contrib/forms/cardiology_set/Forms_Cardiology/view.php

   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", $_GET["id"]);  //#Use the formFetch function from api.inc to get values for existing form.
   7
   8  function chkdata_Txt(&$obj, $var) {
   9          return htmlentities($obj{"$var"});
  10  }
  11  function chkdata_Date(&$obj, $var) {
  12          return htmlentities($obj{"$var"});
  13  }
  14  function chkdata_CB(&$obj, $nam, $var) {
  15         if (preg_match("/$var/",$obj{$nam})) {return "checked";} else {return "";}
  16  }
  17  function chkdata_Radio(&$obj, $nam, $var) {
  18         if (strpos($obj{$nam},$var) !== false) {return "checked";}
  19  }
  20   function chkdata_PopOrScroll(&$obj, $nam, $var) {
  21   if (preg_match("/$var/",$obj{$nam})) {return "selected";} else {return "";}
  22  }
  23
  24  ?>
  25  <html><head>
  26  <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  27  </head>
  28  <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  29  <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>
  36
  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" />
  41
  42  <table width="100%" cellpadding="0" cellspacing="0">
  43
  44      <tr>
  45
  46          <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
  47
  48              <table width="100%" cellpadding="0" cellspacing="0">
  49
  50                  <tr>
  51
  52                      <td class='text'   colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;">
  53
  54                          <h3>
  55
  56                              PATIENT INFORMATION - PLEASE PRINT
  57
  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>
  62
  63                  <tr>
  64
  65                      <td class='text'   style="border: 1px #000000 solid;">
  66
  67  <table>
  68
  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>
  70
  71  </table>
  72                      </td>
  73
  74                      <td class='text'   style="border: 1px #000000 solid;">
  75
  76  <table>
  77
  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>
  79
  80  </table>
  81                      </td>
  82
  83                       <td class='text'   style="border: 1px #000000 solid;">
  84
  85  <table>
  86
  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>
  88
  89  </table>
  90                      </td>
  91
  92                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
  93
  94  <table>
  95
  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>
  97
  98  </table>
  99                      </td>
 100                  </tr>
 101
 102
 103
 104
 105
 106                  <tr>
 107
 108
 109
 110                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 111
 112  <table>
 113
 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>
 115
 116  </table>
 117                      </td>
 118
 119                      <td class='text'   style="border: 1px #000000 solid;">
 120
 121  <table>
 122
 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>
 124
 125  </table>
 126                      </td>
 127
 128                       <td class='text'   style="border: 1px #000000 solid;">
 129
 130  <table>
 131
 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>
 133
 134  </table>
 135                      </td>
 136
 137                      <td class='text'   style="border: 1px #000000 solid;">
 138
 139  <table>
 140
 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>
 142
 143  </table>
 144                      </td>
 145                  </tr>
 146
 147                    <tr>
 148
 149
 150
 151                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 152
 153  <table>
 154
 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>
 156
 157  </table>
 158                      </td>
 159
 160                      <td class='text'   style="border: 1px #000000 solid;">
 161
 162  <table>
 163
 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>
 165
 166  </table>
 167                      </td>
 168
 169                       <td class='text'   style="border: 1px #000000 solid;">
 170
 171  <table>
 172
 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>
 174
 175  </table>
 176                      </td>
 177
 178                      <td class='text'   style="border: 1px #000000 solid;">
 179
 180  <table>
 181
 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>
 183
 184  </table>
 185                      </td>
 186                  </tr>
 187
 188
 189
 190                   <tr>
 191
 192
 193
 194                      <td class='text'   style="border: 1px #000000 solid;">
 195
 196  <table>
 197
 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>
 199
 200  </table>
 201                      </td>
 202
 203                      <td class='text'   style="border: 1px #000000 solid;">
 204
 205  <table>
 206
 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>
 208
 209  </table>
