contrib/forms/chiropractor_set/Chirpractic_physical_therapy_form/view.php

   1 <!-- view.php -->
   2  <?php
   3  include_once("../../globals.php");
   4  include_once("$srcdir/api.inc");
   5  formHeader("Form: Chirpractic_physical_therapy_form");
   6  $returnurl = $GLOBALS['concurrent_layout'] ? 'encounter_top.php' : 'patient_encounter.php';
   7  $obj = formFetch("form_Chirpractic_physical_therapy_form", $_GET["id"]);  //#Use the formFetch function from api.inc to get values for existing form.
   8
   9  function chkdata_Txt(&$obj, $var) {
  10          return htmlentities($obj{"$var"});
  11  }
  12  function chkdata_Date(&$obj, $var) {
  13          return htmlentities($obj{"$var"});
  14  }
  15  function chkdata_CB(&$obj, $nam, $var) {
  16         if (preg_match("/$var/",$obj{$nam})) {return "checked";} else {return "";}
  17  }
  18  function chkdata_Radio(&$obj, $nam, $var) {
  19         if (strpos($obj{$nam},$var) !== false) {return "checked";}
  20  }
  21   function chkdata_PopOrScroll(&$obj, $nam, $var) {
  22                 if (preg_match("/$var/",$obj{$nam})) {return "selected";} else {return "";}
  23
  24  }
  25
  26  ?>
  27  <html><head>
  28  <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
  29  </head>
  30  <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
  31  <form method=post action="<?php echo $rootdir?>/forms/Chirpractic_physical_therapy_form/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form" onSubmit="return top.restoreSession()">
  32  <h1> Chiropractic physical therapy form </h1>
  33  <hr>
  34  <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>
  35
  36 <table cellspacing="0" cellpadding="0" style="width: 100%">
  37
  38              <tr>
  39
  40                  <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
  41
  42                      <h3>
  43
  44                          CONFIDENTIAL PATIENT CASE HISTORY</h3>
  45                  </td>
  46              </tr>
  47
  48              <tr>
  49
  50                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
  51
  52  <table>
  53
  54  <tr><td class="text" > Date:</td> <td class="text" ><input type="text" name="_date" value="<?php $result = chkdata_Txt($obj,"_date"); echo $result;?>"></td></tr>
  55
  56  </table>
  57                  </td>
  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" > Social Security #:</td> <td class="text" ><input type="text" name="_social_security_number" value="<?php $result = chkdata_Txt($obj,"_social_security_number"); echo $result;?>"></td></tr>
  64
  65  </table>
  66                  </td>
  67
  68                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
  69
  70  <table>
  71
  72  <tr><td class="text" > Drivers License #:</td> <td class="text" ><input type="text" name="_drivers_license_number" value="<?php $result = chkdata_Txt($obj,"_drivers_license_number"); echo $result;?>"></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" > Name:</td> <td class="text" ><input type="text" name="_name" value="<?php $result = chkdata_Txt($obj,"_name"); echo $result;?>"></td></tr>
  85
  86  </table>
  87                  </td>
  88
  89                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
  90
  91  <table>
  92
  93  <tr><td class="text" > Address:</td> <td class="text" ><input type="text" name="_address" value="<?php $result = chkdata_Txt($obj,"_address"); echo $result;?>"></td></tr>
  94
  95  </table>
  96                  </td>
  97              </tr>
  98
  99              <tr>
 100
 101                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 102
 103  <table>
 104
 105  <tr><td class="text" > City:</td> <td class="text" ><input type="text" name="_city" value="<?php $result = chkdata_Txt($obj,"_city"); echo $result;?>"></td></tr>
 106
 107  </table>
 108                  </td>
 109
 110                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 111
 112  <table>
 113
 114  <tr><td class="text" > State:</td> <td class="text" ><input type="text" name="_state" value="<?php $result = chkdata_Txt($obj,"_state"); echo $result;?>"></td></tr>
 115
 116  </table>
 117                  </td>
 118
 119                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 120
 121  <table>
 122
 123  <tr><td class="text" > Zip:</td> <td class="text" ><input type="text" name="_zip" value="<?php $result = chkdata_Txt($obj,"_zip"); echo $result;?>"></td></tr>
 124
 125  </table>
 126                  </td>
 127              </tr>
 128
 129              <tr>
 130
 131                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 132
 133  <table>
 134
 135  <tr><td class="text" > Home Phone:</td> <td class="text" ><input type="text" name="_home_phone" value="<?php $result = chkdata_Txt($obj,"_home_phone"); echo $result;?>"></td></tr>
 136
 137  </table>
 138                  </td>
 139
 140                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 141
 142  <table>
 143
 144  <tr><td class="text" > Cell Phone:</td> <td class="text" ><input type="text" name="_cell_phone" value="<?php $result = chkdata_Txt($obj,"_cell_phone"); echo $result;?>"></td></tr>
 145
 146  </table>
 147                  </td>
 148              </tr>
 149
 150              <tr>
 151
 152                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 153
 154  <table>
 155
 156  <tr><td class="text" > Birth Date:</td> <td class="text" ><input type="text" name="_birth_date" value="<?php $result = chkdata_Txt($obj,"_birth_date"); echo $result;?>"></td></tr>
 157
 158  </table>
 159                  </td>
 160
 161                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 162
 163  <table>
 164
 165  <tr><td class="text" > Age:</td> <td class="text" ><input type="text" name="_age" value="<?php $result = chkdata_Txt($obj,"_age"); echo $result;?>"></td></tr>
 166
 167  </table>
 168                  </td>
 169
 170                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 171
 172  <table>
 173
 174  <tr><td class="text" > Sex:</td> <td class="text" ><label><input type="checkbox" name="_sex[]" value="Male" <?php $result = chkdata_CB($obj,"_sex","Male"); echo $result;?> <?php xl(">Male",'e') ?> </label>
 175  <label><input type="checkbox" name="_sex[]" value="Female" <?php $result = chkdata_CB($obj,"_sex","Female"); echo $result;?> <?php xl(">Female",'e') ?> </label></td></tr>
 176
 177  </table>
 178                  </td>
 179              </tr>
 180
 181              <tr>
 182
 183                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 184
 185  <table>
 186
 187  <tr><td class="text" > Business Or Employer:</td> <td class="text" ><input type="text" name="_business_or_employer" value="<?php $result = chkdata_Txt($obj,"_business_or_employer"); echo $result;?>"></td></tr>
 188
 189  </table>
 190                  </td>
 191
 192                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 193
 194  <table>
 195
 196  <tr><td class="text" > Type Of Work:</td> <td class="text" ><input type="text" name="_type_of_work" value="<?php $result = chkdata_Txt($obj,"_type_of_work"); echo $result;?>"></td></tr>
 197
 198  </table>
 199                  </td>
 200              </tr>
 201
 202              <tr>
 203
 204                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 205
 206  <table>
 207
 208  <tr><td class="text" > Business Address And Phone Number:</td> <td class="text" ><input type="text" name="_business_address_and_phone_number" value="<?php $result = chkdata_Txt($obj,"_business_address_and_phone_number"); echo $result;?>"></td></tr>
 209
 210  </table>
