contrib/forms/chiropractor_set/Chirpractic_physical_therapy_form/new.php

   1 <?php
   2 include_once("../../globals.php");
   3 include_once("$srcdir/api.inc");
   4 formHeader("Form: Chirpractic_physical_therapy_form");
   5 $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   6 ?>
   7 <html><head>
   8 <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
   9 </head>
  10 <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  11
  12 <form method=post action="<?php echo $rootdir;?>/forms/Chirpractic_physical_therapy_form/save.php?mode=new" name="Chirpractic_physical_therapy_form" onSubmit="return top.restoreSession()">
  13 <hr>
  14 <input type="submit" name="submit form2" value="submit form" /> <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
  15 <h1> <?php xl("Chiropractic physical therapy form",'e') ?> </h1>
  16 <hr>
  17 <table cellspacing="0" cellpadding="0" style="width: 100%">
  18
  19             <tr>
  20
  21                 <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
  22
  23                     <h3>
  24
  25                         CONFIDENTIAL PATIENT CASE HISTORY</h3>
  26                 </td>
  27             </tr>
  28
  29             <tr>
  30
  31                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
  32
  33 <table>
  34
  35 <tr><td class="text" > Date:</td> <td class="text" ><input type="text" name="_date"  /></td></tr>
  36
  37 </table>
  38                 </td>
  39
  40                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
  41
  42 <table>
  43
  44 <tr><td class="text" > Social Security #:</td> <td class="text" ><input type="text" name="_social_security_number"  /></td></tr>
  45
  46 </table>
  47                 </td>
  48
  49                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
  50
  51 <table>
  52
  53 <tr><td class="text" > Drivers License #:</td> <td class="text" ><input type="text" name="_drivers_license_number"  /></td></tr>
  54
  55 </table>
  56                 </td>
  57             </tr>
  58
  59             <tr>
  60
  61                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
  62
  63 <table>
  64
  65 <tr><td class="text" > Name:</td> <td class="text" ><input type="text" name="_name"  /></td></tr>
  66
  67 </table>
  68                 </td>
  69
  70                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
  71
  72 <table>
  73
  74 <tr><td class="text" > Address:</td> <td class="text" ><input type="text" name="_address"  /></td></tr>
  75
  76 </table>
  77                 </td>
  78             </tr>
  79
  80             <tr>
  81
  82                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
  83
  84 <table>
  85
  86 <tr><td class="text" > City:</td> <td class="text" ><input type="text" name="_city"  /></td></tr>
  87
  88 </table>
  89                 </td>
  90
  91                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
  92
  93 <table>
  94
  95 <tr>
  96   <td class="text" > State</td>
  97   <td class="text" ><input type="text" name="_state"  /></td></tr>
  98
  99 </table>
 100                 </td>
 101
 102                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 103
 104 <table>
 105
 106 <tr><td class="text" > Zip:</td> <td class="text" ><input type="text" name="_zip"  /></td></tr>
 107
 108 </table>
 109                 </td>
 110             </tr>
 111
 112             <tr>
 113
 114                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 115
 116 <table>
 117
 118 <tr><td class="text" > Home Phone:</td> <td class="text" ><input type="text" name="_home_phone"  /></td></tr>
 119
 120 </table>
 121                 </td>
 122
 123                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 124
 125 <table>
 126
 127 <tr><td class="text" > Cell Phone:</td> <td class="text" ><input type="text" name="_cell_phone"  /></td></tr>
 128
 129 </table>
 130                 </td>
 131             </tr>
 132
 133             <tr>
 134
 135                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 136
 137 <table>
 138
 139 <tr><td class="text" > Birth Date:</td> <td class="text" ><input type="text" name="_birth_date"  /></td></tr>
 140
 141 </table>
 142                 </td>
 143
 144                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 145
 146 <table>
 147
 148 <tr><td class="text" > Age:</td> <td class="text" ><input type="text" name="_age"  /></td></tr>
 149
 150 </table>
 151                 </td>
 152
 153                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 154
 155 <table>
 156
 157 <tr><td class="text" > Sex:</td> <td class="text" ><label><input type="checkbox" name="_sex[]" value="Male" /> <?php xl("Male",'e') ?> </label> <label><input type="checkbox" name="_sex[]" value="Female" /> <?php xl("Female",'e') ?> </label></td></tr>
 158
 159 </table>
 160                 </td>
 161             </tr>
 162
 163             <tr>
 164
 165                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 166
 167 <table>
 168
 169 <tr><td class="text" > Business/Employer:</td> <td class="text" ><input type="text" name="_business_or_employer"  /></td></tr>
 170
 171 </table>
 172                 </td>
 173
 174                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 175
 176 <table>
 177
 178 <tr><td class="text" > Type oOf Work:</td> <td class="text" ><input type="text" name="_type_of_work"  /></td></tr>
 179
 180 </table>
 181                 </td>
 182             </tr>
 183
 184             <tr>
 185
 186                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 187
 188 <table>
 189
 190 <tr><td class="text" > Business Address and Phone Number:</td> <td class="text" ><input type="text" name="_business_address_and_phone_number"  /></td></tr>
 191
 192 </table>
 193                 </td>
 194             </tr>
 195
 196             <tr>
 197
 198                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 199
