;?
> <?php
xl(">FEMALE",'e') ?
> </label
></td
></tr
>
311 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
315 <tr
><td
class='text' > marital status
</td
> <td
class='text' ><br
> <label
><input type
="checkbox" name
="_marital_status[]" value
="MARRIED" <?php
$result = chkdata_CB($obj,"_marital_status","MARRIED"); echo $result;?
> <?php
xl(">MARRIED",'e') ?
> </label
>
316 <br
> <label
><input type
="checkbox" name
="_marital_status[]" value
="SINGLE" <?php
$result = chkdata_CB($obj,"_marital_status","SINGLE"); echo $result;?
> <?php
xl(">SINGLE",'e') ?
> </label
></td
></tr
>
321 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
325 <tr
><td
class='text' > occupation
</td
> <td
class='text' ><input type
="text" name
="_occupation" value
="<?php $result = chkdata_Txt($obj,"_occupation
"); echo $result;?>"></td
></tr
>
333 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
337 <tr
><td
class='text' > employer name
</td
> <td
class='text' ><input type
="text" name
="_employer_name" value
="<?php $result = chkdata_Txt($obj,"_employer_name
"); echo $result;?>"></td
></tr
>
342 <td
class='text' colspan
="4" style
="border: 1px #000000 solid;;">
352 <tr
><td
class='text' > employer street address
</td
> <td
class='text' ><input type
="text" name
="_employer_street_address" value
="<?php $result = chkdata_Txt($obj,"_employer_street_address
"); echo $result;?>"></td
></tr
>
361 <tr
><td
class='text' > employer city
</td
> <td
class='text' ><input type
="text" name
="_employer_city" value
="<?php $result = chkdata_Txt($obj,"_employer_city
"); echo $result;?>"></td
></tr
>
370 <tr
><td
class='text' > employer state
</td
> <td
class='text' ><input type
="text" name
="_employer_state" value
="<?php $result = chkdata_Txt($obj,"_employer_state
"); echo $result;?>"></td
></tr
>
379 <tr
><td
class='text' > employer zip code
</td
> <td
class='text' ><input type
="text" name
="_employer_zip_code" value
="<?php $result = chkdata_Txt($obj,"_employer_zip_code
"); echo $result;?>"></td
></tr
>
393 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
397 <tr
><td
class='text' > business phone
</td
> <td
class='text' ><input type
="text" name
="_business_phone" value
="<?php $result = chkdata_Txt($obj,"_business_phone
"); echo $result;?>"></td
></tr
>
402 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
406 <tr
><td
class='text' > extension
</td
> <td
class='text' ><input type
="text" name
="_extension" value
="<?php $result = chkdata_Txt($obj,"_extension
"); echo $result;?>"></td
></tr
>
411 <td
class='text' style
="border: 1px #000000 solid; height: 15px;">
415 <tr
><td
class='text' > drivers license
</td
> <td
class='text' ><input type
="text" name
="_drivers_license" value
="<?php $result = chkdata_Txt($obj,"_drivers_license
"); echo $result;?>"></td
></tr
>
420 <td
class='text' colspan
="2" style
="border: 1px #000000 solid; height: 15px;">
424 <tr
><td
class='text' > drivers license state
</td
> <td
class='text' ><input type
="text" name
="_drivers_license_state" value
="<?php $result = chkdata_Txt($obj,"_drivers_license_state
"); echo $result;?>"></td
></tr
>
450 <td
class='text' valign
="top" style
="border: 1px #000000 solid; height: 15px;">
452 <table width
="100%" cellpadding
="0" cellspacing
="0">
456 <td
class='text' colspan
="7" align
="center" style
="border: 1px #000000 solid; height: 15px;">
460 SPOUSE
'S, PARENT'S
, AND / OR GUARANTER
'S INFORMATION
466 <tr><td class='text
' colspan="7">
470 <tr><td class='text
' > spg refers to spouse/parents/guarantors</td> <td class='text
' ><input type="text" name="_spg_refers_to_spouse_parents_guarantors" /></td></tr>
479 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
483 <tr><td class='text
' > spg first name</td> <td class='text
' ><input type="text" name="_spg_first_name" value="<?php $result = chkdata_Txt($obj,"_spg_first_name"); echo $result;?>"></td></tr>
488 <td class='text
' style="border: 1px #000000 solid;">
492 <tr><td class='text
' > spg middle name</td> <td class='text
' ><input type="text" name="_spg_middle_name" value="<?php $result = chkdata_Txt($obj,"_spg_middle_name"); echo $result;?>"></td></tr>
497 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
501 <tr><td class='text
' > spg last name</td> <td class='text
' ><input type="text" name="_spg_last_name" value="<?php $result = chkdata_Txt($obj,"_spg_last_name"); echo $result;?>"></td></tr>
506 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
510 <tr><td class='text
' > spg occupation</td> <td class='text
' ><input type="text" name="_spg_occupation" value="<?php $result = chkdata_Txt($obj,"_spg_occupation"); echo $result;?>"></td></tr>
522 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
526 <tr><td class='text
' > spg address if different than above</td> <td class='text
' ><input type="text" name="_spg_address_if_different_than_above" value="<?php $result = chkdata_Txt($obj,"_spg_address_if_different_than_above"); echo $result;?>"></td></tr>
531 <td class='text
' style="border: 1px #000000 solid;">
535 <tr><td class='text
' > spg city</td> <td class='text
' ><input type="text" name="_spg_city" value="<?php $result = chkdata_Txt($obj,"_spg_city"); echo $result;?>"></td></tr>
540 <td class='text
' style="border: 1px #000000 solid;">
544 <tr><td class='text
' > spg state</td> <td class='text
' ><input type="text" name="_spg_state" value="<?php $result = chkdata_Txt($obj,"_spg_state"); echo $result;?>"></td></tr>
549 <td class='text
' style="border: 1px #000000 solid;">
553 <tr><td class='text
' > spg zip code</td> <td class='text
' ><input type="text" name="_spg_zip_code" value="<?php $result = chkdata_Txt($obj,"_spg_zip_code"); echo $result;?>"></td></tr>
558 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
562 <tr><td class='text
' > spg home phone</td> <td class='text
' ><input type="text" name="_spg_home_phone" value="<?php $result = chkdata_Txt($obj,"_spg_home_phone"); echo $result;?>"></td></tr>
574 <td class='text
' colspan="2" style="border: 1px #000000 solid;">
578 <tr><td class='text
' > spg employer street address</td> <td class='text
' ><input type="text" name="_spg_employer_street_address" value="<?php $result = chkdata_Txt($obj,"_spg_employer_street_address"); echo $result;?>"></td></tr>
583 <td class='text
' style="border: 1px #000000 solid;">
587 <tr><td class='text
' > spg employer city</td> <td class='text
' ><input type="text" name="_spg_employer_city" value="<?php $result = chkdata_Txt($obj,"_spg_employer_city"); echo $result;?>"></td></tr>
592 <td class='text
' style="border: 1px #000000 solid;">
596 <tr><td class='text
' > spg employer state</td> <td class='text
' ><input type="text" name="_spg_employer_state" value="<?php $result = chkdata_Txt($obj,"_spg_employer_state"); echo $result;?>"></td></tr>
601 <td class='text
' style="border: 1px #000000 solid;">
605 <tr><td class='text
' > spg employer zip code</td> <td class='text
' ><input type="text" name="_spg_employer_zip_code" value="<?php $result = chkdata_Txt($obj,"_spg_employer_zip_code"); echo $result;?>"></td></tr>
610 <td class='text
' style="border: 1px #000000 solid;">
614 <tr><td class='text