 211                  </td>
 212              </tr>
 213
 214              <tr>
 215
 216                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 217
 218  <table>
 219
 220  <tr><td class="text" > check one</td> <td class="text" ><label><input type="checkbox" name="_check_one[]" value="Married" <?php $result = chkdata_CB($obj,"_check_one","Married"); echo $result;?> <?php xl(">Married",'e') ?> </label>
 221  <label><input type="checkbox" name="_check_one[]" value="Single" <?php $result = chkdata_CB($obj,"_check_one","Single"); echo $result;?> <?php xl(">Single",'e') ?> </label>
 222  <label><input type="checkbox" name="_check_one[]" value="Widowed" <?php $result = chkdata_CB($obj,"_check_one","Widowed"); echo $result;?> <?php xl(">Widowed",'e') ?> </label>
 223  <label><input type="checkbox" name="_check_one[]" value="Divorced" <?php $result = chkdata_CB($obj,"_check_one","Divorced"); echo $result;?> <?php xl(">Divorced",'e') ?> </label>
 224  <label><input type="checkbox" name="_check_one[]" value="Separated" <?php $result = chkdata_CB($obj,"_check_one","Separated"); echo $result;?> <?php xl(">Separated",'e') ?> </label></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="4" valign="top">
 233
 234  <table>
 235
 236  <tr><td class="text" > # Of Children:</td> <td class="text" ><input type="text" name="_number_of_children" value="<?php $result = chkdata_Txt($obj,"_number_of_children"); echo $result;?>"></td></tr>
 237
 238  </table>
 239                  </td>
 240              </tr>
 241
 242              <tr>
 243
 244                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 245
 246  <table>
 247
 248  <tr><td class="text" > Name And # Of Emergency Contact:</td> <td class="text" ><input type="text" name="_name_and_number_of_emergency_contact" value="<?php $result = chkdata_Txt($obj,"_name_and_number_of_emergency_contact"); echo $result;?>"></td></tr>
 249
 250  </table>
 251                  </td>
 252              </tr>
 253
 254              <tr>
 255
 256                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="2" valign="top">
 257
 258  <table>
 259
 260  <tr><td class="text" > Spouse Name:</td> <td class="text" ><input type="text" name="_spouse_name" value="<?php $result = chkdata_Txt($obj,"_spouse_name"); echo $result;?>"></td></tr>
 261
 262  </table>
 263                  </td>
 264
 265                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 266
 267  <table>
 268
 269  <tr><td class="text" > Occupation:</td> <td class="text" ><input type="text" name="_occupation" value="<?php $result = chkdata_Txt($obj,"_occupation"); echo $result;?>"></td></tr>
 270
 271  </table>
 272                  </td>
 273
 274                  <td class="text"  style="border: solid 1px #000000" align="left" valign="top">
 275
 276  <table>
 277
 278  <tr><td class="text" > Employer:</td> <td class="text" ><input type="text" name="_employer" value="<?php $result = chkdata_Txt($obj,"_employer"); echo $result;?>"></td></tr>
 279
 280  </table>
 281                  </td>
 282              </tr>
 283
 284              <tr>
 285
 286                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 287
 288  <table>
 289
 290  <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 $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Self"); echo $result;?> <?php xl(">Self",'e') ?> </label>
 291  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Spouse" <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Spouse"); echo $result;?> <?php xl(">Spouse",'e') ?> </label>
 292  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Workmans Comp" <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Workmans Comp"); echo $result;?> <?php xl(">Workmans Comp",'e') ?> </label>
 293  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Medicaid" <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Medicaid"); echo $result;?> <?php xl(">Medicaid",'e') ?> </label>
 294  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Medicare" <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Medicare"); echo $result;?> <?php xl(">Medicare",'e') ?> </label>
 295  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Auto Insurance" <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Auto Insurance"); echo $result;?> <?php xl(">Auto Insurance",'e') ?> </label>
 296  <label><input type="checkbox" name="_who_is_responsible_for_your_bill[]" value="Personal health insurance " <?php $result = chkdata_CB($obj,"_who_is_responsible_for_your_bill","Personal health insurance "); echo $result;?> <?php xl(">Personal health insurance ",'e') ?> </label></td></tr>
 297
 298  </table>
 299
 300  <table>
 301
 302  <tr><td class="text" > Other</td> <td class="text" ><input type="text" name="_other" value="<?php $result = chkdata_Txt($obj,"_other"); echo $result;?>"></td></tr>
 303
 304  </table>
 305                  </td>
 306              </tr>
 307
 308              <tr>
 309
 310                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 311                  </td>
 312              </tr>
 313
 314              <tr>
 315
 316                  <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
 317
 318                      <h3>
 319
 320                          CURRENT HEALTH CONDITION</h3>
 321                  </td>
 322              </tr>
 323
 324              <tr>
 325
 326                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 327
 328  <table>
 329
 330  <tr><td class="text" > Purpose Of This Appointment:</td> <td class="text" ><input type="text" name="_purpose_of_this_appointment" value="<?php $result = chkdata_Txt($obj,"_purpose_of_this_appointment"); echo $result;?>"></td></tr>
 331
 332  </table>
 333                  </td>
 334              </tr>
 335
 336              <tr>
 337
 338                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 339
 340  <table>
 341
 342  <tr><td class="text" > Other Doctors Seen For This Condition:</td> <td class="text" ><input type="text" name="_other_doctors_seen_for_this_condition" value="<?php $result = chkdata_Txt($obj,"_other_doctors_seen_for_this_condition"); echo $result;?>"></td></tr>
 343
 344  </table>
 345                  </td>
 346              </tr>
 347
 348              <tr>
 349
 350                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 351
 352  <table>
 353
 354  <tr><td class="text" > When Did This Condition Begin:</td> <td class="text" ><input type="text" name="_when_did_this_condition_begin" value="<?php $result = chkdata_Txt($obj,"_when_did_this_condition_begin"); echo $result;?>"></td></tr>
 355
 356  </table>
 357                  </td>
 358              </tr>
 359
 360              <tr>
 361
 362                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 363
 364  <table>
 365
 366  <tr><td class="text" > check</td> <td class="text" ><label><input type="checkbox" name="_check[]" value="Gradual Onset" <?php $result = chkdata_CB($obj,"_check","Gradual Onset"); echo $result;?> <?php xl(">Gradual Onset",'e') ?> </label>
 367  <label><input type="checkbox" name="_check[]" value="Job Related" <?php $result = chkdata_CB($obj,"_check","Job Related"); echo $result;?> <?php xl(">Job Related",'e') ?> </label>
 368  <label><input type="checkbox" name="_check[]" value="Auto Related" <?php $result = chkdata_CB($obj,"_check","Auto Related"); echo $result;?> <?php xl(">Auto Related",'e') ?> </label></td></tr>
 369
 370  </table>
 371                  </td>
 372              </tr>
 373
 374              <tr>
 375
 376                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 377