 210                      </td>
 211
 212                       <td class='text'   style="border: 1px #000000 solid;">
 213
 214  <table>
 215
 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>
 217
 218  </table>
 219                      </td>
 220
 221                      <td class='text'   style="border: 1px #000000 solid;">
 222
 223  <table>
 224
 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>
 226
 227  </table>
 228                      </td>
 229
 230                       <td class='text'   style="border: 1px #000000 solid;">
 231
 232  <table>
 233
 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>
 235
 236  </table>
 237                      </td>
 238                  </tr>
 239
 240
 241
 242                  <tr>
 243
 244
 245
 246                      <td class='text'    colspan="4" style="border: 1px #000000 solid; height: 10px;">
 247
 248  <table>
 249
 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>
 251
 252  </table>
 253                      </td>
 254
 255
 256
 257                       <td class='text'   style="border: 1px #000000 solid; height: 10px;">
 258
 259  <table>
 260
 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>
 262
 263  </table>
 264                      </td>
 265                  </tr>
 266
 267
 268
 269                   <tr>
 270
 271
 272
 273                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 274
 275  <table>
 276
 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>
 288
 289  </table>
 290                      </td>
 291
 292                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 293
 294  <table>
 295
 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>
 297
 298  </table>
 299                      </td>
 300
 301                       <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 302
 303  <table>
 304
 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>
 307
 308  </table>
 309                      </td>
 310
 311                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 312
 313  <table>
 314
 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>
 317
 318  </table>
 319                      </td>
 320
 321                       <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 322
 323  <table>
 324
 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>
 326
 327  </table>
 328                      </td>
 329                  </tr>
 330
 331                  <tr>
 332
 333                      <td class='text'     style="border: 1px #000000 solid; height: 15px;">
 334
 335  <table>
 336
 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>
 338
 339  </table>
 340                      </td>
 341
 342                      <td class='text'   colspan="4" style="border: 1px #000000 solid;;">
 343
 344                          <table>
 345
 346                              <tr>
 347
 348                                  <td class='text'  >
 349
 350  <table>
 351
 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>
 353
 354  </table>
 355                                  </td>
 356
 357                                  <td class='text'  >
 358
 359  <table>
 360
 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>
 362
 363  </table>
 364                                  </td>
 365
 366                                  <td class='text'  >
 367
 368  <table>
 369
 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>
 371
 372  </table>
 373                                  </td>
 374
 375                                  <td class='text'  >
 376
 377  <table>
 378
 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>
 380
 381  </table>
 382                                  </td>
 383                              </tr>
 384
 385                          </table>
 386                      </td>
 387                  </tr>
 388
 389                   <tr>
 390
 391
 392
 393                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 394
 395  <table>
 396
 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>
 398
 399  </table>
 400                      </td>
 401
 402                      <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 403
 404  <table>
 405
 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>
 407
 408  </table>
 409                      </td>
 410
 411                       <td class='text'   style="border: 1px #000000 solid; height: 15px;">
 412
 413  <table>
 414
 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>
 416
 417  </table>
 418                      </td>
 419
 420                      <td class='text'   colspan="2" style="border: 1px #000000 solid; height: 15px;">
 421
 422  <table>
 423
 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>
 425
 426  </table>
 427                      </td>
 428
 429
 430                  </tr>
 431
 432
 433
 434
 435
 436              </table>
 437          </td>
 438      </tr>
 439
 440
 441
 442
 443
 444
 445
 446
 447