' > spg employer business phone</td> <td class='text
' ><input type="text" name="_spg_employer_business_phone" value="<?php $result = chkdata_Txt($obj,"_spg_employer_business_phone"); echo $result;?>"></td></tr>
619 <td class='text
' style="border: 1px #000000 solid;">
623 <tr><td class='text
' > spg employer extension</td> <td class='text
' ><input type="text" name="_spg_employer_extension" value="<?php $result = chkdata_Txt($obj,"_spg_employer_extension"); echo $result;?>"></td></tr>
639 <td class='text
' valign="top" style="border: 1px #000000 solid; height: 15px;">
641 <table width="100%" cellpadding="0" cellspacing="0">
645 <td class='text
' colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
659 <td class='text
' colspan="3" style="border: 1px #000000 solid;">
663 <tr><td class='text
' > concerning insurance deatils</td> <td class='text
' ><label><input type="checkbox" name="_concerning_insurance_deatils[]" value="SPOUCE IS POLICY HOLDER" <?php $result = chkdata_CB($obj,"_concerning_insurance_deatils","SPOUCE IS POLICY HOLDER"); echo $result;?> <?php xl(">SPOUCE IS POLICY HOLDER",'e
') ?> </label>
664 <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="MEDICARE" <?php $result = chkdata_CB($obj,"_concerning_insurance_deatils","MEDICARE"); echo $result;?> <?php xl(">MEDICARE",'e
') ?> </label>
665 <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="MEDICAL" <?php $result = chkdata_CB($obj,"_concerning_insurance_deatils","MEDICAL"); echo $result;?> <?php xl(">MEDICAL",'e
') ?> </label>
666 <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="HMO" <?php $result = chkdata_CB($obj,"_concerning_insurance_deatils","HMO"); echo $result;?> <?php xl(">HMO",'e
') ?> </label>
667 <label><input type="checkbox" name="_concerning_insurance_deatils[]" value="WORK COMP" <?php $result = chkdata_CB($obj,"_concerning_insurance_deatils","WORK COMP"); echo $result;?> <?php xl(">WORK COMP",'e
') ?> </label></td></tr>
679 <td class='text
' colspan="3" align="right" >
683 <tr><td class='text
' >
684 <span ><?php xl(' date of
injury (yyyy
-mm
-dd
): ','e
') ?></span>
685 </td><td class='text
' >
686 <input type='text
' size='10' name='_date_of_injury
' id='_date_of_injury
' onkeyup='datekeyup(this
,mypcc
)' onblur='dateblur(this
,mypcc
)' title='yyyy
-mm
-dd last date of this event
' value="<?php $result = chkdata_Date($obj,"_date_of_injury"); echo $result;?>">
687 <img src='../../../interface/pic
/show_calendar
.gif
' align='absbottom
' width='24' height='22'
688 id='img__date_of_injury
' border='0' alt='[?
]' style='cursor
:pointer
'
689 title='Click here to choose a date
'>
691 Calendar.setup({inputField:'_date_of_injury
', ifFormat:'%Y
-%m
-%d
', button:'img__date_of_injury
'});
707 <td class='text
' style="border: 1px #000000 solid;">
711 <tr><td class='text
' > primary insurance co here</td> <td class='text
' ><input type="text" name="_primary_insurance_co_here" value="<?php $result = chkdata_Txt($obj,"_primary_insurance_co_here"); echo $result;?>"></td></tr>
716 <td class='text
' style="border: 1px #000000 solid;">
720 <tr><td class='text
' > primary insurance group number</td> <td class='text
' ><input type="text" name="_primary_insurance_group_number" value="<?php $result = chkdata_Txt($obj,"_primary_insurance_group_number"); echo $result;?>"></td></tr>
725 <td class='text
' style="border: 1px #000000 solid;">
729 <tr><td class='text
' > primary insurance id number</td> <td class='text
' ><input type="text" name="_primary_insurance_id_number" value="<?php $result = chkdata_Txt($obj,"_primary_insurance_id_number"); echo $result;?>"></td></tr>
743 <td class='text
' style="border: 1px #000000 solid;">
747 <tr><td class='text
' > primary insurance insured name</td> <td class='text
' ><input type="text" name="_primary_insurance_insured_name" value="<?php $result = chkdata_Txt($obj,"_primary_insurance_insured_name"); echo $result;?>"></td></tr>
752 <td class='text
' style="border: 1px #000000 solid;">
756 <tr><td class='text
' >
757 <span ><?php xl(' primary insurance insured date of
birth (yyyy
-mm
-dd
): ','e
') ?></span>
758 </td><td class='text
' >
759 <input type='text
' size='10' name='_primary_insurance_insured_date_of_birth
' id='_primary_insurance_insured_date_of_birth
' onkeyup='datekeyup(this
,mypcc
)' onblur='dateblur(this
,mypcc
)' title='yyyy
-mm
-dd last date of this event
' value="<?php $result = chkdata_Date($obj,"_primary_insurance_insured_date_of_birth"); echo $result;?>">
760 <img src='../../../interface/pic
/show_calendar
.gif
' align='absbottom
' width='24' height='22'
761 id='img__primary_insurance_insured_date_of_birth
' border='0' alt='[?
]' style='cursor
:pointer
'
762 title='Click here to choose a date
'>
764 Calendar.setup({inputField:'_primary_insurance_insured_date_of_birth
', ifFormat:'%Y
-%m
-%d
', button:'img__primary_insurance_insured_date_of_birth
'});
771 <td class='text
' style="border: 1px #000000 solid;">
775 <tr><td class='text
' > primary insurance insured address</td> <td class='text
' ><input type="text" name="_primary_insurance_insured_address" value="<?php $result = chkdata_Txt($obj,"_primary_insurance_insured_address"); echo $result;?>"></td></tr>
789 <td class='text
' style="border: 1px #000000 solid;">
793 <tr><td class='text
' > secondary insurance co name</td> <td class='text
' ><input type="text" name="_secondary_insurance_co_name" value="<?php $result = chkdata_Txt($obj,"_secondary_insurance_co_name"); echo $result;?>"></td></tr>
798 <td class='text
' style="border: 1px #000000 solid;">
802 <tr><td class='text
' > secondary insurance group number</td> <td class='text
' ><input type="text" name="_secondary_insurance_group_number" value="<?php $result = chkdata_Txt($obj,"_secondary_insurance_group_number"); echo $result;?>"></td></tr>
807 <td class='text
' style="border: 1px #000000 solid;">
811 <tr><td class='text
' > secondary insurance id number</td> <td class='text
' ><input type="text" name="_secondary_insurance_id_number" value="<?php $result = chkdata_Txt($obj,"_secondary_insurance_id_number"); echo $result;?>"></td></tr>
825 <td class='text
' style="border: 1px #000000 solid;">
829 <tr><td class='text
' > secondary insurance insureds name</td> <td class='text
' ><input type="text" name="_secondary_insurance_insureds_name" value="<?php $result = chkdata_Txt($obj,"_secondary_insurance_insureds_name"); echo $result;?>"></td></tr>
834 <td class='text
' style="border: 1px #000000 solid;">
838 <tr><td class='text
' >
839 <span ><?php xl(' secondary insurance insureds date of
birth (yyyy
-mm
-dd
): ','e
') ?></span>
840 </td><td class='text
' >
841 <input type='text
' size='10' name='_secondary_insurance_insureds_date_of_birth
' id='_secondary_insurance_insureds_date_of_birth
' onkeyup='datekeyup(this
,mypcc
)' onblur='dateblur(this
,mypcc
)' title='yyyy
-mm
-dd last date of this event
' value="<?php $result = chkdata_Date($obj,"_secondary_insurance_insureds_date_of_birth"); echo $result;?>">
842 <img src='../../../interface/pic
/show_calendar
.gif
' align='absbottom
' width='24' height='22'
843 id='img__secondary_insurance_insureds_date_of_birth
' border='0' alt='[?