 378  <table>
 379
 380  <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 $result = chkdata_CB($obj,"_medication_you_now_take","Nerve Pills"); echo $result;?> <?php xl(">Nerve Pills",'e') ?> </label>
 381  <label><input type="checkbox" name="_medication_you_now_take[]" value="Pain Killers or Muscle relaxers" <?php $result = chkdata_CB($obj,"_medication_you_now_take","Pain Killers or Muscle relaxers"); echo $result;?> <?php xl(">Pain Killers or Muscle relaxers",'e') ?> </label>
 382  <label><input type="checkbox" name="_medication_you_now_take[]" value="Insulin" <?php $result = chkdata_CB($obj,"_medication_you_now_take","Insulin"); echo $result;?> <?php xl(">Insulin",'e') ?> </label>
 383  <label><input type="checkbox" name="_medication_you_now_take[]" value="Blood pressure medicine " <?php $result = chkdata_CB($obj,"_medication_you_now_take","Blood pressure medicine "); echo $result;?> <?php xl(">Blood pressure medicine ",'e') ?> </label></td></tr>
 384
 385  </table>
 386
 387  <table>
 388
 389  <tr><td class="text" > others</td> <td class="text" ><input type="text" name="_others" value="<?php $result = chkdata_Txt($obj,"_others"); echo $result;?>"></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                  </td>
 399              </tr>
 400
 401              <tr>
 402
 403                  <td class="text"  style="border: solid 1px #000000" align="center" colspan="4" valign="top">
 404
 405                      <h3>
 406
 407                          PAST HEALTH HISTORY</h3>
 408                  </td>
 409              </tr>
 410
 411              <tr>
 412
 413                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 414
 415  <table>
 416
 417  <tr><td class="text" > Major Surgery Or Operations:</td> <td class="text" ><label><input type="checkbox" name="_major_surgery_or_operations[]" value="Appendectomy" <?php $result = chkdata_CB($obj,"_major_surgery_or_operations","Appendectomy"); echo $result;?> <?php xl(">Appendectomy",'e') ?> </label>
 418  <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Tonsillectomy" <?php $result = chkdata_CB($obj,"_major_surgery_or_operations","Tonsillectomy"); echo $result;?> <?php xl(">Tonsillectomy",'e') ?> </label>
 419  <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Gall Bladder" <?php $result = chkdata_CB($obj,"_major_surgery_or_operations","Gall Bladder"); echo $result;?> <?php xl(">Gall Bladder",'e') ?> </label>
 420  <label><input type="checkbox" name="_major_surgery_or_operations[]" value="Hernia" <?php $result = chkdata_CB($obj,"_major_surgery_or_operations","Hernia"); echo $result;?> <?php xl(">Hernia",'e') ?> </label>
 421  <label><input type="checkbox" name="_major_surgery_or_operations[]" value="BrokenBone" <?php $result = chkdata_CB($obj,"_major_surgery_or_operations","BrokenBone"); echo $result;?> <?php xl(">BrokenBone",'e') ?> </label></td></tr>
 422
 423  </table>
 424
 425  <table>
 426
 427  <tr><td class="text" > otherone</td> <td class="text" ><input type="text" name="_otherone" value="<?php $result = chkdata_Txt($obj,"_otherone"); echo $result;?>"></td></tr>
 428
 429  </table>
 430                  </td>
 431              </tr>
 432
 433              <tr>
 434
 435                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 436
 437  <table>
 438
 439  <tr><td class="text" > Major Accidents Or Falls:</td> <td class="text" ><input type="text" name="_major_accidents_or_falls" value="<?php $result = chkdata_Txt($obj,"_major_accidents_or_falls"); echo $result;?>"></td></tr>
 440
 441  </table>
 442                  </td>
 443              </tr>
 444
 445              <tr>
 446
 447                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 448
 449  <table>
 450
 451  <tr><td class="text" > Hospitalization If Other Than Above:</td> <td class="text" ><input type="text" name="_hospitalization_if_other_than_above" value="<?php $result = chkdata_Txt($obj,"_hospitalization_if_other_than_above"); echo $result;?>"></td></tr>
 452
 453  </table>
 454                  </td>
 455              </tr>
 456
 457              <tr>
 458
 459                  <td class="text"  style="border: solid 1px #000000" align="left" colspan="4" valign="top">
 460
 461  <table>
 462
 463  <tr><td class="text" > Previous Chiropractic Care:</td> <td class="text" ><label><input type="checkbox" name="_previous_chiropractic_care[]" value="None " <?php $result = chkdata_CB($obj,"_previous_chiropractic_care","None "); echo $result;?> <?php xl(">None ",'e') ?> </label> Doctors Name: <input type="text" name="_doctors_name" value="<?php $result = chkdata_Txt($obj,"_doctors_name"); echo $result;?>"> Appox Date Of Last Visit:<input type="text" name="_appox_date_of_last_visit" value="<?php $result = chkdata_Txt($obj,"_appox_date_of_last_visit"); echo $result;?>"></td></tr>
 464
 465  </table>
 466                  </td>
 467              </tr>
 468
 469    </table>
 470
 471          <table cellspacing="0" cellpadding="0" width="100%">
 472
 473              <tr>
 474
 475                  <td class="text"  style="border: solid 1px #000000" colspan="2" align="center">
 476
 477                      <h3>
 478
 479                          Indicate ability to perform the following activities:</h3>                 </td>
 480              </tr>
 481
 482              <tr>
 483
 484                  <td class="text"  style="border: solid 1px #000000">
 485
 486  <table>
 487
 488  <tr><td class="text" > Coughing Or Sneezing</td> <td class="text" ><select name="_coughing_or_sneezing" >
 489  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_coughing_or_sneezing"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 490  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 491  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 492  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 493  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 494  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 495  </select></td></tr>
 496  </table>                 </td>
 497
 498                  <td class="text"  style="border: solid 1px #000000">
 499
 500  <table>
 501
 502  <tr><td class="text" > Climbing</td> <td class="text" ><select name="_climbing" >
 503  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_climbing"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 504  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 505  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 506  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 507  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 508  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 509  </select></td></tr>
 510  </table>                 </td>
 511              </tr>
 512
 513              <tr>
 514
 515                  <td class="text"  style="border: solid 1px #000000">
 516
 517  <table>
 518
 519  <tr><td class="text" > Getting In And Out Of A Car</td> <td class="text" ><select name="_getting_in_and_out_of_a_car" >
 520  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_getting_in_and_out_of_a_car"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 521  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 522  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 523  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 524  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 525  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 526  </select></td></tr>
 527  </table>                 </td>
 528
 529                  <td class="text"  style="border: solid 1px #000000">
 530
 531  <table>
 532
 533  <tr><td class="text" > Kneeling</td> <td class="text" ><select name="_kneeling" >
