Fixed php short tags
[openemr.git] / contrib / forms / cardiology_set / Forms_Cardiology / view.php
blob928e03d4557a161ea3bc816fad7b2e3c2b6c9303
1 <!-- view.php -->
2 <?php
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 "";}
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 <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>
39 <hr>
40 <input type="submit" name="submit form" value="submit form" />
42 <table width="100%" cellpadding="0" cellspacing="0">
44 <tr>
46 <td class='text' valign="top" style="border: 1px #000000 solid; height: 15px;">
48 <table width="100%" cellpadding="0" cellspacing="0">
50 <tr>
52 <td class='text' colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;">
54 <h3>
56 PATIENT INFORMATION - PLEASE PRINT
58 </h3>
59 </td>
60 </tr>
61 <tr><td class='text' colspan="5"><b> <?php xl("FULL LEGAL NAME(FIRST NAME)",'e') ?> </b></td></tr>
63 <tr>
65 <td class='text' style="border: 1px #000000 solid;">
67 <table>
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>
71 </table>
72 </td>
74 <td class='text' style="border: 1px #000000 solid;">
76 <table>
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>
80 </table>
81 </td>
83 <td class='text' style="border: 1px #000000 solid;">
85 <table>
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>
89 </table>
90 </td>
92 <td class='text' colspan="2" style="border: 1px #000000 solid;">
94 <table>
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>
98 </table>
99 </td>
100 </tr>
106 <tr>
110 <td class='text' colspan="2" style="border: 1px #000000 solid;">
112 <table>
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>
116 </table>
117 </td>
119 <td class='text' style="border: 1px #000000 solid;">
121 <table>
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>
125 </table>
126 </td>
128 <td class='text' style="border: 1px #000000 solid;">
130 <table>
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>
134 </table>
135 </td>
137 <td class='text' style="border: 1px #000000 solid;">
139 <table>
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>
143 </table>
144 </td>
145 </tr>
147 <tr>
151 <td class='text' colspan="2" style="border: 1px #000000 solid;">
153 <table>
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>
157 </table>
158 </td>
160 <td class='text' style="border: 1px #000000 solid;">
162 <table>
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>
166 </table>
167 </td>
169 <td class='text' style="border: 1px #000000 solid;">
171 <table>
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>
175 </table>
176 </td>
178 <td class='text' style="border: 1px #000000 solid;">
180 <table>
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>
184 </table>
185 </td>
186 </tr>
190 <tr>
194 <td class='text' style="border: 1px #000000 solid;">
196 <table>
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>
200 </table>
201 </td>
203 <td class='text' style="border: 1px #000000 solid;">
205 <table>
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>
209 </table>
210 </td>
212 <td class='text' style="border: 1px #000000 solid;">
214 <table>
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>
218 </table>
219 </td>
221 <td class='text' style="border: 1px #000000 solid;">
223 <table>
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>
227 </table>
228 </td>
230 <td class='text' style="border: 1px #000000 solid;">
232 <table>
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>
236 </table>
237 </td>
238 </tr>
242 <tr>
246 <td class='text' colspan="4" style="border: 1px #000000 solid; height: 10px;">
248 <table>
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>
252 </table>
253 </td>
257 <td class='text' style="border: 1px #000000 solid; height: 10px;">
259 <table>
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>
263 </table>
264 </td>
265 </tr>
269 <tr>
273 <td class='text' style="border: 1px #000000 solid; height: 15px;">
275 <table>
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'>
284 <script>
285 Calendar.setup({inputField:'_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__date_of_birth'});
286 </script>
287 </td></tr>
289 </table>
290 </td>
292 <td class='text' style="border: 1px #000000 solid; height: 15px;">
294 <table>
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>
298 </table>
299 </td>
301 <td class='text' style="border: 1px #000000 solid; height: 15px;">
303 <table>
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>
308 </table>
309 </td>
311 <td class='text' style="border: 1px #000000 solid; height: 15px;">
313 <table>
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>
318 </table>
319 </td>
321 <td class='text' style="border: 1px #000000 solid; height: 15px;">
323 <table>
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>
327 </table>
328 </td>
329 </tr>
331 <tr>
333 <td class='text' style="border: 1px #000000 solid; height: 15px;">
335 <table>
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>
339 </table>
340 </td>
342 <td class='text' colspan="4" style="border: 1px #000000 solid;;">
344 <table>
346 <tr>
348 <td class='text' >
