contrib/forms/chiropractor_set/Chirpractic_physical_therapy_form/print.php

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