 534  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_kneeling"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 535  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 536  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 537  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 538  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 539  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 540  </select></td></tr>
 541  </table>                 </td>
 542              </tr>
 543
 544              <tr>
 545
 546                  <td class="text"  style="border: solid 1px #000000" width="33%">
 547
 548  <table>
 549
 550  <tr><td class="text" > Bending Forward To Brush Teeth</td> <td class="text" ><select name="_bending_forward_to_brush_teeth" >
 551  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_bending_forward_to_brush_teeth"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 552  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 553  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 554  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 555  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 556  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 557  </select></td></tr>
 558  </table>                 </td>
 559
 560                  <td class="text"  style="border: solid 1px #000000" width="33%">
 561
 562  <table>
 563
 564  <tr><td class="text" > Balancing</td> <td class="text" ><select name="_balancing" >
 565  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_balancing"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 566  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 567  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 568  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 569  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 570  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 571  </select></td></tr>
 572  </table>                 </td>
 573              </tr>
 574
 575              <tr>
 576
 577                  <td class="text"  style="border: solid 1px #000000">
 578
 579  <table>
 580
 581  <tr><td class="text" > Turing Over In Bed</Td> <Td><select name="_turing_over_in_bed" >
 582  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_turing_over_in_bed"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 583  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 584  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 585  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 586  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 587  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 588  </select></td></tr>
 589  </table>                 </td>
 590
 591                  <td class="text"  style="border: solid 1px #000000">
 592
 593  <table>
 594
 595  <tr><td class="text" > Dressing Self</td> <td class="text" ><select name="_dressing_self" >
 596  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_dressing_self"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 597  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 598  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 599  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 600  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 601  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 602  </select></td></tr>
 603  </table>                 </td>
 604              </tr>
 605
 606              <tr>
 607
 608                  <td class="text"  style="border: solid 1px #000000">
 609
 610  <table>
 611
 612  <tr><td class="text" > Walking Short Distance</td> <td class="text" ><select name="_walking_short_distance" >
 613  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_walking_short_distance"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 614  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 615  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 616  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 617  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 618  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 619  </select></td></tr>
 620  </table>                 </td>
 621
 622                  <td class="text"  style="border: solid 1px #000000">
 623
 624  <table>
 625
 626  <tr><td class="text" > Sleeping</td> <td class="text" ><select name="_sleeping" >
 627  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_sleeping"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 628  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 629  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 630  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 631  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 632  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 633  </select></td></tr>
 634  </table>                 </td>
 635              </tr>
 636
 637              <tr>
 638
 639                  <td class="text"  style="border: solid 1px #000000" class="text">
 640
 641  <table>
 642
 643  <tr><td class="text" > Standing More Than One Hour</td> <td class="text" ><select name="_standing_more_than_one_hour" >
 644  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_standing_more_than_one_hour"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 645  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 646  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 647  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 648  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 649  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 650  </select></td></tr>
 651  </table>                 </td>
 652
 653                  <td class="text"  style="border: solid 1px #000000" class="text">
 654
 655  <table>
 656
 657  <tr><td class="text" > Stooping</td> <td class="text" ><select name="_stooping" >
 658  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_stooping"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 659  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 660  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 661  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 662  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 663  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 664  </select></td></tr>
 665  </table>                 </td>
 666              </tr>
 667
 668              <tr>
 669
 670                  <td class="text"  style="border: solid 1px #000000" class="text">
 671
 672  <table>
 673
 674  <tr><td class="text" > Sitting At Table</td> <td class="text" ><select name="_sitting_at_table" >
 675  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_sitting_at_table"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 676  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 677  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 678  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 679  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 680  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 681  </select></td></tr>
 682  </table>                 </td>
 683
 684                  <td class="text"  style="border: solid 1px #000000" class="text">
 685
 686  <table>
 687
 688  <tr><td class="text" > Gripping</td> <td class="text" ><select name="_gripping" >
 689  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_gripping"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 690  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 691
 692  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 693  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 694  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 695  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 696  </select></td></tr>