]' style='cursor
:pointer
'
844 title='Click here to choose a date
'>
846 Calendar.setup({inputField:'_secondary_insurance_insureds_date_of_birth
', ifFormat:'%Y
-%m
-%d
', button:'img__secondary_insurance_insureds_date_of_birth
'});
853 <td class='text
' style="border: 1px #000000 solid;">
857 <tr><td class='text
' > secondary insurance insureds col address</td> <td class='text
' ><input type="text" name="_secondary_insurance_insureds_col_address" value="<?php $result = chkdata_Txt($obj,"_secondary_insurance_insureds_col_address"); echo $result;?>"></td></tr>
881 <td class='text
' valign="top" style="border: 1px #000000 solid; height: 15px;">
883 <table width="100%" cellpadding="0" cellspacing="0">
887 <td class='text
' colspan="4" align="center" style="border: 1px #000000 solid; height: 15px;">
891 EMERGENCY INFORMATION
905 <td class='text
' colspan="3" style="border: 1px #000000 solid;">
909 <tr><td class='text
' > person to notify in case of emergency not leaving with you</td> <td class='text
' ><input type="text" name="_person_to_notify_in_case_of_emergency_not_leaving_with_you" value="<?php $result = chkdata_Txt($obj,"_person_to_notify_in_case_of_emergency_not_leaving_with_you"); echo $result;?>"></td></tr>
914 <td class='text
' style="border: 1px #000000 solid;">
918 <tr><td class='text
' > relationship</td> <td class='text
' ><input type="text" name="_relationship" value="<?php $result = chkdata_Txt($obj,"_relationship"); echo $result;?>"></td></tr>
932 <td class='text
' style="border: 1px #000000 solid;">
936 <tr><td class='text
' > person address</td> <td class='text
' ><input type="text" name="_person_address" value="<?php $result = chkdata_Txt($obj,"_person_address"); echo $result;?>"></td></tr>
941 <td class='text
' style="border: 1px #000000 solid;">
945 <tr><td class='text
' > person street</td> <td class='text
' ><input type="text" name="_person_street" value="<?php $result = chkdata_Txt($obj,"_person_street"); echo $result;?>"></td></tr>
950 <td class='text
' style="border: 1px #000000 solid;">
954 <tr><td class='text
' > person apt</td> <td class='text
' ><input type="text" name="_person_apt" value="<?php $result = chkdata_Txt($obj,"_person_apt"); echo $result;?>"></td></tr>
961 <td class='text
' style="border: 1px #000000 solid;">
965 <tr><td class='text
' > person space</td> <td class='text
' ><input type="text" name="_person_space" value="<?php $result = chkdata_Txt($obj,"_person_space"); echo $result;?>"></td></tr>
977 <td class='text
' style="border: 1px #000000 solid; height: 6px;">
981 <tr><td class='text
' > person city</td> <td class='text
' ><input type="text" name="_person_city" value="<?php $result = chkdata_Txt($obj,"_person_city"); echo $result;?>"></td></tr>
986 <td class='text
' style="border: 1px #000000 solid; height: 6px;">
990 <tr><td class='text
' > person state</td> <td class='text
' ><input type="text" name="_person_state" value="<?php $result = chkdata_Txt($obj,"_person_state"); echo $result;?>"></td></tr>
995 <td class='text
' style="border: 1px #000000 solid; height: 6px;">
999 <tr><td class='text
' > person zip code</td> <td class='text
' ><input type="text" name="_person_zip_code" value="<?php $result = chkdata_Txt($obj,"_person_zip_code"); echo $result;?>"></td></tr>
1006 <td class='text
' style="border: 1px #000000 solid; height: 6px;">
1010 <tr><td class='text
' > person home phone</td> <td class='text
' ><input type="text" name="_person_home_phone" value="<?php $result = chkdata_Txt($obj,"_person_home_phone"); echo $result;?>"></td></tr>
1031 <table><tr><td class='text
' colspan="3"><h3> <?php xl("Health History (Confidential)",'e
') ?> </h3></td></tr>
1034 <td class='text
' colspan="3" style="border: 1px #000000 solid"><h3> <?php xl("History and Physical",'e
') ?> </h3></td></tr>
1036 <tr><td class='text
' >
1037 <?php xl("Heart problems",'e
') ?> <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Attack" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Heart Attack"); echo $result;?> <?php xl(">Heart Attack",'e
') ?> </label>
1038 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Angina" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Angina"); echo $result;?> <?php xl(">Angina",'e
') ?> </label>
1039 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Murmur" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Heart Murmur"); echo $result;?> <?php xl(">Heart Murmur",'e
') ?> </label>
1040 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Rheumatic Fever" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Rheumatic Fever"); echo $result;?> <?php xl(">Rheumatic Fever",'e
') ?> </label>
1041 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Abnormal Rhythm-arrhythmia" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Abnormal Rhythm-arrhythmia"); echo $result;?> <?php xl(">Abnormal Rhythm(arrhythmia)",'e
') ?> </label>
1042 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Palpitations and irregular heartbeats" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Palpitations and irregular heartbeats"); echo $result;?> <?php xl(">Palpitations and irregular heartbeats",'e
') ?> </label><br>
1043 <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Fainting" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Fainting"); echo $result;?> <?php xl(">Fainting",'e
') ?> </label>
1044 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Enlarge Heart" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Enlarge Heart"); echo $result;?> <?php xl(">Enlarge Heart",'e
') ?> </label>
1045 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Chest Pains or Pressure" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Chest Pains or Pressure"); echo $result;?> <?php xl(">Chest Pains or Pressure",'e
') ?> </label>
1046 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Shortness of Breath" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Shortness of Breath"); echo $result;?> <?php xl(">Shortness of Breath",'e
') ?> </label>
1047 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Dizziness" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Dizziness"); echo $result;?> <?php xl(">Dizziness",'e
') ?> </label>
1048 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Swollen Legs" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Swollen Legs"); echo $result;?> <?php xl(">Swollen Legs",'e
') ?> </label>
1049 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Heart Failure" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Heart Failure"); echo $result;?> <?php xl(">Heart Failure",'e
') ?> </label>