 448      <tr>
 449
 450           <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 451
 452              <table width="100%" cellpadding="0" cellspacing="0">
 453
 454                  <tr>
 455
 456                      <td class='text'   colspan="7" align="center" style="border: 1px #000000 solid; height: 15px;">
 457
 458                          <h3>
 459
 460                              SPOUSE'S, PARENT'S, AND / OR GUARANTER'S INFORMATION
 461
 462                          </h3>
 463                      </td>
 464                  </tr>
 465
 466                  <tr><td class='text'   colspan="7">
 467
 468  <table>
 469
 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>
 471
 472  </table>
 473                  </td></tr>
 474
 475                  <tr>
 476
 477
 478
 479                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 480
 481  <table>
 482
 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>
 484
 485  </table>
 486                      </td>
 487
 488                      <td class='text'   style="border: 1px #000000 solid;">
 489
 490  <table>
 491
 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>
 493
 494  </table>
 495                      </td>
 496
 497                       <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 498
 499  <table>
 500
 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>
 502
 503  </table>
 504                      </td>
 505
 506                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 507
 508  <table>
 509
 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>
 511
 512  </table>
 513                      </td>
 514                  </tr>
 515
 516
 517
 518                   <tr>
 519
 520
 521
 522                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 523
 524  <table>
 525
 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>
 527
 528  </table>
 529                      </td>
 530
 531                      <td class='text'   style="border: 1px #000000 solid;">
 532
 533  <table>
 534
 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>
 536
 537  </table>
 538                      </td>
 539
 540                       <td class='text'   style="border: 1px #000000 solid;">
 541
 542  <table>
 543
 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>
 545
 546  </table>
 547                      </td>
 548
 549                      <td class='text'   style="border: 1px #000000 solid;">
 550
 551  <table>
 552
 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>
 554
 555  </table>
 556                      </td>
 557
 558                       <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 559
 560  <table>
 561
 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>
 563
 564  </table>
 565                      </td>
 566                  </tr>
 567
 568
 569
 570                    <tr>
 571
 572
 573
 574                      <td class='text'   colspan="2" style="border: 1px #000000 solid;">
 575
 576  <table>
 577
 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>
 579
 580  </table>
 581                      </td>
 582
 583                     <td class='text'   style="border: 1px #000000 solid;">
 584
 585  <table>
 586
 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>
 588
 589  </table>
 590                      </td>
 591
 592                       <td class='text'   style="border: 1px #000000 solid;">
 593
 594  <table>
 595
 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>
 597
 598  </table>
 599                      </td>
 600
 601                      <td class='text'   style="border: 1px #000000 solid;">
 602
 603  <table>
 604
 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>
 606
 607  </table>
 608                      </td>
 609
 610                       <td class='text'   style="border: 1px #000000 solid;">
 611
 612  <table>
 613
 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>
 615
 616  </table>
 617                      </td>
 618
 619                      <td class='text'    style="border: 1px #000000 solid;">
 620
 621  <table>
 622
 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>
 624
 625  </table>
 626                      </td>
 627                  </tr>
 628
 629
 630
 631              </table>
 632          </td>
 633      </tr>
 634
 635
 636
 637       <tr>
 638
 639           <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 640
 641              <table width="100%" cellpadding="0" cellspacing="0">
 642
 643                  <tr>
 644
 645                      <td class='text'   colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">
 646
 647                          <h3>
 648
 649                              CONCERNING INSURANCE
 650
 651                          </h3>
 652                      </td>
 653                  </tr>
 654
 655                  <tr>
 656
 657
 658
 659                      <td class='text'   colspan="3" style="border: 1px #000000 solid;">