 697  </table>                 </td>
 698              </tr>
 699
 700              <tr>
 701
 702                  <td class="text"  style="border: solid 1px #000000" class="text">
 703
 704  <table>
 705
 706  <tr><td class="text" > Lying On Back</td> <td class="text" ><select name="_lying_on_back" >
 707  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_lying_on_back"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 708  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 709  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 710  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 711  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 712  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 713  </select></td></tr>
 714  </table>                 </td>
 715
 716                  <td class="text"  style="border: solid 1px #000000" class="text">
 717
 718  <table>
 719
 720  <tr><td class="text" > Pushing</td> <td class="text" ><select name="_pushing" >
 721  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_pushing"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 722  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 723  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 724  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 725  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 726  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 727  </select></td></tr>
 728  </table>                 </td>
 729              </tr>
 730
 731              <tr>
 732
 733                  <td class="text"  style="border: solid 1px #000000" class="text">
 734
 735  <table>
 736
 737  <tr><td class="text" > Lying Flat On Stomach</Td> <td class="text" ><select name="_lying_flat_on_stomach" >
 738  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_lying_flat_on_stomach"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 739  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 740  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 741  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 742  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 743  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 744  </select></td></tr>
 745  </table>                 </td>
 746
 747                  <td class="text"  style="border: solid 1px #000000" class="text">
 748
 749  <table>
 750
 751  <tr><td class="text" > Pulling</td> <td class="text" ><select name="_pulling" >
 752  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_pulling"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 753  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 754  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 755  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 756  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 757  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 758  </select></td></tr>
 759  </table>                 </td>
 760              </tr>
 761
 762              <tr>
 763
 764                  <td class="text"  style="border: solid 1px #000000" class="text">
 765
 766  <table>
 767
 768  <tr><td class="text" > Lying On Side With Knees Bent</td> <td class="text" ><select name="_lying_on_side_with_knees_bent" >
 769  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_lying_on_side_with_knees_bent"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 770  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 771  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 772  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 773  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 774  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 775  </select></td></tr>
 776  </table>                 </td>
 777
 778                  <td class="text"  style="border: solid 1px #000000" class="text">
 779
 780  <table>
 781
 782  <tr><td class="text" > Reaching</td> <td class="text" ><select name="_reaching" >
 783  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_reaching"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 784  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 785  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 786  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 787  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 788  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 789  </select></td></tr>
 790  </table>                 </td>
 791              </tr>
 792
 793              <tr>
 794
 795                  <td class="text"  style="border: solid 1px #000000" class="text">
 796
 797  <table>
 798
 799  <tr><td class="text" > Bending Over Forward</td> <td class="text" ><select name="_bending_over_forward" >
 800  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_bending_over_forward"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 801  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 802  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 803  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 804  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 805  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 806  </select></td></tr>
 807  </table>                 </td>
 808
 809                  <td class="text"  style="border: solid 1px #000000" class="text">
 810
 811  <table>
 812
 813  <tr><td class="text" > Sexual Activity</td> <td class="text" ><select name="_sexual_activity" >
 814  <option value=" " <?php $result = chkdata_PopOrScroll($obj,"_sexual_activity"," "); echo $result;?> <?php xl("> ",'e') ?> </option>
 815  <option value="U-unable"> <?php xl("U-unable",'e') ?> </option>
 816  <option value="P-painful"> <?php xl("P-painful",'e') ?> </option>
 817  <option value="D-Diificult"> <?php xl("D-Diificult",'e') ?> </option>
 818  <option value="L-Limited"> <?php xl("L-Limited",'e') ?> </option>
 819  <option value="N-Normal"> <?php xl("N-Normal",'e') ?> </option>
 820  </select></td></tr>
 821  </table>                 </td>
 822              </tr>
 823              <tr>
 824                <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">Checking Symptoms of Nervous Systems</td>
 825
 826              </tr>
 827              <tr>
 828                <td class="text"  style="border: solid 1px #000000" class="text"><label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="Blurring Vision" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","Blurring Vision"); echo $result;?> <?php xl(">Blurring Vision",'e') ?> </label>
 829  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="buzzing or ringing in ears" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","buzzing or ringing in ears"); echo $result;?> <?php xl(">Buzzing Or Ringing In Ears",'e') ?> </label>
 830  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="confusion" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","confusion"); echo $result;?> <?php xl(">Confusion",'e') ?> </label>
 831  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="convulsions" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","convulsions"); echo $result;?> <?php xl(">Convulsions",'e') ?> </label>
 832  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="depression or crying spells" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","depression or crying spells"); echo $result;?> <?php xl(">Depression Or Crying Spells",'e') ?> </label>
 833  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="dizziness" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","dizziness"); echo $result;?> <?php xl(">Dizziness",'e') ?> </label>
