/contrib/forms/cardiology_set/Forms3_Cardiology/view.php

https://bitbucket.org/DenizYldrm/openemr · PHP · 745 lines · 409 code · 336 blank · 0 comment · 5 complexity · 6ec367853046cd0356880050a9b2f767 MD5 · raw file 

    

  1. <!-- view.php --> 
    2. 

  2.  <?php 
    3. 

  3.  include_once("../../globals.php"); 
    4. 

  4.  include_once("$srcdir/api.inc"); 
    5. 

  5.  formHeader("Form: Forms3_Cardiology"); 
    6. 

  6.  $obj = formFetch("form_Forms3_Cardiology", $_GET["id"]);  //#Use the formFetch function from api.inc to get values for existing form. 
    7. 

  7.   
    8. 

  8.  function chkdata_Txt(&$obj, $var) { 
    9. 

  9.          return htmlentities($obj{"$var"}); 
    10. 

  10.  } 
    11. 

  11.  function chkdata_Date(&$obj, $var) { 
    12. 

  12.          return htmlentities($obj{"$var"}); 
    13. 

  13.  } 
    14. 

  14.  function chkdata_CB(&$obj, $nam, $var) { 
    15. 

  15.  	if (preg_match("/$var/",$obj{$nam})) {return "checked";} else {return "";}
    16. 

  16.  } 
    17. 

  17.  function chkdata_Radio(&$obj, $nam, $var) { 
    18. 

  18.  	if (strpos($obj{$nam},$var) !== false) {return "checked";} 
    19. 

  19.  } 
    20. 

  20.   function chkdata_PopOrScroll(&$obj, $nam, $var) { 
    21. 

  21.   if (preg_match("/$var/",$obj{$nam})) {return "selected";} else {return "";} 	
    22. 

  22.  } 
    23. 

  23.   
    24. 

  24.  ?> 
    25. 

  25.  <html><head> 
    26. 

  26.  <link rel=stylesheet href="<?php echo $css_header;?>" type="text/css">
    27. 

  27.  </head> 
    28. 

  28.  <body <?php echo $top_bg_line;?> topmargin=0 rightmargin=0 leftmargin=2 bottommargin=0 marginwidth=2 marginheight=0>
    29. 

  29.  <form method=post action="<?php echo $rootdir?>/forms/Forms3_Cardiology/save.php?mode=update&id=<?php echo $_GET["id"];?>" name="my_form" onSubmit="return top.restoreSession()">
    30. 

  30.  <h1> Forms3_Cardiology </h1> 
    31. 

  31.  <hr> 
    32. 

  32.  <input type="submit" name="submit form" value="submit form" />
    33. 

  33.  
    34. 

  34.  <table width="100%" cellpadding="0" cellspacing="0"> 
    35. 

  35.  
    36. 

  36.      <tr> 
    37. 

  37.  
    38. 

  38.          <td class='text'  valign="top"> 
    39. 

  39.  
    40. 

  40.              <table width="100%" cellpadding="0" cellspacing="0"> 
    41. 

  41.  
    42. 

  42.                  <tr> 
    43. 

  43.  
    44. 

  44.                      <td class='text'  style="border: 1px #000000 solid;"> 
    45. 

  45.   
    46. 

  46.  <table> 
    47. 

  47.   
    48. 

  48.  <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> 
    49. 

  49.   
    50. 

  50.  </table> 
    51. 

  51.                      </td> 
    52. 

  52.  
    53. 

  53.                      <td class='text'   style="border: 1px #000000 solid;"> 
    54. 

  54.   
    55. 

  55.  <table> 
    56. 

  56.   
    57. 

  57.  <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> 
    58. 

  58.   
    59. 

  59.  </table> 
    60. 

  60.                      </td> 
    61. 

  61.  
    62. 

  62.                       
    63. 

  63.                  </tr> 
    64. 

  64.  
    65. 

  65.  		<tr> 
    66. 

  66.  
    67. 

  67.  			<td class='text'  colspan='2' style="border: 1px #000000 solid;"> 
    68. 

  68.   
    69. 

  69.  <table> 
    70. 

  70.   
    71. 

  71.  <tr><td class='text' > chief complaint</td> <td class='text' ><input type="text" name="_chief_complaint" value="<?php $result = chkdata_Txt($obj,"_chief_complaint"); echo $result;?>"></td></tr> 
    72. 

  72.   
    73. 

  73.  </table> 
    74. 

  74.                      </td></tr> 
    75. 

  75.  
    76. 

  76.              </table> 
    77. 

  77.          </td> 
    78. 