 660
 661  <table>
 662
 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>
 668
 669  </table>
 670                      </td>
 671
 672
 673                  </tr>
 674
 675                  <tr>
 676
 677
 678
 679                      <td class='text'   colspan="3" align="right" >
 680
 681  <table>
 682
 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>
 694
 695  </table>
 696                      </td>
 697
 698
 699                  </tr>
 700
 701
 702
 703                   <tr>
 704
 705
 706
 707                      <td class='text'   style="border: 1px #000000 solid;">
 708
 709  <table>
 710
 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>
 712
 713  </table>
 714                      </td>
 715
 716                      <td class='text'   style="border: 1px #000000 solid;">
 717
 718  <table>
 719
 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>
 721
 722  </table>
 723                      </td>
 724
 725                       <td class='text'   style="border: 1px #000000 solid;">
 726
 727  <table>
 728
 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>
 730
 731  </table>
 732                      </td>
 733
 734
 735                  </tr>
 736
 737
 738
 739                   <tr>
 740
 741
 742
 743                      <td class='text'   style="border: 1px #000000 solid;">
 744
 745  <table>
 746
 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>
 748
 749  </table>
 750                      </td>
 751
 752                      <td class='text'   style="border: 1px #000000 solid;">
 753
 754  <table>
 755
 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>
 767
 768  </table>
 769                      </td>
 770
 771                       <td class='text'   style="border: 1px #000000 solid;">
 772
 773  <table>
 774
 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>
 776
 777  </table>
 778                      </td>
 779
 780
 781                  </tr>
 782
 783
 784
 785                    <tr>
 786
 787
 788
 789                      <td class='text'   style="border: 1px #000000 solid;">
 790
 791  <table>
 792
 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>
 794
 795  </table>
 796                      </td>
 797
 798                      <td class='text'   style="border: 1px #000000 solid;">
 799
 800  <table>
 801
 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>
 803
 804  </table>
 805                      </td>
 806
 807                       <td class='text'   style="border: 1px #000000 solid;">
 808
 809  <table>
 810
 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>
 812
 813  </table>
 814                      </td>
 815
 816
 817                  </tr>
 818
 819
 820
 821                    <tr>
 822
 823
 824
 825                      <td class='text'   style="border: 1px #000000 solid;">
 826
 827  <table>
 828
 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>
 830
 831  </table>
 832                      </td>
 833
 834                      <td class='text'   style="border: 1px #000000 solid;">
 835
 836  <table>
 837
 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>
 849
 850  </table>
 851                      </td>
 852
 853                       <td class='text'   style="border: 1px #000000 solid;">
 854
 855  <table>
 856
 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>
 858
 859  </table>
 860                      </td>
 861
 862
 863                  </tr>
 864
 865
 866
 867
 868
 869
 870
 871              </table>
 872          </td>
 873      </tr>
 874
 875
 876
 877
 878
 879        <tr>
 880
 881           <td class='text'   valign="top" style="border: 1px #000000 solid; height: 15px;">
 882
 883              <table width="100%" cellpadding="0" cellspacing="0">
 884
 885                  <tr>
 886
 887                      <td class='text'   colspan="4" align="center" style="border: 1px #000000 solid; height: 15px;">
 888
 889                          <h3>
 890
 891                              EMERGENCY INFORMATION
 892
 893                          </h3>
 894                      </td>
 895                  </tr>
 896
 897
 898
 899
 900
 901                   <tr>
 902
 903
 904
 905                      <td class='text'   colspan="3" style="border: 1px #000000 solid;">
 906
 907  <table>
 908
 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>
 910
 911  </table>
 912                      </td>
 913
 914                      <td class='text'   style="border: 1px #000000 solid;">
 915
 916  <table>
 917
 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>
 919
 920  </table>
 921                      </td>
 922
 923
 924                  </tr>
 925
 926
 927
 928                   <tr>
 929
 930
 931
 932                      <td class='text'   style="border: 1px #000000 solid;">
 933
 934  <table>
 935
 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>
 937
 938  </table>
 939                      </td>