350 <table>
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>
354 </table>
355 </td>
357 <td class='text' >
359 <table>
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>
363 </table>
364 </td>
366 <td class='text' >
368 <table>
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>
372 </table>
373 </td>
375 <td class='text' >
377 <table>
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>
381 </table>
382 </td>
383 </tr>
385 </table>
386 </td>
387 </tr>
389 <tr>
393 <td class='text' style="border: 1px #000000 solid; height: 15px;">
395 <table>
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>
399 </table>
400 </td>
402 <td class='text' style="border: 1px #000000 solid; height: 15px;">
404 <table>
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>
408 </table>
409 </td>
411 <td class='text' style="border: 1px #000000 solid; height: 15px;">
413 <table>
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>
417 </table>
418 </td>
420 <td class='text' colspan="2" style="border: 1px #000000 solid; height: 15px;">
422 <table>
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>
426 </table>
427 </td>
430 </tr>
436 </table>
437 </td>
438 </tr>
448 <tr>
450 <td class='text' valign="top" style="border: 1px #000000 solid; height: 15px;">
452 <table width="100%" cellpadding="0" cellspacing="0">
454 <tr>
456 <td class='text' colspan="7" align="center" style="border: 1px #000000 solid; height: 15px;">
458 <h3>
460 SPOUSE'S, PARENT'S, AND / OR GUARANTER'S INFORMATION
462 </h3>
463 </td>
464 </tr>
466 <tr><td class='text' colspan="7">
468 <table>
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>
472 </table>
473 </td></tr>
475 <tr>
479 <td class='text' colspan="2" style="border: 1px #000000 solid;">
481 <table>
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>
485 </table>
486 </td>
488 <td class='text' style="border: 1px #000000 solid;">
490 <table>
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>
494 </table>
495 </td>
497 <td class='text' colspan="2" style="border: 1px #000000 solid;">
499 <table>
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>
503 </table>
504 </td>
506 <td class='text' colspan="2" style="border: 1px #000000 solid;">
508 <table>
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>
512 </table>
513 </td>
514 </tr>
518 <tr>
522 <td class='text' colspan="2" style="border: 1px #000000 solid;">
524 <table>
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>
528 </table>
529 </td>
531 <td class='text' style="border: 1px #000000 solid;">
533 <table>
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>
537 </table>
538 </td>
540 <td class='text' style="border: 1px #000000 solid;">
542 <table>
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>
546 </table>
547 </td>
549 <td class='text' style="border: 1px #000000 solid;">
551 <table>
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>
555 </table>
556 </td>
558 <td class='text' colspan="2" style="border: 1px #000000 solid;">
560 <table>
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>
564 </table>
565 </td>
566 </tr>
570 <tr>
574 <td class='text' colspan="2" style="border: 1px #000000 solid;">
576 <table>
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>
580 </table>
581 </td>
583 <td class='text' style="border: 1px #000000 solid;">
585 <table>
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>
589 </table>
590 </td>
592 <td class='text' style="border: 1px #000000 solid;">
594 <table>
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>
598 </table>
599 </td>
601 <td class='text' style="border: 1px #000000 solid;">
603 <table>
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>
607 </table>
608 </td>
610 <td class='text' style="border: 1px #000000 solid;">
612 <table>
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>
616 </table>
617 </td>
619 <td class='text' style="border: 1px #000000 solid;">
621 <table>
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>
625 </table>
626 </td>
627 </tr>
631 </table>
632 </td>
633 </tr>
637 <tr>
639 <td class='text' valign="top" style="border: 1px #000000 solid; height: 15px;">
641 <table width="100%" cellpadding="0" cellspacing="0">
643 <tr>
645 <td class='text' colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
647 <h3>
649 CONCERNING INSURANCE
651 </h3>
652 </td>
653 </tr>
655 <tr>
659 <td class='text' colspan="3" style="border: 1px #000000 solid;">
661 <table>
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>
669 </table>
670 </td>
673 </tr>
675 <tr>
679 <td class='text' colspan="3" align="right" >
681 <table>
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'>
690 <script>
691 Calendar.setup({inputField:'_date_of_injury', ifFormat:'%Y-%m-%d', button:'img__date_of_injury'});
692 </script>
693 </td></tr>
695 </table>
696 </td>
699 </tr>
703 <tr>
707 <td class='text' style="border: 1px #000000 solid;">
709 <table>
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>
713 </table>
714 </td>
716 <td class='text' style="border: 1px #000000 solid;">
718 <table>
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>