1050 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Blue Lips or Fingernails" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Blue Lips or Fingernails"); echo $result;?> <?php xl(">Blue Lips or Fingernails",'e
') ?> </label>
1051 <br> <label><input type="checkbox" name="heart_problems_or_symptoms[]" value="Leg Cramps when you walk" <?php $result = chkdata_CB($obj,"heart_problems_or_symptoms","Leg Cramps when you walk"); echo $result;?> <?php xl(">Leg Cramps when you walk",'e
') ?> </label>
1054 <td class='text
' valign="top">
1055 <?php xl("Have you ever had",'e
') ?> <br> <label><input type="checkbox" name="have_you_ever_had[]" value="A Stress Test" <?php $result = chkdata_CB($obj,"have_you_ever_had","A Stress Test"); echo $result;?> <?php xl(">A Stress Test",'e
') ?> </label>
1056 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="An Echocardiogram" <?php $result = chkdata_CB($obj,"have_you_ever_had","An Echocardiogram"); echo $result;?> <?php xl(">An Echocardiogram",'e
') ?> </label>
1057 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Cardiac Catheterization" <?php $result = chkdata_CB($obj,"have_you_ever_had","Cardiac Catheterization"); echo $result;?> <?php xl(">Cardiac Catheterization",'e
') ?> </label>
1058 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Coronary Angioplasty" <?php $result = chkdata_CB($obj,"have_you_ever_had","Coronary Angioplasty"); echo $result;?> <?php xl(">Coronary Angioplasty",'e
') ?> </label>
1059 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Coronary Bypass Surgery" <?php $result = chkdata_CB($obj,"have_you_ever_had","Coronary Bypass Surgery"); echo $result;?> <?php xl(">Coronary Bypass Surgery",'e
') ?> </label>
1060 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Valve Surgery" <?php $result = chkdata_CB($obj,"have_you_ever_had","Valve Surgery"); echo $result;?> <?php xl(">Valve Surgery",'e
') ?> </label>
1061 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Electrophysiology Study or Proc" <?php $result = chkdata_CB($obj,"have_you_ever_had","Electrophysiology Study or Proc"); echo $result;?> <?php xl(">Electrophysiology Study or Proc",'e
') ?> </label>
1062 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="A Pacemaker" <?php $result = chkdata_CB($obj,"have_you_ever_had","A Pacemaker"); echo $result;?> <?php xl(">A Pacemaker",'e
') ?> </label>
1063 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Implanted Defibrillator" <?php $result = chkdata_CB($obj,"have_you_ever_had","Implanted Defibrillator"); echo $result;?> <?php xl(">Implanted Defibrillator",'e
') ?> </label>
1064 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="ECG" <?php $result = chkdata_CB($obj,"have_you_ever_had","ECG"); echo $result;?> <?php xl(">ECG",'e
') ?> </label>
1065 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="24 Holter Monitor" <?php $result = chkdata_CB($obj,"have_you_ever_had","24 Holter Monitor"); echo $result;?> <?php xl(">24 Holter Monitor",'e
') ?> </label>
1066 <br> <label><input type="checkbox" name="have_you_ever_had[]" value="Event Recorder " <?php $result = chkdata_CB($obj,"have_you_ever_had","Event Recorder "); echo $result;?> <?php xl(">Event Recorder ",'e
') ?> </label>
1069 <td class='text
' valign="top">
1070 <?php xl("Check if you have",'e
') ?> <br> <label><input type="checkbox" name="check_if_you_have[]" value="High Blood Pressure" <?php $result = chkdata_CB($obj,"check_if_you_have","High Blood Pressure"); echo $result;?> <?php xl(">High Blood Pressure",'e
') ?> </label> <br> <label><input type="checkbox" name="check_if_you_have[]" value="High Cholestrol" <?php $result = chkdata_CB($obj,"check_if_you_have","High Cholestrol"); echo $result;?> <?php xl(">High Cholestrol",'e
') ?> </label>
1071 <br> <label><input type="checkbox" name="check_if_you_have[]" value="Ever Smoked" <?php $result = chkdata_CB($obj,"check_if_you_have","Ever Smoked"); echo $result;?> <?php xl(">Ever Smoked",'e
') ?> </label>
1072 <br> <label><input type="checkbox" name="check_if_you_have[]" value="Diabetes" <?php $result = chkdata_CB($obj,"check_if_you_have","Diabetes"); echo $result;?> <?php xl(">Diabetes",'e
') ?> </label>
1073 <br> <label><input type="checkbox" name="check_if_you_have[]" value="Do You Exercise" <?php $result = chkdata_CB($obj,"check_if_you_have","Do You Exercise"); echo $result;?> <?php xl(">Do You Exercise",'e
') ?> </label><br> <?php xl("Close family member with",'e
') ?> <br> <label><input type="checkbox" name="close_family_member_with[]" value="Heart Attack" <?php $result = chkdata_CB($obj,"close_family_member_with","Heart Attack"); echo $result;?> <?php xl(">Heart Attack",'e
') ?> </label>
1074 <br> <label><input type="checkbox" name="close_family_member_with[]" value="Angina" <?php $result = chkdata_CB($obj,"close_family_member_with","Angina"); echo $result;?> <?php xl(">Angina",'e
') ?> </label><br><?php xl("If a woman have you",'e
') ?> <br> <label><input type="checkbox" name="if_a_woman_have_you[]" value="Passed Menopause" <?php $result = chkdata_CB($obj,"if_a_woman_have_you","Passed Menopause"); echo $result;?> <?php xl(">Passed Menopause",'e
') ?> </label><br> <?php xl("Menopause passed on what age",'e
') ?> <input type="text" name="menopause_passed_on_what_age" value="<?php $result = chkdata_Txt($obj,"menopause_passed_on_what_age"); echo $result;?>">
1076 <br> <label><input type="checkbox" name="have_you_take_estrogen_replacement" value="yes" <?php $result = chkdata_CB($obj,"have_you_take_estrogen_replacement","yes"); echo $result;?>></label> <?php xl("Have you take estrogen replacement",'e
') ?>
1081 <tr><td class='text
' colspan="3" > <?php xl("Please tell us anything else about heart",'e
') ?> <textarea name="please_tell_us_anything_else_about_heart" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"please_tell_us_anything_else_about_heart"); echo $result;?></textarea></td></tr>
1084 <tr><td class='text
' colspan="3" style="border: 1px #000000 solid; height: 28px;"><h3> <?php xl("Current Medications",'e
') ?> </h3></td></tr>
1088 <td class='text
' colspan="3">
1089 <strong> <?php xl("Please tell us about medicines(name,dose or strength,how many times a day).Include over the counter medictaions:",'e
') ?> </strong></td></tr>
1091 <tr><td class='text
' colspan="3">
1095 <tr><td class='text
' > <?php xl("Medicine detail1",'e
') ?> <textarea name="medicine_detail1" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail1"); echo $result;?></textarea></td></tr>
1100 <tr><td class='text
' colspan="3">
1104 <tr><td class='text
' > <?php xl("Medicine detail2",'e
') ?> <textarea name="medicine_detail2" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail2"); echo $result;?></textarea></td></tr>