 834  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="fainting" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","fainting"); echo $result;?> <?php xl(">Fainting",'e') ?> </label> </td>
 835                <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemsvalign="top"> <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="paralysis" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","paralysis"); echo $result;?> <?php xl(">Paralysis",'e') ?> </label>
 836  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="loss of sleep" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","loss of sleep"); echo $result;?> <?php xl(">Loss Of Sleep",'e') ?> </label>
 837  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="low resistance" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","low resistance"); echo $result;?> <?php xl(">Low Resistance",'e') ?> </label>
 838  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="muscle jerking" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","muscle jerking"); echo $result;?> <?php xl(">Muscle Jerking",'e') ?> </label>
 839  <label><input type="checkbox" name="_checking_symptoms_of_nervous_systems[]" value="headaches" <?php $result = chkdata_CB($obj,"_checking_symptoms_of_nervous_systems","headaches"); echo $result;?> <?php xl(">Headaches",'e') ?> </label>
 840
 841  How Often Do You Have Headaches <input type="text" name="_how_often_do_you_have_headaches" value="<?php $result = chkdata_Txt($obj,"_how_often_do_you_have_headaches"); echo $result;?>"></td>
 842              </tr>
 843
 844              <tr>
 845
 846                  <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
 847
 848
 849
 850                  </td>
 851              </tr>
 852
 853              <tr>
 854
 855                  <td class="text"  style="border: solid 1px #000000" class="text">
 856
 857  <table>
 858
 859  <tr><td class="text" > Symptoms Are Better In</td> <td class="text" ><label><input type="checkbox" name="_symptoms_are_better_in[]" value="AM" <?php $result = chkdata_CB($obj,"_symptoms_are_better_in","AM"); echo $result;?> <?php xl(">AM",'e') ?> </label>
 860  <label><input type="checkbox" name="_symptoms_are_better_in[]" value="Midday" <?php $result = chkdata_CB($obj,"_symptoms_are_better_in","Midday"); echo $result;?> <?php xl(">Midday",'e') ?> </label>
 861  <label><input type="checkbox" name="_symptoms_are_better_in[]" value="PM" <?php $result = chkdata_CB($obj,"_symptoms_are_better_in","PM"); echo $result;?> <?php xl(">PM",'e') ?> </label></td></tr>
 862  </table>                 </td>
 863
 864                  <td class="text"  style="border: solid 1px #000000" class="text">
 865
 866  <table>
 867
 868  <tr><td class="text" > Symptoms Are Worse In</td> <td class="text" ><label><input type="checkbox" name="_symptoms_are_worse_in[]" value="AM" <?php $result = chkdata_CB($obj,"_symptoms_are_worse_in","AM"); echo $result;?> <?php xl(">AM",'e') ?> </label>
 869  <label><input type="checkbox" name="_symptoms_are_worse_in[]" value="Midday" <?php $result = chkdata_CB($obj,"_symptoms_are_worse_in","Midday"); echo $result;?> <?php xl(">Midday",'e') ?> </label>
 870  <label><input type="checkbox" name="_symptoms_are_worse_in[]" value="PM" <?php $result = chkdata_CB($obj,"_symptoms_are_worse_in","PM"); echo $result;?> <?php xl(">PM",'e') ?> </label></td></tr>
 871  </table>                 </td>
 872              </tr>
 873
 874              <tr>
 875
 876                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 877
 878  <table>
 879
 880  <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" <?php $result = chkdata_CB($obj,"_symptoms_do_not_change_with_time_of_day","yes"); echo $result;?>></label></td></tr>
 881  </table>                 </td>
 882              </tr>
 883
 884              <tr>
 885
 886                  <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
 887
 888                      For woman only                 </td>
 889              </tr>
 890
 891              <tr>
 892
 893                  <td class="text"  style="border: solid 1px #000000" class="text">
 894
 895  <table>
 896
 897  <tr><td class="text" > Are You Pregnant</td> <td class="text" ><label><input type="checkbox" name="_are_you_pregnant[]" value="Yes" <?php $result = chkdata_CB($obj,"_are_you_pregnant","Yes"); echo $result;?> <?php xl(">Yes",'e') ?> </label>
 898  <label><input type="checkbox" name="_are_you_pregnant[]" value="No" <?php $result = chkdata_CB($obj,"_are_you_pregnant","No"); echo $result;?> <?php xl(">No",'e') ?> </label></td></tr>
 899  </table>                 </td>
 900
 901                  <td class="text"  style="border: solid 1px #000000">
 902
 903  <table>
 904
 905  <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" value="<?php $result = chkdata_Txt($obj,"_date_of_onset_of_last_menstrual_cycle"); echo $result;?>"></td></tr>
 906  </table>                 </td>
 907              </tr>
 908
 909              <tr>
 910
 911                  <td class="text"  style="border: solid 1px #000000" class="text">
 912
 913  <table>
 914
 915  <tr><td class="text" > Give Date Of Last Xray</td> <td class="text" ><input type="text" name="_give_date_of_last_xray" value="<?php $result = chkdata_Txt($obj,"_give_date_of_last_xray"); echo $result;?>"></td></tr>
 916  </table>                 </td>
 917
 918                  <td class="text"  style="border: solid 1px #000000">
 919
 920  <table>
 921
 922  <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" value="<?php $result = chkdata_Txt($obj,"_what_body_part_were_they_taken_of"); echo $result;?>"></td></tr>
 923  </table>                 </td>
 924              </tr>
 925
 926              <tr>
 927
 928                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 929                  Family History:</td>
 930              </tr>
 931
 932              <tr>
 933
 934                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 935
 936  <table>
 937
 938  <tr><td class="text" > Cancer</td> <td class="text" ><label><input type="checkbox" name="_cancer[]" value="Mother" <?php $result = chkdata_CB($obj,"_cancer","Mother"); echo $result;?> <?php xl(">Mother",'e') ?> </label>
 939  <label><input type="checkbox" name="_cancer[]" value="Father" <?php $result = chkdata_CB($obj,"_cancer","Father"); echo $result;?> <?php xl(">Father",'e') ?> </label>
 940  <label><input type="checkbox" name="_cancer[]" value="Brother" <?php $result = chkdata_CB($obj,"_cancer","Brother"); echo $result;?> <?php xl(">Brother",'e') ?> </label>
 941  <label><input type="checkbox" name="_cancer[]" value="Sister" <?php $result = chkdata_CB($obj,"_cancer","Sister"); echo $result;?> <?php xl(">Sister",'e') ?> </label>
 942  <label><input type="checkbox" name="_cancer[]" value="None" <?php $result = chkdata_CB($obj,"_cancer","None"); echo $result;?> <?php xl(">None",'e') ?> </label></td></tr>
 943  </table>                 </td>
 944              </tr>
 945
 946              <tr>
 947
 948                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 949
 950  <table>
 951
 952  <tr><td class="text" > Diabetes</td> <td class="text" ><label><input type="checkbox" name="_diabetes[]" value="Mother" <?php $result = chkdata_CB($obj,"_diabetes","Mother"); echo $result;?> <?php xl(">Mother",'e') ?> </label>
 953  <label><input type="checkbox" name="_diabetes[]" value="Father" <?php $result = chkdata_CB($obj,"_diabetes","Father"); echo $result;?> <?php xl(">Father",'e') ?> </label>
 954  <label><input type="checkbox" name="_diabetes[]" value="Brother" <?php $result = chkdata_CB($obj,"_diabetes","Brother"); echo $result;?> <?php xl(">Brother",'e') ?> </label>