 200 <table>
 201
 202 <tr><td class="text" > Check One</td> <td class="text" ><label><input type="checkbox" name="_check_one[]" value="Married" /> <?php xl("Married",'e') ?> </label> <label><input type="checkbox" name="_check_one[]" value="Single" /> <?php xl("Single",'e') ?> </label> <label><input type="checkbox" name="_check_one[]" value="Widowed" /> <?php xl("Widowed",'e') ?> </label> <label><input type="checkbox" name="_check_one[]" value="Divorced" /> <?php xl("Divorced",'e') ?> </label> <label><input type="checkbox" name="_check_one[]" value="Separated" /> <?php xl("Separated",'e') ?> </label></td></tr>
 203
 204 </table>
 205                 </td>
 206             </tr>
 207
 208             <tr>
 209
 210                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 211
 212 <table>
 213
 214 <tr><td class="text" > # of Children:</td> <td class="text" ><input type="text" name="_number_of_children"  /></td></tr>
 215
 216 </table>
 217                 </td>
 218             </tr>
 219
 220             <tr>
 221
 222                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 223
 224 <table>
 225
 226 <tr><td class="text" > Name and # Of  Emergency Contact:</td> <td class="text" ><input type="text" name="_name_and_number_of_emergency_contact"  /></td></tr>
 227
 228 </table>
 229                 </td>
 230             </tr>
 231
 232             <tr>
 233
 234                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 235
 236 <table>
 237
 238 <tr><td class="text" > Spouse Name:</td> <td class="text" ><input type="text" name="_spouse_name"  /></td></tr>
 239
 240 </table>
 241                 </td>
 242
 243                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 244
 245 <table>
 246
 247 <tr><td class="text" > Occupation:</td> <td class="text" ><input type="text" name="_occupation"  /></td></tr>
 248
 249 </table>
 250                 </td>
 251
 252                 <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 253
 254 <table>
 255
 256 <tr><td class="text" > Employer:</td> <td class="text" ><input type="text" name="_employer"  /></td></tr>
 257
 258 </table>
 259                 </td>
 260             </tr>
 261
 262             <tr>
 263
 264                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 265
 266 <table>
 267
 268 <tr><td class="text" > Who Is Responsible For Your Bill:</td> <td class="text" ><label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Self" /> <?php xl("Self",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Spouse" /> <?php xl("Spouse",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Workmans Comp" /> <?php xl("Workmans Comp",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Medicaid" /> <?php xl("Medicaid",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Medicare" /> <?php xl("Medicare",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Auto Insurance" /> <?php xl("Auto Insurance",'e') ?> </label> <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Personal health insurance " /> <?php xl("Personal health insurance ",'e') ?> </label></td></tr>
 269
 270 </table>
 271
 272 <table>
 273
 274 <tr><td class="text" > Other:</td> <td class="text" ><input type="text" name="_other"  /></td></tr>
 275
 276 </table>
 277                 </td>
 278             </tr>
 279
 280             <tr>
 281
 282                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 283                 </td>
 284             </tr>
 285
 286             <tr>
 287
 288                 <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
 289
 290                     <h3>
 291
 292                         CURRENT HEALTH CONDITION</h3>
 293                 </td>
 294             </tr>
 295
 296
 297             <tr>
 298
 299                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 300
 301 <table>
 302
 303 <tr><td class="text" > Purpose Of This Appointment:</td> <td class="text" ><input type="text" name="_purpose_of_this_appointment"  /></td></tr>
 304
 305 </table>
 306                 </td>
 307             </tr>
 308
 309             <tr>
 310
 311                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 312
 313 <table>
 314
 315 <tr><td class="text" > Other Doctors Seen For This Condition:</td> <td class="text" ><input type="text" name="_other_doctors_seen_for_this_condition"  /></td></tr>
 316
 317 </table>
 318                 </td>
 319             </tr>
 320
 321             <tr>
 322
 323                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 324
 325 <table>
 326
 327 <tr><td class="text" > When Did This Condition Begin:</td> <td class="text" ><input type="text" name="_when_did_this_condition_begin"  /></td></tr>
 328
 329 </table>
 330                 </td>
 331             </tr>
 332
 333             <tr>
 334
 335                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 336
 337 <table>
 338
 339 <tr><td class="text" > check</td> <td class="text" ><label><input type="checkbox" name="_check[]" value="Gradual Onset" /> <?php xl("Gradual Onset",'e') ?> </label> <label><input type="checkbox" name="_check[]" value="Job Related" /> <?php xl("Job Related",'e') ?> </label> <label><input type="checkbox" name="_check[]" value="Auto Related" /> <?php xl("Auto Related",'e') ?> </label></td></tr>
 340
 341 </table>
 342                 </td>
 343             </tr>
 344
 345             <tr>
 346
 347                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 348
 349 <table>
 350
 351 <tr><td class="text" > Medication You Now Take:</td> <td class="text" ><label><input type="checkbox" name="_medication_you_now_take[]" value="Nerve Pills" /> <?php xl("Nerve Pills",'e') ?> </label> <label><input type="checkbox" name="_medication_you_now_take[]" value="Pain Killers or Muscle relaxers" /> <?php xl("Pain Killers or Muscle relaxers",'e') ?> </label> <label><input type="checkbox" name="_medication_you_now_take[]" value="Insulin" /> <?php xl("Insulin",'e') ?> </label> <label><input type="checkbox" name="_medication_you_now_take[]" value="Blood pressure medicine " /> <?php xl("Blood pressure medicine ",'e') ?> </label></td></tr>