1109 <tr><td class='text
' colspan="3">
1113 <tr><td class='text
' > <?php xl("Medicine detail3",'e
') ?> <textarea name="medicine_detail3" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail3"); echo $result;?></textarea></td></tr>
1118 <tr><td class='text
' colspan="3">
1122 <tr><td class='text
' > <?php xl("Medicine detail4",'e
') ?> <textarea name="medicine_detail4" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail4"); echo $result;?></textarea></td></tr>
1127 <tr><td class='text
' colspan="3">
1131 <tr><td class='text
' > <?php xl("Medicine detail5",'e
') ?> <textarea name="medicine_detail5" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail5"); echo $result;?></textarea></td></tr>
1136 <tr><td class='text
' colspan="3">
1140 <tr><td class='text
' > <?php xl("Medicine detail6",'e
') ?> <textarea name="medicine_detail6" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail6"); echo $result;?></textarea></td></tr>
1145 <tr><td class='text
' colspan="3">
1149 <tr><td class='text
' > <?php xl("Medicine detail7",'e
') ?> <textarea name="medicine_detail7" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail7"); echo $result;?></textarea></td></tr>
1154 <tr><td class='text
' colspan="3">
1158 <tr><td class='text
' > <?php xl("Medicine detail8",'e
') ?> <textarea name="medicine_detail8" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"medicine_detail8"); echo $result;?></textarea></td></tr>
1164 <td class='text
' colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Allergies",'e
') ?> </h3></td></tr>
1166 <tr><td class='text
' colspan="3">
1170 <tr><td class='text
' > <?php xl("Are you allergic to any medications",'e
') ?>
1171 <label><input type="checkbox" name="are_you_allergic_to_any_medications[]" value="Yes" <?php $result = chkdata_CB($obj,"are_you_allergic_to_any_medications","Yes"); echo $result;?> <?php xl(">Yes",'e
') ?> </label>
1172 <label><input type="checkbox" name="are_you_allergic_to_any_medications[]" value="No" <?php $result = chkdata_CB($obj,"are_you_allergic_to_any_medications","No"); echo $result;?> <?php xl(">No",'e
') ?> </label></td></tr>
1177 <tr><td class='text
' colspan="3">
1181 <tr><td class='text
' > <?php xl("Lis medicine to which you are allergic",'e
') ?> <input type="text" name="lis_medicine_to_which_you_are_allergic" value="<?php $result = chkdata_Txt($obj,"lis_medicine_to_which_you_are_allergic"); echo $result;?>"></td></tr>
1186 <tr><td class='text
' colspan="3">
1190 <tr><td class='text
' > <?php xl("What kind of reaction did you have",'e
') ?> <input type="text" name="what_kind_of_reaction_did_you_have" value="<?php $result = chkdata_Txt($obj,"what_kind_of_reaction_did_you_have"); echo $result;?>"></td></tr>
1197 <td class='text
' valign="top">
1199 <?php xl("Constitutional",'e
') ?> <br> <label><input type="checkbox" name="constitutional[]" value="Lack of energy" <?php $result = chkdata_CB($obj,"constitutional","Lack of energy"); echo $result;?> <?php xl(">Lack of energy",'e
') ?> </label>
1200 <br> <label><input type="checkbox" name="constitutional[]" value="Trouble sleeping" <?php $result = chkdata_CB($obj,"constitutional","Trouble sleeping"); echo $result;?> <?php xl(">Trouble sleeping",'e
') ?> </label>
1201 <br> <label><input type="checkbox" name="constitutional[]" value="Loss of appetite" <?php $result = chkdata_CB($obj,"constitutional","Loss of appetite"); echo $result;?> <?php xl(">Loss of appetite",'e
') ?> </label>
1202 <br> <label><input type="checkbox" name="constitutional[]" value="Weight changes" <?php $result = chkdata_CB($obj,"constitutional","Weight changes"); echo $result;?> <?php xl(">Weight changes",'e
') ?> </label>
1203 <br> <label><input type="checkbox" name="constitutional[]" value="Fever" <?php $result = chkdata_CB($obj,"constitutional","Fever"); echo $result;?> <?php xl(">Fever",'e
') ?> </label>
1206 <td class='text
' valign="top">
1208 <?php xl("Heent",'e
') ?> <br> <label><input type="checkbox" name="heent[]" value="Blurred vision" <?php $result = chkdata_CB($obj,"heent","Blurred vision"); echo $result;?> <?php xl(">Blurred vision",'e
') ?> </label>
1209 <br> <label><input type="checkbox" name="heent[]" value="Glaucoma" <?php $result = chkdata_CB($obj,"heent","Glaucoma"); echo $result;?> <?php xl(">Glaucoma",'e
') ?> </label>
1210 <br> <label><input type="checkbox" name="heent[]" value="Cataracts" <?php $result = chkdata_CB($obj,"heent","Cataracts"); echo $result;?> <?php xl(">Cataracts",'e
') ?> </label>
1211 <br> <label><input type="checkbox" name="heent[]" value="Buzzing or ringing in ears" <?php $result = chkdata_CB($obj,"heent","Buzzing or ringing in ears"); echo $result;?> <?php xl(">Buzzing or ringing in ears",'e
') ?> </label>
1212 <br> <label><input type="checkbox" name="heent[]" value="Hay fever" <?php $result = chkdata_CB($obj,"heent","Hay fever"); echo $result;?> <?php xl(">Hay fever",'e
') ?> </label>
1213 <br> <label><input type="checkbox" name="heent[]" value="Sinus problem" <?php $result = chkdata_CB($obj,"heent","Sinus problem"); echo $result;?> <?php xl(">Sinus problem",'e
') ?> </label>
1216 <td class='text
' valign="top">
1218 <?php xl("Respiratory",'e
') ?> <br> <label><input type="checkbox" name="respiratory[]" value="Wheezing" <?php $result = chkdata_CB($obj,"respiratory","Wheezing"); echo $result;?> <?php xl(">Wheezing",'e
') ?> </label>
1219 <br> <label><input type="checkbox" name="respiratory[]" value="Cough" <?php $result = chkdata_CB($obj,"respiratory","Cough"); echo $result;?> <?php xl(">Cough",'e
') ?> </label>
1220 <br> <label><input type="checkbox" name="respiratory[]" value="Coughing Blood" <?php $result = chkdata_CB($obj,"respiratory","Coughing Blood"); echo $result;?> <?php xl(">Coughing Blood",'e
') ?> </label>
1221 <br> <label><input type="checkbox" name="respiratory[]" value="Asthma" <?php $result = chkdata_CB($obj,"respiratory","Asthma"); echo $result;?> <?php xl(">Asthma",'e
') ?> </label>
1222 <br> <label><input type="checkbox" name="respiratory[]" value="Tuberculosis" <?php $result = chkdata_CB($obj,"respiratory","Tuberculosis"); echo $result;?> <?php xl(">Tuberculosis",'e
') ?> </label>
1228 <td class='text
' valign="top">
1230 <?php xl("Digestive",'e
') ?> <br> <label><input type="checkbox" name="digestive[]" value="Indigestion" <?php $result = chkdata_CB($obj,"digestive","Indigestion"); echo $result;?> <?php xl(">Indigestion",'e
') ?> </label>
1231 <br> <label><input type="checkbox" name="digestive[]" value="Change in bowel habits" <?php $result = chkdata_CB($obj,"digestive","Change in bowel habits"); echo $result;?> <?php xl(">Change in bowel habits",'e