722 </table>
723 </td>
725 <td class='text' style="border: 1px #000000 solid;">
727 <table>
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>
731 </table>
732 </td>
735 </tr>
739 <tr>
743 <td class='text' style="border: 1px #000000 solid;">
745 <table>
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>
749 </table>
750 </td>
752 <td class='text' style="border: 1px #000000 solid;">
754 <table>
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'>
763 <script>
764 Calendar.setup({inputField:'_primary_insurance_insured_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__primary_insurance_insured_date_of_birth'});
765 </script>
766 </td></tr>
768 </table>
769 </td>
771 <td class='text' style="border: 1px #000000 solid;">
773 <table>
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>
777 </table>
778 </td>
781 </tr>
785 <tr>
789 <td class='text' style="border: 1px #000000 solid;">
791 <table>
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>
795 </table>
796 </td>
798 <td class='text' style="border: 1px #000000 solid;">
800 <table>
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>
804 </table>
805 </td>
807 <td class='text' style="border: 1px #000000 solid;">
809 <table>
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>
813 </table>
814 </td>
817 </tr>
821 <tr>
825 <td class='text' style="border: 1px #000000 solid;">
827 <table>
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>
831 </table>
832 </td>
834 <td class='text' style="border: 1px #000000 solid;">
836 <table>
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'>
845 <script>
846 Calendar.setup({inputField:'_secondary_insurance_insureds_date_of_birth', ifFormat:'%Y-%m-%d', button:'img__secondary_insurance_insureds_date_of_birth'});
847 </script>
848 </td></tr>
850 </table>
851 </td>
853 <td class='text' style="border: 1px #000000 solid;">
855 <table>
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>
859 </table>
860 </td>
863 </tr>
871 </table>
872 </td>
873 </tr>
879 <tr>
881 <td class='text' valign="top" style="border: 1px #000000 solid; height: 15px;">
883 <table width="100%" cellpadding="0" cellspacing="0">
885 <tr>
887 <td class='text' colspan="4" align="center" style="border: 1px #000000 solid; height: 15px;">
889 <h3>
891 EMERGENCY INFORMATION
893 </h3>
894 </td>
895 </tr>
901 <tr>
905 <td class='text' colspan="3" style="border: 1px #000000 solid;">
907 <table>
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>
911 </table>
912 </td>
914 <td class='text' style="border: 1px #000000 solid;">
916 <table>
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>
920 </table>
921 </td>
924 </tr>
928 <tr>
932 <td class='text' style="border: 1px #000000 solid;">
934 <table>
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>
938 </table>
939 </td>
941 <td class='text' style="border: 1px #000000 solid;">
943 <table>
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>
947 </table>
948 </td>
950 <td class='text' style="border: 1px #000000 solid;">
952 <table>
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>
956 </table>
957 </td>
961 <td class='text' style="border: 1px #000000 solid;">
963 <table>
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>
967 </table>
968 </td>
971 </tr>
973 <tr>
977 <td class='text' style="border: 1px #000000 solid; height: 6px;">
979 <table>
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>
983 </table>
984 </td>
986 <td class='text' style="border: 1px #000000 solid; height: 6px;">
988 <table>
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>
992 </table>
993 </td>
995 <td class='text' style="border: 1px #000000 solid; height: 6px;">
997 <table>
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>
1001 </table>
1002 </td>
1006 <td class='text' style="border: 1px #000000 solid; height: 6px;">
1008 <table>
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>
1012 </table>
1013 </td>
1014 </tr>
1026 </table>
1027 </td>
1028 </tr>
1030 </table>
1031 <table><tr><td class='text' colspan="3"><h3> <?php xl("Health History (Confidential)",'e') ?> </h3></td></tr>
1033 <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>
1052 </td>
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>
1067 </td>
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') ?>
1077 </td>
1078 </tr>
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>
1086 <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">
1093 <table>
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>
1097 </table>
1098 </td></tr>
1100 <tr><td class='text' colspan="3">
1102 <table>
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>
1106 </table>
1107 </td></tr>
1109 <tr><td class='text' colspan="3">
1111 <table>
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>
1115 </table>
1116 </td></tr>
1118 <tr><td class='text' colspan="3">
1120 <table>
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>
1124 </table>
1125 </td></tr>
1127 <tr><td class='text' colspan="3">
1129 <table>
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>
1133 </table>
1134 </td></tr>
1136 <tr><td class='text' colspan="3">