 955  <label><input type="checkbox" name="_diabetes[]" value="Sister" <?php $result = chkdata_CB($obj,"_diabetes","Sister"); echo $result;?> <?php xl(">Sister",'e') ?> </label>
 956  <label><input type="checkbox" name="_diabetes[]" value="None" <?php $result = chkdata_CB($obj,"_diabetes","None"); echo $result;?> <?php xl(">None",'e') ?> </label></td></tr>
 957  </table>                 </td>
 958              </tr>
 959
 960              <tr>
 961
 962                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 963
 964  <table>
 965
 966  <tr><td class="text" > Heart Problems</td> <td class="text" ><label><input type="checkbox" name="_heart_problems[]" value="Mother" <?php $result = chkdata_CB($obj,"_heart_problems","Mother"); echo $result;?> <?php xl(">Mother",'e') ?> </label>
 967  <label><input type="checkbox" name="_heart_problems[]" value="Father" <?php $result = chkdata_CB($obj,"_heart_problems","Father"); echo $result;?> <?php xl(">Father",'e') ?> </label>
 968  <label><input type="checkbox" name="_heart_problems[]" value="Brother" <?php $result = chkdata_CB($obj,"_heart_problems","Brother"); echo $result;?> <?php xl(">Brother",'e') ?> </label>
 969  <label><input type="checkbox" name="_heart_problems[]" value="Sister" <?php $result = chkdata_CB($obj,"_heart_problems","Sister"); echo $result;?> <?php xl(">Sister",'e') ?> </label>
 970  <label><input type="checkbox" name="_heart_problems[]" value="None" <?php $result = chkdata_CB($obj,"_heart_problems","None"); echo $result;?> <?php xl(">None",'e') ?> </label></td></tr>
 971  </table>                 </td>
 972              </tr>
 973
 974              <tr>
 975
 976                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 977
 978  <table>
 979
 980  <tr><td class="text" > Back Or Neck Problems</td> <td class="text" ><label><input type="checkbox" name="_back_or_neck_problems[]" value="Mother" <?php $result = chkdata_CB($obj,"_back_or_neck_problems","Mother"); echo $result;?> <?php xl(">Mother",'e') ?> </label>
 981  <label><input type="checkbox" name="_back_or_neck_problems[]" value="Father" <?php $result = chkdata_CB($obj,"_back_or_neck_problems","Father"); echo $result;?> <?php xl(">Father",'e') ?> </label>
 982  <label><input type="checkbox" name="_back_or_neck_problems[]" value="Brother" <?php $result = chkdata_CB($obj,"_back_or_neck_problems","Brother"); echo $result;?> <?php xl(">Brother",'e') ?> </label>
 983  <label><input type="checkbox" name="_back_or_neck_problems[]" value="Sister" <?php $result = chkdata_CB($obj,"_back_or_neck_problems","Sister"); echo $result;?> <?php xl(">Sister",'e') ?> </label>
 984  <label><input type="checkbox" name="_back_or_neck_problems[]" value="None" <?php $result = chkdata_CB($obj,"_back_or_neck_problems","None"); echo $result;?> <?php xl(">None",'e') ?> </label></td></tr>
 985  </table>                 </td>
 986              </tr>
 987
 988              <tr>
 989
 990                  <td class="text"  style="border: solid 1px #000000" colspan="2">
 991
 992                      <table cellspacing="0" cellpadding="0" width="100%">
 993
 994                          <tr>
 995
 996                              <td class="text"  style="border: solid 1px #000000" colspan="2" align="center">
 997
 998                                  <h3>
 999
1000                                      Accident Information</h3>                             </td>
1001                          </tr>
1002
1003                          <tr>
1004
1005                              <td class="text"  style="border: solid 1px #000000" width="50%">
1006
1007  <table>
1008
1009  <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 $result = chkdata_CB($obj,"_have_you_retained_an_attorney","Yes"); echo $result;?> <?php xl(">Yes",'e') ?> </label>
1010  <label><input type="checkbox" name="_have_you_retained_an_attorney[]" value="no" <?php $result = chkdata_CB($obj,"_have_you_retained_an_attorney","no"); echo $result;?> <?php xl(">no",'e') ?> </label></td></tr>
1011  </table>                             </td>
1012
1013                              <td class="text"  style="border: solid 1px #000000" width="50%"> <?php xl("&nbsp;
1014                                  ",'e') ?> </td>
1015                          </tr>
1016
1017                          <tr>
1018
1019                              <td class="text"  style="border: solid 1px #000000">
1020                                 <?php xl("If yes",'e') ?></td>
1021
1022                              <td class="text"  style="border: solid 1px #000000"> <?php xl("&nbsp;
1023                                  ",'e') ?> </td>
1024                          </tr>
1025
1026                          <tr>
1027
1028                              <td class="text"  style="border: solid 1px #000000">
1029
1030  <table>
1031
1032  <tr><td class="text" > Name:</td> <td class="text" ><input type="text" name="_attorney_name" value="<?php $result = chkdata_Txt($obj,"_attorney_name"); echo $result;?>"></td></tr>
1033  </table>                             </td>
1034
1035                              <td class="text"  style="border: solid 1px #000000">
1036
1037  <table>
1038
1039  <tr><td class="text" > Address:</td> <td class="text" ><input type="text" name="_attorney_address" value="<?php $result = chkdata_Txt($obj,"_attorney_address"); echo $result;?>"></td></tr>
1040  </table>                             </td>
1041                          </tr>
1042
1043                          <tr>
1044
1045                              <td class="text"  style="border: solid 1px #000000">
1046
1047  <table>
1048
1049  <tr><td class="text" > Phone:</td> <td class="text" ><input type="text" name="_attorney_phone" value="<?php $result = chkdata_Txt($obj,"_attorney_phone"); echo $result;?>"></td></tr>
1050  </table>                             </td>
1051
1052                              <td class="text"  style="border: solid 1px #000000">&nbsp;
1053                             </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" > Number Of People In Vechicle And Their Name</td> <td class="text" ><input type="text" name="_number_of_people_in_vechicle_and_their_name" value="<?php $result = chkdata_Txt($obj,"_number_of_people_in_vechicle_and_their_name"); echo $result;?>"></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" > were the policy notified</td> <td class="text" ><label><input type="checkbox" name="_were_the_policy_notified[]" value="Yes" <?php $result = chkdata_CB($obj,"_were_the_policy_notified","Yes"); echo $result;?> <?php xl(">Yes",'e') ?> </label>
1073  <label><input type="checkbox" name="_were_the_policy_notified[]" value="no" <?php $result = chkdata_CB($obj,"_were_the_policy_notified","no"); echo $result;?> <?php xl(">no",'e') ?> </label></td></tr>
1074  </table>                             </td>
1075                          </tr>
1076
1077                          <tr>
1078
1079                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1080
1081  <table>
1082
1083  <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 $result = chkdata_CB($obj,"_what_direction_were_you_headed","North"); echo $result;?> <?php xl(">North",'e') ?> </label>
1084  <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="East" <?php $result = chkdata_CB($obj,"_what_direction_were_you_headed","East"); echo $result;?> <?php xl(">East",'e') ?> </label>
1085  <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="South" <?php $result = chkdata_CB($obj,"_what_direction_were_you_headed","South"); echo $result;?> <?php xl(">South",'e') ?> </label>