 940
 941                      <td class='text'   style="border: 1px #000000 solid;">
 942
 943  <table>
 944
 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>
 946
 947  </table>
 948                      </td>
 949
 950                       <td class='text'   style="border: 1px #000000 solid;">
 951
 952  <table>
 953
 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>
 955
 956  </table>
 957                      </td>
 958
 959
 960
 961                        <td class='text'   style="border: 1px #000000 solid;">
 962
 963  <table>
 964
 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>
 966
 967  </table>
 968                      </td>
 969
 970
 971                  </tr>
 972
 973                    <tr>
 974
 975
 976
 977                      <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 978
 979  <table>
 980
 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>
 982
 983  </table>
 984                      </td>
 985
 986                      <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 987
 988  <table>
 989
 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>
 991
 992  </table>
 993                      </td>
 994
 995                       <td class='text'   style="border: 1px #000000 solid; height: 6px;">
 996
 997  <table>
 998
 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>
1000
1001  </table>
1002                      </td>
1003
1004
1005
1006                       <td class='text'   style="border: 1px #000000 solid; height: 6px;">
1007
1008  <table>
1009
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>
1011
1012  </table>
1013                      </td>
1014                  </tr>
1015
1016
1017
1018
1019
1020
1021
1022
1023
1024
1025
1026              </table>
1027          </td>
1028      </tr>
1029
1030  </table>
1031  <table><tr><td class='text'   colspan="3"><h3> <?php xl("Health History (Confidential)",'e') ?> </h3></td></tr>
1032
1033  <tr>
1034  <td class='text'   colspan="3" style="border: 1px #000000 solid"><h3> <?php xl("History and Physical",'e') ?> </h3></td></tr>
1035
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>
1053
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>
1068
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;?>">
1075
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>
1079
1080
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>
1082
1083
1084  <tr><td class='text'   colspan="3" style="border: 1px #000000 solid; height: 28px;"><h3> <?php xl("Current Medications",'e') ?> </h3></td></tr>
1085
1086  <tr>
1087
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>
1090
1091  <tr><td class='text'   colspan="3">
1092
1093  <table>
1094
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>
1096
1097  </table>
1098  </td></tr>
1099
1100  <tr><td class='text'   colspan="3">
1101
1102  <table>
1103
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>
1105
1106  </table>
1107  </td></tr>
1108
1109  <tr><td class='text'   colspan="3">
1110
1111  <table>
1112
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>
1114
1115  </table>
1116  </td></tr>
1117
1118  <tr><td class='text'   colspan="3">
1119
1120  <table>
1121
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>
1123
1124  </table>
1125  </td></tr>
1126
1127  <tr><td class='text'   colspan="3">
1128
1129  <table>
1130
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>
1132
1133  </table>
1134  </td></tr>
1135
1136  <tr><td class='text'   colspan="3">
1137
1138  <table>
1139
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>
1141
1142  </table>
1143  </td></tr>
1144
1145  <tr><td class='text'   colspan="3">
1146
1147  <table>
1148
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>
1150
1151  </table>
1152  </td></tr>
1153
1154  <tr><td class='text'   colspan="3">
1155
1156  <table>
1157
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>
1159
1160  </table>
1161  </td></tr>
1162
1163  <tr>
1164  <td class='text'   colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Allergies",'e') ?> </h3></td></tr>
1165
1166  <tr><td class='text'   colspan="3">
1167
1168  <table>
1169
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>
1173
1174  </table>
1175  </td></tr>
1176
1177  <tr><td class='text'   colspan="3">
1178
1179  <table>
1180
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>
1182
1183  </table>
1184  </td></tr>
1185
1186  <tr><td class='text'   colspan="3">
1187
1188  <table>
1189
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>
1191
1192  </table>
1193  </td></tr>
1194
1195  <tr>
1196
1197 <td class='text'    valign="top">
1198
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>
1205
1206 <td class='text'    valign="top">
1207
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>
1215
1216 <td class='text'    valign="top">
1217
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>
1225
1226  <tr>
1227
1228 <td class='text'    valign="top">
1229