  78.      </tr> 
    79. 

  79.  
    80. 

  80.      <tr> 
    81. 

  81.  
    82. 

  82.          <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;"> 
    83. 

  83.  
    84. 

  84.              <table width="100%" cellpadding="0" cellspacing="0">                 
    85. 

  85.  
    86. 

  86.                  <tr> 
    87. 

  87.  
    88. 

  88.                       
    89. 

  89.  
    90. 

  90.                      <td class='text'  colspan="2" style="border: 1px #000000 solid;"> 
    91. 

  91.   
    92. 

  92.  <table> 
    93. 

  93.   
    94. 

  94.  <tr><td class='text' > wt</td> <td class='text' ><input type="text" name="_wt" value="<?php $result = chkdata_Txt($obj,"_wt"); echo $result;?>"></td></tr> 
    95. 

  95.   
    96. 

  96.  </table> 
    97. 

  97.                      </td> 
    98. 

  98.  
    99. 

  99.                      <td class='text'  style="border: 1px #000000 solid;"> 
    100. 

  100.   
    101. 

  101.  <table> 
    102. 

  102.   
    103. 

  103.  <tr><td class='text' > bp</td> <td class='text' ><input type="text" name="_bp" value="<?php $result = chkdata_Txt($obj,"_bp"); echo $result;?>"></td></tr> 
    104. 

  104.   
    105. 

  105.  </table> 
    106. 

  106.                      </td> 
    107. 

  107.  
    108. 

  108.                       <td class='text'  style="border: 1px #000000 solid;"> 
    109. 

  109.   
    110. 

  110.  <table> 
    111. 

  111.   
    112. 

  112.  <tr><td class='text' > p</td> <td class='text' ><input type="text" name="_p" value="<?php $result = chkdata_Txt($obj,"_p"); echo $result;?>"></td></tr> 
    113. 

  113.   
    114. 

  114.  </table> 
    115. 

  115.                      </td> 
    116. 

  116.  
    117. 

  117.                      <td class='text'  style="border: 1px #000000 solid;"> 
    118. 

  118.   
    119. 

  119.  <table> 
    120. 

  120.   
    121. 

  121.  <tr><td class='text' > t</td> <td class='text' ><input type="text" name="_t" value="<?php $result = chkdata_Txt($obj,"_t"); echo $result;?>"></td></tr> 
    122. 

  122.   
    123. 

  123.  </table> 
    124. 

  124.                      </td> 
    125. 

  125.  
    126. 

  126.  		<td class='text'  style="border: 1px #000000 solid;"> 
    127. 

  127.   
    128. 

  128.  <table> 
    129. 

  129.   
    130. 

  130.  <tr><td class='text' > r</td> <td class='text' ><input type="text" name="_r" value="<?php $result = chkdata_Txt($obj,"_r"); echo $result;?>"></td></tr> 
    131. 

  131.   
    132. 

  132.  </table> 
    133. 

  133.                      </td> 
    134. 

  134.  
    135. 

  135.  		<td class='text'  style="border: 1px #000000 solid;"> 
    136. 

  136.   
    137. 

  137.  <table> 
    138. 

  138.   
    139. 

  139.  <tr><td class='text' > ht</td> <td class='text' ><input type="text" name="_ht" value="<?php $result = chkdata_Txt($obj,"_ht"); echo $result;?>"></td></tr> 
    140. 

  140.   
    141. 

  141.  </table> 
    142. 

  142.                      </td> 
    143. 

  143.                  </tr>     
    144. 

  144.  
    145. 

  145.                   
    146. 

  146.  
    147. 

  147.              </table> 
    148. 

  148.          </td> 
    149. 

  149.      </tr> 
    150. 

  150.  
    151. 

  151.       
    152. 

  152.  
    153. 

  153.       
    154. 

  154.  
    155. 

  155.       
    156. 

  156.  
    157. 

  157.       
    158. 

  158.  
    159. 

  159.      <tr> 
    160. 

  160.  
    161. 

  161.           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;"> 
    162. 

  162.  
    163. 

  163.              <table width="100%" cellpadding="0" cellspacing="0"> 
    164. 

  164.  
    165. 

  165.                  <tr> 
    166. 

  166.  
    167. 

  167.                      <td class='text'  colspan="5" align="center" style="border: 1px #000000 solid; height: 15px;"> 
    168. 

  168.  
    169. 

  169.                          <h3> 
    170. 

  170.  
    171. 

  171.                              HPI 
    172. 

  172.  
    173. 

  173.                          </h3> 
    174. 

  174.                      </td> 
    175. 

  175.                  </tr> 
    176. 