 352
 353 </table>
 354
 355 <table>
 356
 357 <tr><td class="text" > Others</td> <td class="text" ><input type="text" name="_others"  /></td></tr>
 358
 359 </table>
 360                 </td>
 361             </tr>
 362
 363             <tr>
 364
 365                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 366                 </td>
 367             </tr>
 368
 369             <tr>
 370
 371                 <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
 372
 373                     <h3>
 374
 375                         PAST HEALTH HISTORY</h3>
 376                 </td>
 377             </tr>
 378
 379             <tr>
 380
 381                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 382
 383 <table>
 384
 385 <tr><td class="text" > Major Surgery Or Operations:</td> <td class="text" ><label><input type="checkbox" name="_major_surgery_or_operations[]" value="Appendectomy" /> <?php xl("Appendectomy",'e') ?> </label> <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Tonsillectomy" /> <?php xl("Tonsillectomy",'e') ?> </label> <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Gall Bladder" /> <?php xl("Gall Bladder",'e') ?> </label> <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Hernia" /> <?php xl("Hernia",'e') ?> </label> <label><input type="checkbox" name="_major_surgery_or_operations[]" value="BrokenBone" /> <?php xl("BrokenBone",'e') ?> </label></td></tr>
 386
 387 </table>
 388
 389 <table>
 390
 391 <tr><td class="text" > Otherone</td> <td class="text" ><input type="text" name="_otherone"  /></td></tr>
 392
 393 </table>
 394                 </td>
 395             </tr>
 396
 397             <tr>
 398
 399                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 400
 401 <table>
 402
 403 <tr><td class="text" > Major Accidents or Falls:</td> <td class="text" ><input type="text" name="_major_accidents_or_falls"  /></td></tr>
 404
 405 </table>
 406                 </td>
 407             </tr>
 408
 409             <tr>
 410
 411                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 412
 413 <table>
 414
 415 <tr><td class="text" > Hospitalization if Other Than Above:</td> <td class="text" ><input type="text" name="_hospitalization_if_other_than_above"  /></td></tr>
 416
 417 </table>
 418                 </td>
 419             </tr>
 420
 421             <tr>
 422
 423                 <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 424
 425 <table>
 426
 427 <tr><td class="text" > Previous Chiropractic Care:</td> <td class="text" ><label><input type="checkbox" name="_previous_chiropractic_care[]" value="None " /> <?php xl("None ",'e') ?> </label> Doctors Name:</td> <td class="text" ><input type="text" name="_doctors_name"  /> Appox Date of Last Visit:<input type="text" name="_appox_date_of_last_visit"  /></td></tr>
 428
 429 </table>
 430                 </td>
 431             </tr>
 432
 433   </table>
 434
 435         <table cellspacing="0" cellpadding="0" width="100%">
 436
 437             <tr>
 438
 439                 <td class="text"  style="border: solid 1px #000000" colspan="2" align="center">
 440
 441                     <h3>
 442
 443                         Indicate ability to perform the following activities:</h3>                </td>
 444             </tr>
 445
 446             <tr>
 447
 448                 <td class="text"  style="border: solid 1px #000000">
 449
 450 <table>
 451
 452 <tr><td class="text" > Coughing Or Sneezing</td> <td class="text" ><select name="_coughing_or_sneezing" >
 453 <option value=" "> </option>
 454 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 455 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 456 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 457 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 458 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 459 </select></td></tr>
 460 </table>                </td>
 461
 462                 <td class="text"  style="border: solid 1px #000000">
 463
 464 <table>
 465
 466 <tr><td class="text" > Climbing</td> <td class="text" ><select name="_climbing" >
 467 <option value=" "> </option>
 468 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 469 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 470 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 471 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 472 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 473 </select></td></tr>
 474 </table>                </td>
 475             </tr>
 476
 477             <tr>
 478
 479                 <td class="text"  style="border: solid 1px #000000">
 480
 481 <table>
 482
 483 <tr><td class="text" > Getting In And Out Of A Car</td> <td class="text" ><select name="_getting_in_and_out_of_a_car" >
 484 <option value=" "> </option>
 485 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 486 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 487 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 488 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 489 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 490 </select></td></tr>
 491 </table>                </td>
 492
 493                 <td class="text"  style="border: solid 1px #000000">
 494
 495 <table>
 496
 497 <tr><td class="text" > Kneeling</td> <td class="text" ><select name="_kneeling" >
 498 <option value=" "> </option>
 499 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 500 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 501 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 502 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 503 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 504 </select></td></tr>
 505 </table>                </td>
 506             </tr>
 507
 508             <tr>
 509