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>
1238
1239 <td class='text'    valign="top">
1240
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>
1246
1247 <td class='text'    valign="top">
1248
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>
1257
1258  <tr>
1259
1260 <td class='text'    valign="top">
1261
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>
1266
1267 <td class='text'    valign="top">
1268
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>
1272
1273 <td class='text'    valign="top">
1274
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>
1279
1280  <tr>
1281
1282 <td class='text'    valign="top">
1283
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>
1288
1289 <td class='text'    valign="top">
1290
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>
1297
1298 <td class='text'    valign="top">
1299
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>
1307
1308  <tr>
1309
1310 <td class='text'    valign="top">
1311
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>
1318
1319 <td class='text'    valign="top">
1320
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>
1327
1328 <td class='text'    valign="top">&nbsp;
1329
1330
1331  </td>
1332  </tr>
1333
1334  <tr><td class='text'   colspan="3">
1335
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>
1338
1339  <tr><td class='text'   colspan="3">
1340
1341  <table>
1342
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>
1344
1345  </table>
1346  </td></tr>
1347
1348  <tr><td class='text'   colspan="3" style="border: 1px #000000 solid;"><h3> <?php xl("Social History
1349  ",'e') ?></h3> </td></tr>
1350
1351  <tr>
1352
1353  <td   colspan="2" class='text'><strong>
1354
1355  Marital </strong></td>
1356
1357 <td    valign="top" class='text'><strong>
1358
1359  Health Habits: </strong></td>
1360  </tr>
1361
1362  <tr>
1363
1364  <td class='text'   colspan="2">
1365
1366  <table>
1367
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>
1373
1374  </table>
1375  </td>
1376
1377 <td class='text'    valign="top">
1378
1379  <table>
1380
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>
1384
1385  </table>
1386  </td>
1387  </tr>
1388
1389  <tr>
1390
1391  <td class='text'   colspan="2">
1392
1393  <table>
1394
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>
1396
1397  </table>
1398  </td>
1399
1400 <td class='text'    valign="top">
1401
1402  <table>
1403
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>
1405
1406  </table>
1407  </td>
1408  </tr>
1409
1410  <tr>
1411
1412  <td class='text'   colspan="2">
1413
1414  <table>
1415
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>
1417
1418  </table>
1419  </td>
1420
1421 <td class='text'    valign="top">
1422
1423  <table>
1424
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>
1426
1427  </table>
1428  </td>
1429  </tr>
1430
1431  <tr>
1432
1433  <td class='text'   colspan="2">
1434
1435  <table>
1436
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>
1438
1439  </table>
1440  </td>
1441
1442 <td class='text'    valign="top">
1443
1444  <table>
1445
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>
1447
1448  </table>
1449  </td>
1450  </tr>
1451
1452  <tr>
1453
1454  <td class='text'   colspan="2">&nbsp;
1455
1456
1457  </td>
1458
1459 <td class='text'    valign="top">
1460
1461  <table>
1462
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>
1464
1465  </table>
1466  </td>
1467  </tr>
1468
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>
1474
1475  <tr><td class='text'   colspan="3">
1476
1477  <table>
1478
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>
1486
1487  </table>
1488  </td></tr>
1489
1490  <tr><td class='text'   colspan="3">
1491
1492  <table>
1493
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>
1501
1502  </table>
1503  </td></tr>
1504
1505  <tr><td class='text'   colspan="3">
1506
1507  <table>
1508
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>
1516
1517  </table>
1518  </td></tr>
1519
1520  <tr><td class='text'   colspan="3">
1521
1522  <table>
1523
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>
1530
1531  </table>
1532      </td></tr>
1533
1534  <tr>
1535
1536  <td class='text'   colspan="3" style="border: 1px #000000 solid;">
1537   <h3>
1538  Hospitalizations: </h3>
1539  </td></tr>
1540
1541  <tr>
1542
1543 <td class='text'    valign="top">
1544
1545  <table>
1546
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>
1548
1549  </table>
1550  </td>
1551
1552 <td class='text'    valign="top">
1553
1554  <table>
1555
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>
1557
1558  </table>
1559  </td>
1560
1561 <td class='text'    valign="top">
1562
1563  <table>
1564
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>
1566
1567  </table>
1568  </td>
1569  </tr>
1570
1571  </table>
1572  <table></table><input type="submit" name="submit form" value="submit form" />
1573
1574  </form>
1575  <?php
1576  formFooter();
1577  ?>