  176.  
    177. 

  177.                  <tr> 
    178. 

  178.  
    179. 

  179.                       
    180. 

  180.  
    181. 

  181.                      <td class='text'   style="border: 1px #000000 solid;"> 
    182. 

  182.   
    183. 

  183.  <table> 
    184. 

  184.   
    185. 

  185.  <tr><td class='text' > location</td> <td class='text' ><input type="text" name="_location" value="<?php $result = chkdata_Txt($obj,"_location"); echo $result;?>"></td></tr> 
    186. 

  186.   
    187. 

  187.  </table> 
    188. 

  188.                      </td> 
    189. 

  189.  
    190. 

  190.                      <td class='text'  style="border: 1px #000000 solid;"> 
    191. 

  191.   
    192. 

  192.  <table> 
    193. 

  193.   
    194. 

  194.  <tr><td class='text' > quality</td> <td class='text' ><input type="text" name="_quality" value="<?php $result = chkdata_Txt($obj,"_quality"); echo $result;?>"></td></tr> 
    195. 

  195.   
    196. 

  196.  </table> 
    197. 

  197.                      </td> 
    198. 

  198.  
    199. 

  199.                       <td class='text'  style="border: 1px #000000 solid;"> 
    200. 

  200.   
    201. 

  201.  <table> 
    202. 

  202.   
    203. 

  203.  <tr><td class='text' > severity</td> <td class='text' ><input type="text" name="_severity" value="<?php $result = chkdata_Txt($obj,"_severity"); echo $result;?>"></td></tr> 
    204. 

  204.   
    205. 

  205.  </table> 
    206. 

  206.                      </td> 
    207. 

  207.  
    208. 

  208.                      <td class='text'  style="border: 1px #000000 solid;"> 
    209. 

  209.   
    210. 

  210.  <table> 
    211. 

  211.   
    212. 

  212.  <tr><td class='text' > duration</td> <td class='text' ><input type="text" name="_duration" value="<?php $result = chkdata_Txt($obj,"_duration"); echo $result;?>"></td></tr> 
    213. 

  213.   
    214. 

  214.  </table> 
    215. 

  215.                      </td>	 
    216. 

  216.  
    217. 

  217.                      <td class='text'  style="border: 1px #000000 solid;">&nbsp; 
    218. 

  218.  
    219. 

  219.                          
    220. 

  220.                      </td>		 
    221. 

  221.                  </tr> 
    222. 

  222.  
    223. 

  223.  <tr> 
    224. 

  224.  
    225. 

  225.  <td class='text'  style="border: 1px #000000 solid;"> 
    226. 

  226.   
    227. 

  227.  <table> 
    228. 

  228.   
    229. 

  229.  <tr><td class='text' > timing</td> <td class='text' ><input type="text" name="_timing" value="<?php $result = chkdata_Txt($obj,"_timing"); echo $result;?>"></td></tr> 
    230. 

  230.   
    231. 

  231.  </table> 
    232. 

  232.                      </td> 
    233. 

  233.  
    234. 

  234.  		<td class='text'  style="border: 1px #000000 solid;"> 
    235. 

  235.   
    236. 

  236.  <table> 
    237. 

  237.   
    238. 

  238.  <tr><td class='text' > context</td> <td class='text' ><input type="text" name="_context" value="<?php $result = chkdata_Txt($obj,"_context"); echo $result;?>"></td></tr> 
    239. 

  239.   
    240. 

  240.  </table> 
    241. 

  241.                      </td> 
    242. 

  242.  
    243. 

  243.  		<td class='text'  style="border: 1px #000000 solid;"> 
    244. 

  244.   
    245. 

  245.  <table> 
    246. 

  246.   
    247. 

  247.  <tr><td class='text' > modifying factors</td> <td class='text' ><input type="text" name="_modifying_factors" value="<?php $result = chkdata_Txt($obj,"_modifying_factors"); echo $result;?>"></td></tr> 
    248. 

  248.   
    249. 

  249.  </table> 
    250. 

  250.                      </td> 
    251. 

  251.  
    252. 

  252.  		<td class='text'  style="border: 1px #000000 solid;"> 
    253. 

  253.   
    254. 

  254.  <table> 
    255. 

  255.   
    256. 

  256.  <tr><td class='text' > signs symptoms</td> <td class='text' ><input type="text" name="_signs_symptoms" value="<?php $result = chkdata_Txt($obj,"_signs_symptoms"); echo $result;?>"></td></tr> 
    257. 

  257.   
    258. 

  258.  </table> 
    259. 

  259.                      </td> 
    260. 