 510                 <td class="text"  style="border: solid 1px #000000" width="33%">
 511
 512 <table>
 513
 514 <tr><td class="text" > Bending Forward To Brush Teeth</td> <td class="text" ><select name="_bending_forward_to_brush_teeth" >
 515 <option value=" "> </option>
 516 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 517 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 518 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 519 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 520 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 521 </select></td></tr>
 522 </table>                </td>
 523
 524                 <td class="text"  style="border: solid 1px #000000" width="33%">
 525
 526 <table>
 527
 528 <tr><td class="text" > Balancing</td> <td class="text" ><select name="_balancing" >
 529 <option value=" "> </option>
 530 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 531 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 532 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 533 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 534 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 535 </select></td></tr>
 536 </table>                </td>
 537             </tr>
 538
 539             <tr>
 540
 541                 <td class="text"  style="border: solid 1px #000000">
 542
 543 <table>
 544
 545 <tr><td class="text" > Turing Over In Bed</td> <td class="text" ><select name="_turing_over_in_bed" >
 546 <option value=" "> </option>
 547 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 548 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 549 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 550 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 551 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 552 </select></td></tr>
 553 </table>                </td>
 554
 555                 <td class="text"  style="border: solid 1px #000000">
 556
 557 <table>
 558
 559 <tr><td class="text" > Dressing Self</td> <td class="text" ><select name="_dressing_self" >
 560 <option value=" "> </option>
 561 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 562 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 563 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 564 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 565 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 566 </select></td></tr>
 567 </table>                </td>
 568             </tr>
 569
 570             <tr>
 571
 572                 <td class="text"  style="border: solid 1px #000000">
 573
 574 <table>
 575
 576 <tr><td class="text" > Walking Short Distance</td> <td class="text" ><select name="_walking_short_distance" >
 577 <option value=" "> </option>
 578 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 579 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 580 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 581 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 582 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 583 </select></td></tr>
 584 </table>                </td>
 585
 586                 <td class="text"  style="border: solid 1px #000000">
 587
 588 <table>
 589
 590 <tr><td class="text" > Sleeping</td> <td class="text" ><select name="_sleeping" >
 591 <option value=" "> </option>
 592 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 593 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 594 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 595 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 596 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 597 </select></td></tr>
 598 </table>                </td>
 599             </tr>
 600
 601             <tr>
 602
 603                 <td class="text"  style="border: solid 1px #000000" >
 604
 605 <table>
 606
 607 <tr><td class="text" > Standing More Than One Hour</td> <td class="text" ><select name="_standing_more_than_one_hour" >
 608 <option value=" "> </option>
 609 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 610 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 611 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 612 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 613 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 614 </select></td></tr>
 615 </table>                </td>
 616
 617                 <td class="text"  style="border: solid 1px #000000" >
 618
 619 <table>
 620
 621 <tr><td class="text" > Stooping</td> <td class="text" ><select name="_stooping" >
 622 <option value=" "> </option>
 623 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 624 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 625 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 626 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 627 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 628 </select></td></tr>
 629 </table>                </td>
 630             </tr>
 631
 632             <tr>
 633
 634                 <td class="text"  style="border: solid 1px #000000" >
 635
 636 <table>
 637
 638 <tr><td class="text" > Sitting At Table</td> <td class="text" ><select name="_sitting_at_table" >
 639 <option value=" "> </option>
 640 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 641 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 642 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 643 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 644 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 645 </select></td></tr>
 646 </table>                </td>
 647
 648                 <td class="text"  style="border: solid 1px #000000" >
 649
 650 <table>
 651
 652 <tr><td class="text" > Gripping</td> <td class="text" ><select name="_gripping" >
 653 <option value=" "> </option>
 654 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 655 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 656 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 657 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 658 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 659 </select></td></tr>