') ?> </label>
1232 <br> <label><input type="checkbox" name="digestive[]" value="Bloody or tarry stools" <?php $result = chkdata_CB($obj,"digestive","Bloody or tarry stools"); echo $result;?> <?php xl(">Bloody or tarry stools",'e
') ?> </label>
1233 <br> <label><input type="checkbox" name="digestive[]" value="Jaundice" <?php $result = chkdata_CB($obj,"digestive","Jaundice"); echo $result;?> <?php xl(">Jaundice",'e
') ?> </label>
1234 <br> <label><input type="checkbox" name="digestive[]" value="Liver problems" <?php $result = chkdata_CB($obj,"digestive","Liver problems"); echo $result;?> <?php xl(">Liver problems",'e
') ?> </label>
1235 <br> <label><input type="checkbox" name="digestive[]" value="Ulcers" <?php $result = chkdata_CB($obj,"digestive","Ulcers"); echo $result;?> <?php xl(">Ulcers",'e
') ?> </label>
1236 <br> <label><input type="checkbox" name="digestive[]" value="Gallstone" <?php $result = chkdata_CB($obj,"digestive","Gallstone"); echo $result;?> <?php xl(">Gallstone",'e
') ?> </label>
1239 <td class='text
' valign="top">
1241 <?php xl("Urinary",'e
') ?> <br> <label><input type="checkbox" name="urinary[]" value="Frequency" <?php $result = chkdata_CB($obj,"urinary","Frequency"); echo $result;?> <?php xl(">Frequency",'e
') ?> </label>
1242 <br> <label><input type="checkbox" name="urinary[]" value="Infections" <?php $result = chkdata_CB($obj,"urinary","Infections"); echo $result;?> <?php xl(">Infections",'e
') ?> </label>
1243 <br> <label><input type="checkbox" name="urinary[]" value="Stones" <?php $result = chkdata_CB($obj,"urinary","Stones"); echo $result;?> <?php xl(">Stones",'e
') ?> </label>
1244 <br> <label><input type="checkbox" name="urinary[]" value="Bladder incontinence" <?php $result = chkdata_CB($obj,"urinary","Bladder incontinence"); echo $result;?> <?php xl(">Bladder incontinence",'e
') ?> </label>
1247 <td class='text
' valign="top">
1249 <?php xl("Musculoskeletal",'e
') ?> <br> <label><input type="checkbox" name="musculoskeletal[]" value="Joint pain swelling or redness" <?php $result = chkdata_CB($obj,"musculoskeletal","Joint pain swelling or redness"); echo $result;?> <?php xl(">Joint pain swelling or redness",'e
') ?> </label>
1250 <br> <label><input type="checkbox" name="musculoskeletal[]" value="arthritis" <?php $result = chkdata_CB($obj,"musculoskeletal","arthritis"); echo $result;?> <?php xl(">arthritis",'e
') ?> </label>
1251 <br> <label><input type="checkbox" name="musculoskeletal[]" value="back pain" <?php $result = chkdata_CB($obj,"musculoskeletal","back pain"); echo $result;?> <?php xl(">back pain",'e
') ?> </label>
1252 <br> <label><input type="checkbox" name="musculoskeletal[]" value="muscle aches" <?php $result = chkdata_CB($obj,"musculoskeletal","muscle aches"); echo $result;?> <?php xl(">muscle aches",'e
') ?> </label>
1253 <br> <label><input type="checkbox" name="musculoskeletal[]" value="muscle tenderness" <?php $result = chkdata_CB($obj,"musculoskeletal","muscle tenderness"); echo $result;?> <?php xl(">muscle tenderness",'e
') ?> </label>
1254 <br> <label><input type="checkbox" name="musculoskeletal[]" value="gout" <?php $result = chkdata_CB($obj,"musculoskeletal","gout"); echo $result;?> <?php xl(">gout",'e
') ?> </label>
1260 <td class='text
' valign="top">
1262 <?php xl("Dermatological",'e
') ?> <br> <label><input type="checkbox" name="dermatological[]" value="Rash" <?php $result = chkdata_CB($obj,"dermatological","Rash"); echo $result;?> <?php xl(">Rash",'e
') ?> </label>
1263 <br> <label><input type="checkbox" name="dermatological[]" value="Itching" <?php $result = chkdata_CB($obj,"dermatological","Itching"); echo $result;?> <?php xl(">Itching",'e
') ?> </label>
1264 <br> <label><input type="checkbox" name="dermatological[]" value="other skin problems" <?php $result = chkdata_CB($obj,"dermatological","other skin problems"); echo $result;?> <?php xl(">other skin problems",'e
') ?> </label>
1267 <td class='text
' valign="top">
1269 <?php xl("Men",'e
') ?> <br> <label><input type="checkbox" name="men[]" value="Prostate problems" <?php $result = chkdata_CB($obj,"men","Prostate problems"); echo $result;?> <?php xl(">Prostate problems",'e
') ?> </label>
1270 <br> <label><input type="checkbox" name="men[]" value="night time urination" <?php $result = chkdata_CB($obj,"men","night time urination"); echo $result;?> <?php xl(">night time urination",'e
') ?> </label>
1273 <td class='text
' valign="top">
1275 > <?php xl("Women",'e
') ?> <br> <label><input type="checkbox" name="women[]" value="Abnormal Menstrua periods" <?php $result = chkdata_CB($obj,"women","Abnormal Menstrua periods"); echo $result;?> <?php xl(">Abnormal Menstrua periods",'e
') ?> </label>
1276 <br> <label><input type="checkbox" name="women[]" value="could you be pregnant" <?php $result = chkdata_CB($obj,"women","could you be pregnant"); echo $result;?> <?php xl(">could you be pregnant",'e
') ?> </label>
1282 <td class='text
' valign="top">
1284 <?php xl("Female reproductive",'e
') ?> <br> <label><input type="checkbox" name="female_reproductive[]" value="breast lumps" <?php $result = chkdata_CB($obj,"female_reproductive","breast lumps"); echo $result;?> <?php xl(">breast lumps",'e
') ?> </label>
1285 <br> <label><input type="checkbox" name="female_reproductive[]" value="recent mamogram" <?php $result = chkdata_CB($obj,"female_reproductive","recent mamogram"); echo $result;?> <?php xl(">recent mamogram",'e
') ?> </label>
1286 <br> <label><input type="checkbox" name="female_reproductive[]" value="pap smear or pelvic exam" <?php $result = chkdata_CB($obj,"female_reproductive","pap smear or pelvic exam"); echo $result;?> <?php xl(">pap smear or pelvic exam",'e
') ?> </label>
1289 <td class='text
' valign="top">
1291 <?php xl("Neurological",'e
') ?> <br> <label><input type="checkbox" name="neurological[]" value="Paralysis-even temporary" /> <?php xl("Paralysis-even temporary",'e
') ?> </label>
1292 <br> <label><input type="checkbox" name="neurological[]" value="stroke" <?php $result = chkdata_CB($obj,"neurological","stroke"); echo $result;?> <?php xl(">stroke",'e
') ?> </label>
1293 <br> <label><input type="checkbox" name="neurological[]" value="numbness" <?php $result = chkdata_CB($obj,"neurological","numbness"); echo $result;?> <?php xl(">numbness",'e
') ?> </label>
1294 <br> <label><input type="checkbox" name="neurological[]" value="loss of balance" <?php $result = chkdata_CB($obj,"neurological","loss of balance"); echo $result;?> <?php xl(">loss of balance",'e
') ?> </label>
1295 <br> <label><input type="checkbox" name="neurological[]" value="dizziness" <?php $result = chkdata_CB($obj,"neurological","dizziness"); echo $result;?> <?php xl(">dizziness",'e