1138 <table>
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>
1142 </table>
1143 </td></tr>
1145 <tr><td class='text' colspan="3">
1147 <table>
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>
1151 </table>
1152 </td></tr>
1154 <tr><td class='text' colspan="3">
1156 <table>
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>
1160 </table>
1161 </td></tr>
1163 <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">
1168 <table>
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>
1174 </table>
1175 </td></tr>
1177 <tr><td class='text' colspan="3">
1179 <table>
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>
1183 </table>
1184 </td></tr>
1186 <tr><td class='text' colspan="3">
1188 <table>
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>
1192 </table>
1193 </td></tr>
1195 <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>
1204 </td>
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>
1214 </td>
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>
1223 </td>
1224 </tr>
1226 <tr>
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>
1237 </td>
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>
1245 </td>
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>
1255 </td>
1256 </tr>
1258 <tr>
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>
1265 </td>
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>
1271 </td>
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>
1277 </td>
1278 </tr>
1280 <tr>
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>
1287 </td>
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>
1296 </td>
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>
1305 </td>
1306 </tr>
1308 <tr>
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>
1317 </td>
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>
1326 </td>
1328 <td class='text' valign="top">&nbsp;
1331 </td>
1332 </tr>
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>
1337 </td></tr>
1339 <tr><td class='text' colspan="3">
1341 <table>
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>
1345 </table>
1346 </td></tr>
1348 <tr><td class='text' colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Social History
1349 ",'e') ?></h3> </td></tr>
1351 <tr>
1353 <td colspan="2" class='text'><strong>
1355 Marital </strong></td>
1357 <td valign="top" class='text'><strong>
1359 Health Habits: </strong></td>
1360 </tr>
1362 <tr>
1364 <td class='text' colspan="2">
1366 <table>
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>
1374 </table>
1375 </td>
1377 <td class='text' valign="top">
1379 <table>
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>
1385 </table>
1386 </td>
1387 </tr>
1389 <tr>
1391 <td class='text' colspan="2">
1393 <table>
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>
1397 </table>
1398 </td>
1400 <td class='text' valign="top">
1402 <table>
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>
1406 </table>
1407 </td>
1408 </tr>
1410 <tr>
1412 <td class='text' colspan="2">
1414 <table>
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>
1418 </table>
1419 </td>
1421 <td class='text' valign="top">
1423 <table>
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>
1427 </table>
1428 </td>
1429 </tr>
1431 <tr>
1433 <td class='text' colspan="2">
1435 <table>
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>
1439 </table>
1440 </td>
1442 <td class='text' valign="top">
1444 <table>
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>
1448 </table>
1449 </td>
1450 </tr>
1452 <tr>
1454 <td class='text' colspan="2">&nbsp;
1457 </td>
1459 <td class='text' valign="top">
1461 <table>
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>
1465 </table>
1466 </td>
1467 </tr>
1469 <tr><td class='text' colspan="3" style="border: 1px #000000 solid;">
1470 <h3>
1471 Family History: </h3>
1472 </td></tr>
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">
1477 <table>
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>
1487 </table>
1488 </td></tr>
1490 <tr><td class='text' colspan="3">
1492 <table>
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>
1502 </table>
1503 </td></tr>
1505 <tr><td class='text' colspan="3">
1507 <table>
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>
1517 </table>
1518 </td></tr>
1520 <tr><td class='text' colspan="3">
1522 <table>
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>
1531 </table>
1532 </td></tr>
1534 <tr>
1536 <td class='text' colspan="3" style="border: 1px #000000 solid;">
1537 <h3>
1538 Hospitalizations: </h3>
1539 </td></tr>
1541 <tr>
1543 <td class='text' valign="top">
1545 <table>
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>
1549 </table>
1550 </td>
1552 <td class='text' valign="top">
1554 <table>
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>
1558 </table>
1559 </td>
1561 <td class='text' valign="top">
1563 <table>
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>
1567 </table>
1568 </td>
1569 </tr>
1571 </table>
1572 <table></table><input type="submit" name="submit form" value="submit form" />
1574 </form>
1575 <?php
1576 formFooter();