 660 </table>                </td>
 661             </tr>
 662
 663             <tr>
 664
 665                 <td class="text"  style="border: solid 1px #000000" >
 666
 667 <table>
 668
 669 <tr><td class="text" > Lying On Back</td> <td class="text" ><select name="_lying_on_back" >
 670 <option value=" "> </option>
 671 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 672 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 673 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 674 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 675 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 676 </select></td></tr>
 677 </table>                </td>
 678
 679                 <td class="text"  style="border: solid 1px #000000" >
 680
 681 <table>
 682
 683 <tr><td class="text" > Pushing</td> <td class="text" ><select name="_pushing" >
 684 <option value=" "> </option>
 685 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 686 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 687 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 688 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 689 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 690 </select></td></tr>
 691 </table>                </td>
 692             </tr>
 693
 694             <tr>
 695
 696                 <td class="text"  style="border: solid 1px #000000" >
 697
 698 <table>
 699
 700 <tr><td class="text" > Lying Flat On Stomach</td> <td class="text" ><select name="_lying_flat_on_stomach" >
 701 <option value=" "> </option>
 702 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 703 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 704 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 705 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 706 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 707 </select></td></tr>
 708 </table>                </td>
 709
 710                 <td class="text"  style="border: solid 1px #000000" >
 711
 712 <table>
 713
 714 <tr><td class="text" > Pulling</td> <td class="text" ><select name="_pulling" >
 715 <option value=" "> </option>
 716 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 717 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 718 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 719 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 720 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 721 </select></td></tr>
 722 </table>                </td>
 723             </tr>
 724
 725             <tr>
 726
 727                 <td class="text"  style="border: solid 1px #000000" >
 728
 729 <table>
 730
 731 <tr><td class="text" > Lying On Side With Knees Bent</td> <td class="text" ><select name="_lying_on_side_with_knees_bent" >
 732 <option value=" "> </option>
 733 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 734 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 735 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 736 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 737 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 738 </select></td></tr>
 739 </table>                </td>
 740
 741                 <td class="text"  style="border: solid 1px #000000" >
 742
 743 <table>
 744
 745 <tr><td class="text" > Reaching</td> <td class="text" ><select name="_reaching" >
 746 <option value=" "> </option>
 747 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 748 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 749 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 750 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 751 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 752 </select></td></tr>
 753 </table>                </td>
 754             </tr>
 755
 756             <tr>
 757
 758                 <td class="text"  style="border: solid 1px #000000" >
 759
 760 <table>
 761
 762 <tr><td class="text" > Bending Over Forward</td> <td class="text" ><select name="_bending_over_forward" >
 763 <option value=" "> </option>
 764 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 765 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 766 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 767 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 768 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 769 </select></td></tr>
 770 </table>                </td>
 771
 772                 <td class="text"  style="border: solid 1px #000000" >
 773
 774 <table>
 775
 776 <tr><td class="text" > Sexual Activity</td> <td class="text" ><select name="_sexual_activity" >
 777 <option value=" "> </option>
 778 <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 779 <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 780 <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 781 <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 782 <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 783 </select></td></tr>
 784 </table>                </td>
 785             </tr>
 786                         <tr>
 787                         <td class="text"  colspan="2">Checking Symptoms Of Nervous Systems
 788                         </td>
 789
 790                         </tr>
 791             <tr>
 792               <td class="text"  style="border: solid 1px #000000" ><label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="Blurring Vision" /> <?php xl("Blurring Vision",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="buzzing or ringing in ears" /> <?php xl("Buzzing Or Ringing In Ears",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="confusion" /> <?php xl("Confusion",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="convulsions" /> <?php xl("Convulsions",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="depression or crying spells" /> <?php xl("depression or crying spells",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="Dizziness" /> <?php xl("dizziness",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="fainting" /> <?php xl("Fainting",'e') ?> </label></td>