') ?> </label>
1298 <td class='text
' valign="top">
1300 <?php xl("Psychiatric",'e
') ?> <br> <label><input type="checkbox" name="psychiatric[]" value="Unusual thoughts" <?php $result = chkdata_CB($obj,"psychiatric","Unusual thoughts"); echo $result;?> <?php xl(">Unusual thoughts",'e
') ?> </label>
1301 <br> <label><input type="checkbox" name="psychiatric[]" value="Nervousness" <?php $result = chkdata_CB($obj,"psychiatric","Nervousness"); echo $result;?> <?php xl(">Nervousness",'e
') ?> </label>
1302 <br> <label><input type="checkbox" name="psychiatric[]" value="crying or sadness" <?php $result = chkdata_CB($obj,"psychiatric","crying or sadness"); echo $result;?> <?php xl(">crying or sadness",'e
') ?> </label>
1303 <br> <label><input type="checkbox" name="psychiatric[]" value="depression" <?php $result = chkdata_CB($obj,"psychiatric","depression"); echo $result;?> <?php xl(">depression",'e
') ?> </label>
1304 <br> <label><input type="checkbox" name="psychiatric[]" value="suicide attempts" <?php $result = chkdata_CB($obj,"psychiatric","suicide attempts"); echo $result;?> <?php xl(">suicide attempts",'e
') ?> </label>
1310 <td class='text
' valign="top">
1312 <?php xl("Endocrinology",'e
') ?> <br> <label><input type="checkbox" name="endocrinology[]" value="Thyroid disorder" <?php $result = chkdata_CB($obj,"endocrinology","Thyroid disorder"); echo $result;?> <?php xl(">Thyroid disorder",'e
') ?> </label>
1313 <br> <label><input type="checkbox" name="endocrinology[]" value="Diabetes" <?php $result = chkdata_CB($obj,"endocrinology","Diabetes"); echo $result;?> <?php xl(">Diabetes",'e
') ?> </label>
1314 <br> <label><input type="checkbox" name="endocrinology[]" value="Excess thirst" <?php $result = chkdata_CB($obj,"endocrinology","Excess thirst"); echo $result;?> <?php xl(">Excess thirst",'e
') ?> </label>
1315 <br> <label><input type="checkbox" name="endocrinology[]" value="Excess hunger" <?php $result = chkdata_CB($obj,"endocrinology","Excess hunger"); echo $result;?> <?php xl(">Excess hunger",'e
') ?> </label>
1316 <br> <label><input type="checkbox" name="endocrinology[]" value="excess urination" <?php $result = chkdata_CB($obj,"endocrinology","excess urination"); echo $result;?> <?php xl(">excess urination",'e
') ?> </label>
1319 <td class='text
' valign="top">
1321 <?php xl("Hematological",'e
') ?> <br> <label><input type="checkbox" name="hematological[]" value="Bleeding" <?php $result = chkdata_CB($obj,"hematological","Bleeding"); echo $result;?> <?php xl(">Bleeding",'e
') ?> </label>
1322 <br> <label><input type="checkbox" name="hematological[]" value="Easy bruising" <?php $result = chkdata_CB($obj,"hematological","Easy bruising"); echo $result;?> <?php xl(">Easy bruising",'e
') ?> </label>
1323 <br> <label><input type="checkbox" name="hematological[]" value="risk factors for hiv" <?php $result = chkdata_CB($obj,"hematological","risk factors for hiv"); echo $result;?> <?php xl(">risk factors for hiv",'e
') ?> </label>
1324 <br> <label><input type="checkbox" name="hematological[]" value="Anemia" <?php $result = chkdata_CB($obj,"hematological","Anemia"); echo $result;?> <?php xl(">Anemia",'e
') ?> </label>
1325 <br> <label><input type="checkbox" name="hematological[]" value="Cancer" <?php $result = chkdata_CB($obj,"hematological","Cancer"); echo $result;?> <?php xl(">Cancer",'e
') ?> </label>
1328 <td class='text
' valign="top">
1334 <tr><td class='text
' colspan="3">
1336 <?php xl("Have you had any operations",'e
') ?> <textarea name="have_you_had_any_operations" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"have_you_had_any_operations"); echo $result;?></textarea>
1339 <tr><td class='text
' colspan="3">
1343 <tr><td class='text
' > <?php xl("Are you being treated now or have been treated for any illness",'e
') ?> <textarea name="are_you_being_treated_now_or_have_been_treated_for_any_illness" rows="4" cols="40"><?php $result = chkdata_Txt($obj,"are_you_being_treated_now_or_have_been_treated_for_any_illness"); echo $result;?></textarea></td></tr>
1348 <tr><td class='text
' colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Social History
1349 ",'e
') ?></h3> </td></tr>
1353 <td colspan="2" class='text
'><strong>
1355 Marital </strong></td>
1357 <td valign="top" class='text
'><strong>
1359 Health Habits: </strong></td>
1364 <td class='text
' colspan="2">
1368 <tr><td class='text
' > <?php xl("Marital status",'e
') ?>
1369 <label><input type="checkbox" name="marital_status[]" value="single" <?php $result = chkdata_CB($obj,"marital_status","single"); echo $result;?> <?php xl(">single",'e
') ?> </label>
1370 <label><input type="checkbox" name="marital_status[]" value="married" <?php $result = chkdata_CB($obj,"marital_status","married"); echo $result;?> <?php xl(">married",'e
') ?> </label>
1371 <label><input type="checkbox" name="marital_status[]" value="widowed" <?php $result = chkdata_CB($obj,"marital_status","widowed"); echo $result;?> <?php xl(">widowed",'e
') ?> </label>
1372 <label><input type="checkbox" name="marital_status[]" value="divorced" <?php $result = chkdata_CB($obj,"marital_status","divorced"); echo $result;?> <?php xl(">divorced",'e
') ?> </label></td></tr>
1377 <td class='text
' valign="top">
1381 <tr><td class='text
' > <?php xl("Do you smoke",'e
') ?>
1382 <label><input type="checkbox" name="do_you_smoke[]" value="Yes" <?php $result = chkdata_CB($obj,"do_you_smoke","Yes"); echo $result;?> <?php xl(">Yes",'e
') ?> </label>
1383 <label><input type="checkbox" name="do_you_smoke[]" value="No" <?php $result = chkdata_CB($obj,"do_you_smoke","No"); echo $result;?> <?php xl(">No",'e
') ?> </label></td></tr>
1391 <td class='text
' colspan="2">
1395 <tr><td class='text
' > <?php xl("Occupation",'e
') ?> <input type="text" name="occupation" value="<?php $result = chkdata_Txt($obj,"occupation"); echo $result;?>"></td></tr>
1400 <td class='text
' valign="top">
1404 <tr><td class='text
' > <?php xl("How many packs per day",'e
') ?> <input type="text" name="how_many_packs_per_day" value="<?php $result = chkdata_Txt($obj,"how_many_packs_per_day"); echo $result;?>"></td></tr>
1412 <td class='text
' colspan="2">
1416 <tr><td class='text
' > <?php xl("Leisure activities",'e
') ?> <input type="text" name="leisure_activities" value="<?php $result = chkdata_Txt($obj,"leisure_activities"); echo $result;?>"></td></tr>
1421 <td class='text
' valign="top">
1425 <tr><td class='text
' > <?php xl("For how many years",'e
') ?> <input type="text" name="for_how_many_years" value="<?php $result = chkdata_Txt($obj,"for_how_many_years"); echo $result;?>"></td></tr>