1086  <label><input type="checkbox" name="_what_direction_were_you_headed[]" value="West" <?php $result = chkdata_CB($obj,"_what_direction_were_you_headed","West"); echo $result;?> <?php xl(">West",'e') ?> </label></td></tr>
1087  </table>                             </td>
1088                          </tr>
1089
1090                          <tr>
1091
1092                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1093
1094  <table>
1095
1096  <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 $result = chkdata_CB($obj,"_what_direction_was_other_vechicle","North"); echo $result;?> <?php xl(">North",'e') ?> </label>
1097  <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="East" <?php $result = chkdata_CB($obj,"_what_direction_was_other_vechicle","East"); echo $result;?> <?php xl(">East",'e') ?> </label>
1098  <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="South" <?php $result = chkdata_CB($obj,"_what_direction_was_other_vechicle","South"); echo $result;?> <?php xl(">South",'e') ?> </label>
1099  <label><input type="checkbox" name="_what_direction_was_other_vechicle[]" value="Wst" <?php $result = chkdata_CB($obj,"_what_direction_was_other_vechicle","Wst"); echo $result;?> <?php xl(">Wst",'e') ?> </label></td></tr>
1100  </table>                             </td>
1101                          </tr>
1102
1103                          <tr>
1104
1105                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1106
1107  <table>
1108
1109  <tr><td class="text" > Name Of Street Or Town</td> <td class="text" ><input type="text" name="_name_of_street_or_town" value="<?php $result = chkdata_Txt($obj,"_name_of_street_or_town"); echo $result;?>"></td></tr>
1110  </table>                             </td>
1111                          </tr>
1112
1113                          <tr>
1114
1115                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1116
1117  <table>
1118
1119  <tr>
1120    <td class="text" > Were You Struck From</td> <td class="text" ><label><input type="checkbox" name="_were_you_struck_from[]" value="behind" <?php $result = chkdata_CB($obj,"_were_you_struck_from","behind"); echo $result;?> <?php xl(">behind",'e') ?> </label>
1121  <label><input type="checkbox" name="_were_you_struck_from[]" value="front" <?php $result = chkdata_CB($obj,"_were_you_struck_from","front"); echo $result;?> <?php xl(">front",'e') ?> </label>
1122  <label><input type="checkbox" name="_were_you_struck_from[]" value="left side" <?php $result = chkdata_CB($obj,"_were_you_struck_from","left side"); echo $result;?> <?php xl(">left side",'e') ?> </label>
1123  <label><input type="checkbox" name="_were_you_struck_from[]" value="right side" <?php $result = chkdata_CB($obj,"_were_you_struck_from","right side"); echo $result;?> <?php xl(">right side",'e') ?> </label></td></tr>
1124  </table>                             </td>
1125                          </tr>
1126
1127                          <tr>
1128
1129                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1130
1131  <table>
1132
1133  <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"><?php $result = chkdata_Txt($obj,"_in_your_own_words_please_describe_accident"); echo $result;?></textarea></td></tr>
1134  </table>                             </td>
1135                          </tr>
1136
1137                          <tr>
1138
1139                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1140
1141  <table>
1142
1143  <tr><td class="text" > Please Complaints And Symptoms</td> <td class="text" ><textarea name="_please_complaints_and_symptoms"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"_please_complaints_and_symptoms"); echo $result;?></textarea></td></tr>
1144  </table>                             </td>
1145                          </tr>
1146
1147                          <tr>
1148
1149                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1150
1151  <table>
1152
1153  <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 $result = chkdata_CB($obj,"_did_you_lose_any_time_from_work","Yes"); echo $result;?> <?php xl(">Yes",'e') ?> </label>
1154  <label><input type="checkbox" name="_did_you_lose_any_time_from_work[]" value="No" <?php $result = chkdata_CB($obj,"_did_you_lose_any_time_from_work","No"); echo $result;?> <?php xl(">No",'e') ?> </label></td></tr>
1155  </table>                             </td>
1156                          </tr>
1157
1158                          <tr>
1159
1160                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1161
1162  <table>
1163
1164  <tr><td class="text" > Date When You Lose From Work</td> <td class="text" ><input type="text" name="_date_when_you_lose_from_work" value="<?php $result = chkdata_Txt($obj,"_date_when_you_lose_from_work"); echo $result;?>"></td></tr>
1165  </table>                             </td>
1166                          </tr>
1167
1168                          <tr>
1169
1170                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1171
1172  <table>
1173
1174  <tr><td class="text" > Type Of Employment</td> <td class="text" ><input type="text" name="_type_of_employment" value="<?php $result = chkdata_Txt($obj,"_type_of_employment"); echo $result;?>"></td></tr>
1175  </table>                             </td>
1176                          </tr>
1177
1178                          <tr>
1179
1180                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1181
1182  <table>
1183
1184  <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" value="<?php $result = chkdata_Txt($obj,"_where_were_you_taken_immediately_following_accident"); echo $result;?>"></td></tr>
1185  </table>                             </td>
1186                          </tr>
1187
1188                          <tr>
1189
1190                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1191
1192  <table>
1193
1194  <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 $result = chkdata_CB($obj,"_if_taken_to_the_hospital_did_you","Go by ambulance"); echo $result;?> <?php xl(">Go by ambulance",'e') ?> </label>
1195  <label><input type="checkbox" name="_if_taken_to_the_hospital_did_you[]" value="Drove self" <?php $result = chkdata_CB($obj,"_if_taken_to_the_hospital_did_you","Drove self"); echo $result;?> <?php xl(">Drove self",'e') ?> </label>
1196  <label><input type="checkbox" name="_if_taken_to_the_hospital_did_you[]" value="Taken by someone else" <?php $result = chkdata_CB($obj,"_if_taken_to_the_hospital_did_you","Taken by someone else"); echo $result;?> <?php xl(">Taken by someone else",'e') ?> </label></td></tr>
1197  </table>                             </td>
1198                          </tr>
1199
1200                          <tr>
1201
1202                              <td class="text"  style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
1203
1204  <table>
1205
1206  <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 $result = chkdata_CB($obj,"_have_you_ever_been_involved_in_an_accident_before","yes"); echo $result;?> <?php xl(">yes",'e') ?> </label>
1207  <label><input type="checkbox" name="_have_you_ever_been_involved_in_an_accident_before[]" value="no" <?php $result = chkdata_CB($obj,"_have_you_ever_been_involved_in_an_accident_before","no"); echo $result;?> <?php xl(">no",'e') ?> </label></td></tr>
1208  </table>                             </td>
1209                          </tr>
1210
1211                      </table>                 </td>
1212              </tr>
1213
1214          </table>
1215
1216  <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>
1217
1218  </form>
1219  <?php
1220  formFooter();
1221  ?>