 793               <td class="text"  style="border: solid 1px #000000"  valign="top"> <label>
 794               <input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="paralysis" /> <?php xl("Paralysis",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="loss of sleep" /> <?php xl("Loss Of Sleep",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="low resistance" /> <?php xl("Low Resistance",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="muscle jerking" /> <?php xl("Muscle Jerking",'e') ?> </label> <label><br><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="headaches" /> <?php xl("Headaches",'e') ?> </label> <br>How Often Do You Have Headaches <input type="text" name="_how_often_do_you_have_headaches"  /></td>
 795             </tr>
 796
 797             <tr>
 798
 799                 <td class="text"  style="border: solid 1px #000000"  colspan="2">
 800
 801
 802
 803            </td>
 804             </tr>
 805
 806             <tr>
 807
 808                 <td class="text"  style="border: solid 1px #000000" >
 809
 810 <table>
 811
 812 <tr><td class="text" > Symptoms Are Better In</td> <td class="text" ><label><input type="checkbox" name="_symptoms_are_better_in[]" value="AM" /> <?php xl("AM",'e') ?> </label> <label><input type="checkbox" name="_symptoms_are_better_in[]" value="Midday" /> <?php xl("Midday",'e') ?> </label> <label><input type="checkbox" name="_symptoms_are_better_in[]" value="PM" /> <?php xl("PM",'e') ?> </label></td></tr>
 813 </table>                </td>
 814
 815                 <td class="text"  style="border: solid 1px #000000" >
 816
 817 <table>
 818
 819 <tr><td class="text" > Symptoms Are Worse In</td> <td class="text" ><label><input type="checkbox" name="_symptoms_are_worse_in[]" value="AM" /> <?php xl("AM",'e') ?> </label> <label><input type="checkbox" name="_symptoms_are_worse_in[]" value="Midday" /> <?php xl("Midday",'e') ?> </label> <label><input type="checkbox" name="_symptoms_are_worse_in[]" value="PM" /> <?php xl("PM",'e') ?> </label></td></tr>
 820 </table>                </td>
 821             </tr>
 822
 823             <tr>
 824
 825                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 826
 827 <table>
 828
 829 <tr><td class="text" > Symptoms Do Not Change With Time Of Day</td> <td class="text" ><label><input type="checkbox" name="_symptoms_do_not_change_with_time_of_day" value="yes" /></label></td></tr>
 830 </table>                </td>
 831             </tr>
 832
 833             <tr>
 834
 835                 <td class="text"  style="border: solid 1px #000000"  colspan="2">
 836
 837                     For woman only                </td>
 838             </tr>
 839
 840             <tr>
 841
 842                 <td class="text"  style="border: solid 1px #000000" >
 843
 844 <table>
 845
 846 <tr><td class="text" > Are You Pregnant</td> <td class="text" ><label><input type="checkbox" name="_are_you_pregnant[]" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="checkbox" name="_are_you_pregnant[]" value="No" /> <?php xl("No",'e') ?> </label></td></tr>
 847 </table>                </td>
 848
 849                 <td class="text"  style="border: solid 1px #000000">
 850
 851 <table>
 852
 853 <tr><td class="text" > Date Of Onset Of Last Menstrual Cycle</td> <td class="text" ><input type="text" name="_date_of_onset_of_last_menstrual_cycle"  /></td></tr>
 854 </table>                </td>
 855             </tr>
 856
 857             <tr>
 858
 859                 <td class="text"  style="border: solid 1px #000000" >
 860
 861 <table>
 862
 863 <tr><td class="text" > Give Date Of Last Xray</td> <td class="text" ><input type="text" name="_give_date_of_last_xray"  /></td></tr>
 864 </table>                </td>
 865
 866                 <td class="text"  style="border: solid 1px #000000">
 867
 868 <table>
 869
 870 <tr><td class="text" > What Body Part Were They Taken Of</td> <td class="text" ><input type="text" name="_what_body_part_were_they_taken_of"  /></td></tr>
 871 </table>                </td>
 872             </tr>
 873
 874             <tr>
 875
 876                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 877                 Family History:</td>
 878             </tr>
 879
 880             <tr>
 881
 882                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 883
 884 <table>
 885
 886 <tr><td class="text" > Cancer</td> <td class="text" ><label><input type="checkbox" name="_cancer[]" value="Mother" /> <?php xl("Mother",'e') ?> </label> <label><input type="checkbox" name="_cancer[]" value="Father" /> <?php xl("Father",'e') ?> </label> <label><input type="checkbox" name="_cancer[]" value="Brother" /> <?php xl("Brother",'e') ?> </label> <label><input type="checkbox" name="_cancer[]" value="Sister" /> <?php xl("Sister",'e') ?> </label> <label><input type="checkbox" name="_cancer[]" value="None" /> <?php xl("None",'e') ?> </label></td></tr>
 887 </table>                </td>
 888             </tr>
 889
 890             <tr>
 891
 892                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 893
 894 <table>
 895
 896 <tr><td class="text" > Diabetes</td> <td class="text" ><label><input type="checkbox" name="_diabetes[]" value="Mother" /> <?php xl("Mother",'e') ?> </label> <label><input type="checkbox" name="_diabetes[]" value="Father" /> <?php xl("Father",'e') ?> </label> <label><input type="checkbox" name="_diabetes[]" value="Brother" /> <?php xl("Brother",'e') ?> </label> <label><input type="checkbox" name="_diabetes[]" value="Sister" /> <?php xl("Sister",'e') ?> </label> <label><input type="checkbox" name="_diabetes[]" value="None" /> <?php xl("None",'e') ?> </label></td></tr>
 897 </table>                </td>
 898             </tr>
 899
 900             <tr>
 901
 902                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 903
 904 <table>
 905