1433 <td class='text
' colspan="2">
1437 <tr><td class='text
' > <?php xl("Educational level",'e
') ?> <input type="text" name="educational_level" value="<?php $result = chkdata_Txt($obj,"educational_level"); echo $result;?>"></td></tr>
1442 <td class='text
' valign="top">
1446 <tr><td class='text
' > <?php xl("How much alcohol do you drink",'e
') ?> <input type="text" name="how_much_alcohol_do_you_drink" value="<?php $result = chkdata_Txt($obj,"how_much_alcohol_do_you_drink"); echo $result;?>"></td></tr>
1454 <td class='text
' colspan="2">
1459 <td class='text
' valign="top">
1463 <tr><td class='text
' > <?php xl("Do you use any drugs",'e
') ?> <input type="text" name="do_you_use_any_drugs" value="<?php $result = chkdata_Txt($obj,"do_you_use_any_drugs"); echo $result;?>"></td></tr>
1469 <tr><td class='text
' colspan="3" style="border: 1px #000000 solid;">
1471 Family History: </h3>
1473 <tr><td class='text
' colspan="3"> <?php xl("Check if any close family members(parents,brothers and sisters,children) have:",'e
') ?> </td></tr>
1475 <tr><td class='text
' colspan="3">
1479 <tr><td class='text
' > <?php xl("Heart problems",'e
') ?>
1480 <label><input type="checkbox" name="heart_problems[]" value="Mother" <?php $result = chkdata_CB($obj,"heart_problems","Mother"); echo $result;?> <?php xl(">Mother",'e
') ?> </label>
1481 <label><input type="checkbox" name="heart_problems[]" value="Father" <?php $result = chkdata_CB($obj,"heart_problems","Father"); echo $result;?> <?php xl(">Father",'e
') ?> </label>
1482 <label><input type="checkbox" name="heart_problems[]" value="Brother" <?php $result = chkdata_CB($obj,"heart_problems","Brother"); echo $result;?> <?php xl(">Brother",'e
') ?> </label>
1483 <label><input type="checkbox" name="heart_problems[]" value="Sister" <?php $result = chkdata_CB($obj,"heart_problems","Sister"); echo $result;?> <?php xl(">Sister",'e
') ?> </label>
1484 <label><input type="checkbox" name="heart_problems[]" value="Child" <?php $result = chkdata_CB($obj,"heart_problems","Child"); echo $result;?> <?php xl(">Child",'e
') ?> </label>
1485 <label><input type="checkbox" name="heart_problems[]" value="None" <?php $result = chkdata_CB($obj,"heart_problems","None"); echo $result;?> <?php xl(">None",'e
') ?> </label></td></tr>
1490 <tr><td class='text
' colspan="3">
1494 <tr><td class='text
' > <?php xl("High blood pressure",'e
') ?>
1495 <label><input type="checkbox" name="high_blood_pressure[]" value="Mother" <?php $result = chkdata_CB($obj,"high_blood_pressure","Mother"); echo $result;?> <?php xl(">Mother",'e
') ?> </label>
1496 <label><input type="checkbox" name="high_blood_pressure[]" value="Father" <?php $result = chkdata_CB($obj,"high_blood_pressure","Father"); echo $result;?> <?php xl(">Father",'e
') ?> </label>
1497 <label><input type="checkbox" name="high_blood_pressure[]" value="Brother" <?php $result = chkdata_CB($obj,"high_blood_pressure","Brother"); echo $result;?> <?php xl(">Brother",'e
') ?> </label>
1498 <label><input type="checkbox" name="high_blood_pressure[]" value="Sister" <?php $result = chkdata_CB($obj,"high_blood_pressure","Sister"); echo $result;?> <?php xl(">Sister",'e
') ?> </label>
1499 <label><input type="checkbox" name="high_blood_pressure[]" value="Child" <?php $result = chkdata_CB($obj,"high_blood_pressure","Child"); echo $result;?> <?php xl(">Child",'e
') ?> </label>
1500 <label><input type="checkbox" name="high_blood_pressure[]" value="None" <?php $result = chkdata_CB($obj,"high_blood_pressure","None"); echo $result;?> <?php xl(">None",'e
') ?> </label></td></tr>
1505 <tr><td class='text
' colspan="3">
1509 <tr><td class='text
' > <?php xl("Diabetes",'e
') ?>
1510 <label><input type="checkbox" name="diabetes[]" value="Mother" <?php $result = chkdata_CB($obj,"diabetes","Mother"); echo $result;?> <?php xl(">Mother",'e
') ?> </label>
1511 <label><input type="checkbox" name="diabetes[]" value="Father" <?php $result = chkdata_CB($obj,"diabetes","Father"); echo $result;?> <?php xl(">Father",'e
') ?> </label>
1512 <label><input type="checkbox" name="diabetes[]" value="Brother" <?php $result = chkdata_CB($obj,"diabetes","Brother"); echo $result;?> <?php xl(">Brother",'e
') ?> </label>
1513 <label><input type="checkbox" name="diabetes[]" value="Sister" <?php $result = chkdata_CB($obj,"diabetes","Sister"); echo $result;?> <?php xl(">Sister",'e
') ?> </label>
1514 <label><input type="checkbox" name="diabetes[]" value="Child" <?php $result = chkdata_CB($obj,"diabetes","Child"); echo $result;?> <?php xl(">Child",'e
') ?> </label>
1515 <label><input type="checkbox" name="diabetes[]" value="None" <?php $result = chkdata_CB($obj,"diabetes","None"); echo $result;?> <?php xl(">None",'e
') ?> </label></td></tr>
1520 <tr><td class='text
' colspan="3">
1524 <tr><td class='text
' > cancer<label><input type="checkbox" name="_cancer[]" value="Mother" <?php $result = chkdata_CB($obj,"_cancer","Mother"); echo $result;?> <?php xl(">Mother",'e
') ?> </label>
1525 <label><input type="checkbox" name="_cancer[]" value="Father" <?php $result = chkdata_CB($obj,"_cancer","Father"); echo $result;?> <?php xl(">Father",'e
') ?> </label>
1526 <label><input type="checkbox" name="_cancer[]" value="Brother" <?php $result = chkdata_CB($obj,"_cancer","Brother"); echo $result;?> <?php xl(">Brother",'e
') ?> </label>
1527 <label><input type="checkbox" name="_cancer[]" value="Sister" <?php $result = chkdata_CB($obj,"_cancer","Sister"); echo $result;?> <?php xl(">Sister",'e
') ?> </label>
1528 <label><input type="checkbox" name="_cancer[]" value="Child" <?php $result = chkdata_CB($obj,"_cancer","Child"); echo $result;?> <?php xl(">Child",'e
') ?> </label>
1529 <label><input type="checkbox" name="_cancer[]" value="None" <?php $result = chkdata_CB($obj,"_cancer","None"); echo $result;?> <?php xl(">None",'e
') ?> </label></td></tr>
1536 <td class='text
' colspan="3" style="border: 1px #000000 solid;">
1538 Hospitalizations: </h3>
1543 <td class='text
' valign="top">
1547 <tr><td class='text
' > <?php xl("Year",'e
') ?> <input type="text" name="year" value="<?php $result = chkdata_Txt($obj,"year"); echo $result;?>"></td></tr>
1552 <td class='text
' valign="top">
1556 <tr><td class='text
' > <?php xl("Hospital",'e
') ?> <input type="text" name="hospital" value="<?php $result = chkdata_Txt($obj,"hospital"); echo $result;?>"></td></tr>
1561 <td class='text
' valign="top">
1565 <tr><td class='text
' > <?php xl("Reason",'e
') ?> <input type="text" name="reason" value="<?php $result = chkdata_Txt($obj,"reason"); echo $result;?>"></td></tr>
1572 <table></table><input type="submit" name="submit form" value="submit form" />