 906 <tr><td class="text" > Heart Problems</td> <td class="text" ><label><input type="checkbox" name="_heart_problems[]" value="Mother" /> <?php xl("Mother",'e') ?> </label> <label><input type="checkbox" name="_heart_problems[]" value="Father" /> <?php xl("Father",'e') ?> </label> <label><input type="checkbox" name="_heart_problems[]" value="Brother" /> <?php xl("Brother",'e') ?> </label> <label><input type="checkbox" name="_heart_problems[]" value="Sister" /> <?php xl("Sister",'e') ?> </label> <label><input type="checkbox" name="_heart_problems[]" value="None" /> <?php xl("None",'e') ?> </label></td></tr>
 907 </table>                </td>
 908             </tr>
 909
 910             <tr>
 911
 912                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 913
 914 <table>
 915
 916 <tr><td class="text" > Back Or Neck Problems</td> <td class="text" ><label><input type="checkbox" name="_back_or_neck_problems[]" value="Mother" /> <?php xl("Mother",'e') ?> </label> <label><input type="checkbox" name="_back_or_neck_problems[]" value="Father" /> <?php xl("Father",'e') ?> </label> <label><input type="checkbox" name="_back_or_neck_problems[]" value="Brother" /> <?php xl("Brother",'e') ?> </label> <label><input type="checkbox" name="_back_or_neck_problems[]" value="Sister" /> <?php xl("Sister",'e') ?> </label> <label><input type="checkbox" name="_back_or_neck_problems[]" value="None" /> <?php xl("None",'e') ?> </label></td></tr>
 917 </table>                </td>
 918             </tr>
 919
 920             <tr>
 921
 922                 <td class="text"  style="border: solid 1px #000000" colspan="2">
 923
 924                     <table cellspacing="0" cellpadding="0" width="100%">
 925
 926                         <tr>
 927
 928                             <td class="text"  style="border: solid 1px #000000" colspan="2" align="center">
 929
 930                                 <h3>
 931
 932                                     Accident Information</h3>                            </td>
 933                         </tr>
 934
 935                         <tr>
 936
 937                             <td class="text"  style="border: solid 1px #000000" width="50%">
 938
 939 <table>
 940
 941 <tr><td class="text" > Have You Retained An Attorney</td> <td class="text" ><label><input type="checkbox" name="_have_you_retained_an_attorney[]" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="checkbox" name="_have_you_retained_an_attorney[]" value="no" /> <?php xl("no",'e') ?> </label></td></tr>
 942 </table>                            </td>
 943
 944                             <td class="text"  style="border: solid 1px #000000" width="50%"> <?php xl("&nbsp;
 945                                 ",'e') ?> </td>
 946                         </tr>
 947
 948                         <tr>
 949
 950                             <td class="text"  style="border: solid 1px #000000">
 951                                  <?php xl("If yes",'e') ?> </td>
 952
 953                             <td class="text"  style="border: solid 1px #000000"> <?php xl("&nbsp;
 954                                 ",'e') ?> </td>
 955                         </tr>
 956
 957                         <tr>
 958
 959                             <td class="text"  style="border: solid 1px #000000">
 960
 961 <table>
 962
 963 <tr><td class="text" > Name</td> <td class="text" ><input type="text" name="_attorney_name"  /></td></tr>
 964 </table>                            </td>
 965
 966                             <td class="text"  style="border: solid 1px #000000">
 967
 968 <table>
 969
 970 <tr><td class="text" > Address</td> <td class="text" ><input type="text" name="_attorney_address"  /></td></tr>
 971 </table>                            </td>
 972                         </tr>
 973
 974                         <tr>
 975
 976                             <td class="text"  style="border: solid 1px #000000">
 977
 978 <table>
 979
 980 <tr><td class="text" > Phone</td> <td class="text" ><input type="text" name="_attorney_phone"  /></td></tr>
 981 </table>                            </td>
 982
 983                             <td class="text"  style="border: solid 1px #000000">&nbsp;                          </td>
 984                         </tr>
 985
 986                         <tr>
 987
 988                             <td class="text"  style="border: solid 1px #000000" colspan="2">
 989
 990 <table>
 991
 992 <tr><td class="text" > Number Of People In Vechicle And Their Name</td> <td class="text" ><input type="text" name="_number_of_people_in_vechicle_and_their_name"  /></td></tr>
 993 </table>                            </td>
 994                         </tr>
 995
 996                         <tr>
 997
 998                             <td class="text"  style="border: solid 1px #000000" colspan="2">
 999
1000 <table>
1001
1002 <tr><td class="text" > Were The Policy Notified</td> <td class="text" ><label><input type="checkbox" name="_were_the_policy_notified[]" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="checkbox" name="_were_the_policy_notified[]" value="no" /> <?php xl("no",'e') ?> </label></td></tr>
1003 </table>                            </td>
1004                         </tr>
1005
1006                         <tr>
1007
1008                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1009
1010 <table>
1011
1012 <tr><td class="text" > What Direction Were You Headed</td> <td class="text" ><label><input type="checkbox" name="_what_direction_were_you_headed[]" value="North" /> <?php xl("North",'e') ?> </label> <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="East" /> <?php xl("East",'e') ?> </label> <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="South" /> <?php xl("South",'e') ?> </label> <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="West" /> <?php xl("West",'e') ?> </label></td></tr>
1013 </table>                            </td>
1014                         </tr>
1015
1016                         <tr>
1017
1018                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1019
1020 <table>
1021
1022 <tr><td class="text" > What Direction Was Other Vechicle</td> <td class="text" ><label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="North" /> <?php xl("North",'e') ?> </label> <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="East" /> <?php xl("East",'e') ?> </label> <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="South" /> <?php xl("South",'e') ?> </label> <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="Wst" /> <?php xl("Wst",'e') ?> </label></td></tr>
1023 </table>                            </td>
1024                         </tr>
1025
1026                         <tr>
1027
1028                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1029
1030 <table>
1031
1032 <tr><td class="text" > Name Of Street Or Town</td> <td class="text" ><input type="text" name="_name_of_street_or_town"  /></td></tr>
1033 </table>                            </td>
1034                         </tr>
1035
1036                         <tr>
1037
1038                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1039
1040 <table>
1041
1042 <tr><td class="text" > Were You Struck From</td> <td class="text" ><label><input type="checkbox" name="_were_you_struck_from[]" value="behind" /> <?php xl("behind",'e') ?> </label> <label><input type="checkbox" name="_were_you_struck_from[]" value="front" /> <?php xl("front",'e') ?> </label> <label><input type="checkbox" name="_were_you_struck_from[]" value="left side" /> <?php xl("left side",'e') ?> </label> <label><input type="checkbox" name="_were_you_struck_from[]" value="right side" /> <?php xl("right side",'e') ?> </label></td></tr>
1043 </table>                            </td>
1044                         </tr>
1045
1046                         <tr>
1047
1048                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1049
1050 <table>
1051
1052 <tr><td class="text" > In Your Own Words Please Describe Accident</td> <td class="text" ><textarea name="_in_your_own_words_please_describe_accident"  rows="4" cols="40"></textarea></td></tr>
1053 </table>                            </td>
1054                         </tr>
1055
1056                         <tr>
1057
1058                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1059
1060 <table>
1061
1062 <tr><td class="text" > Please Complaints And Symptoms</td> <td class="text" ><textarea name="_please_complaints_and_symptoms"  rows="4" cols="40"></textarea></td></tr>
1063 </table>                            </td>
1064                         </tr>
1065
1066                         <tr>
1067
1068                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1069
1070 <table>
1071
1072 <tr><td class="text" > Did You Lose Any Time From Work</td> <td class="text" ><label><input type="checkbox" name="_did_you_lose_any_time_from_work[]" value="Yes" /> <?php xl("Yes",'e') ?> </label> <label><input type="checkbox" name="_did_you_lose_any_time_from_work[]" value="No" /> <?php xl("No",'e') ?> </label></td></tr>
1073 </table>                            </td>
1074                         </tr>
1075
1076                         <tr>
1077
1078                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1079
1080 <table>
1081
1082 <tr><td class="text" > Date When You Lose From Work</td> <td class="text" ><input type="text" name="_date_when_you_lose_from_work"  /></td></tr>
1083 </table>                            </td>
1084                         </tr>
1085
1086                         <tr>
1087
1088                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1089
1090 <table>
1091
1092 <tr><td class="text" > Type Of Employment</td> <td class="text" ><input type="text" name="_type_of_employment"  /></td></tr>
1093 </table>                            </td>
1094                         </tr>
1095
1096                         <tr>
1097
1098                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1099
1100 <table>
1101
1102 <tr><td class="text" > Where Were You Taken Immediately Following Accident</td> <td class="text" ><input type="text" name="_where_were_you_taken_immediately_following_accident"  /></td></tr>
1103 </table>                            </td>
1104                         </tr>
1105
1106                         <tr>
1107
1108                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1109
1110 <table>
1111
1112 <tr><td class="text" > If Taken To The Hospital Did You</td> <td class="text" ><label><input type="checkbox" name="_if_taken_to_the_hospital_did_you[]" value="Go by ambulance" /> <?php xl("Go by ambulance",'e') ?> </label> <label><input type="checkbox" name="_if_taken_to_the_hospital_did_you[]" value="Drove self" /> <?php xl("Drove self",'e') ?> </label> <label><input type="checkbox" name="_if_taken_to_the_hospital_did_you[]" value="Taken by someone else" /> <?php xl("Taken by someone else",'e') ?> </label></td></tr>
1113 </table>                            </td>
1114                         </tr>
1115
1116                         <tr>
1117
1118                             <td class="text"  style="border: solid 1px #000000"  colspan="2">
1119
1120 <table>
1121
1122 <tr><td class="text" > Have You Ever Been Involved In An Accident Before</td> <td class="text" ><label><input type="checkbox" name="_have_you_ever_been_involved_in_an_accident_before[]" value="yes" /> <?php xl("yes",'e') ?> </label> <label><input type="checkbox" name="_have_you_ever_been_involved_in_an_accident_before[]" value="no" /> <?php xl("no",'e') ?> </label></td></tr>
1123 </table>                            </td>
1124                         </tr>
1125                     </table>                </td>
1126             </tr>
1127         </table>
1128
1129 <table></table><input type="submit" name="submit form" value="submit form" /> <a href='<?php echo $GLOBALS['webroot']?>/interface/patient_file/encounter/<?php echo $returnurl?>' onclick='top.restoreSession()'> <?php xl("[do not save]",'e') ?> </a>
1130 </form>
1131
1132 <?php
1133 formFooter();
1134 ?>