  260.  
    261. 

  261.  		<td class='text'  style="border: 1px #000000 solid;"> 
    262. 

  262.   
    263. 

  263.  <table> 
    264. 

  264.   
    265. 

  265.  <tr><td class='text' > status of chronic illness</td> <td class='text' ><input type="text" name="_status_of_chronic_illness" value="<?php $result = chkdata_Txt($obj,"_status_of_chronic_illness"); echo $result;?>"></td></tr> 
    266. 

  266.   
    267. 

  267.  </table> 
    268. 

  268.                      </td></tr> 
    269. 

  269.  
    270. 

  270.                   
    271. 

  271.  
    272. 

  272.                   
    273. 

  273.  
    274. 

  274.              </table> 
    275. 

  275.          </td> 
    276. 

  276.      </tr> 
    277. 

  277.  
    278. 

  278.       
    279. 

  279.  
    280. 

  280.       <tr> 
    281. 

  281.  
    282. 

  282.           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;"> 
    283. 

  283.  
    284. 

  284.              <table width="100%" cellpadding="0" cellspacing="0"> 
    285. 

  285.  
    286. 

  286.                  <tr> 
    287. 

  287.  
    288. 

  288.                      <td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;">                        
    289. 

  289.  
    290. 

  290.                              ROS 
    291. 

  291.  
    292. 

  292.                           
    293. 

  293.                      </td> 
    294. 

  294.  
    295. 

  295.  	<td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;"> 
    296. 

  296.  
    297. 

  297.                           
    298. 

  298.  
    299. 

  299.                              + 
    300. 

  300.  
    301. 

  301.                           
    302. 

  302.                      </td> 
    303. 

  303.  
    304. 

  304.  	<td class='text'  align="center" style="border: 1px #000000 solid; height: 15px;"> 
    305. 

  305.  
    306. 

  306.                           
    307. 

  307.  
    308. 

  308.                              - 
    309. 

  309.  
    310. 

  310.                          
    311. 

  311.                      </td> 
    312. 

  312.                  </tr> 
    313. 

  313.  
    314. 

  314.                  <tr> 
    315. 

  315.  
    316. 

  316.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    317. 

  317.  
    318. 

  318.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    319. 

  319.                          Systemic</td> 
    320. 

  320.  
    321. 

  321.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    322. 

  322.  
    323. 

  323.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    324. 

  324.   
    325. 

  325.  <table> 
    326. 

  326.   
    327. 

  327.  <tr><td class='text' > systemic positive</td> <td class='text' ><input type="text" name="_systemic_positive" value="<?php $result = chkdata_Txt($obj,"_systemic_positive"); echo $result;?>"></td></tr> 
    328. 

  328.   
    329. 

  329.  </table> 
    330. 

  330.                      </td> 
    331. 

  331.  
    332. 

  332.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    333. 

  333.  
    334. 

  334.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    335. 

  335.   
    336. 

  336.  <table> 
    337. 

  337.   
    338. 

  338.  <tr><td class='text' > systemic negative</td> <td class='text' ><input type="text" name="_systemic_negative" value="<?php $result = chkdata_Txt($obj,"_systemic_negative"); echo $result;?>"></td></tr> 
    339. 

  339.   
    340. 

  340.  </table> 
    341. 

  341.                      </td> 
    342. 

  342.                  </tr> 
    343. 

  343.  
    344. 

  344.                  <tr> 
    345. 

  345.  
    346. 

  346.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    347. 

  347.  
    348. 

  348.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    349. 

  349.                          ENT</td> 
    350. 

  350.  
    351. 

  351.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    352. 

  352.  
    353. 

  353.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    354. 

  354.   
    355. 

  355.  <table> 
    356. 

  356.   
    357. 

  357.  <tr><td class='text' > ent positive</td> <td class='text' ><input type="text" name="_ent_positive" value="<?php $result = chkdata_Txt($obj,"_ent_positive"); echo $result;?>"></td></tr> 
    358. 

  358.   
    359. 

  359.  </table> 
    360. 

  360.                      </td> 
    361. 

  361.  
    362. 

  362.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    363. 

  363.  
    364. 

  364.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    365. 

  365.   
    366. 

  366.  <table> 
    367. 

  367.   
    368. 

  368.  <tr><td class='text' > ent negative</td> <td class='text' ><input type="text" name="_ent_negative" value="<?php $result = chkdata_Txt($obj,"_ent_negative"); echo $result;?>"></td></tr> 
    369. 

  369.   
    370. 

  370.  </table> 
    371. 

  371.                      </td> 
    372. 

  372.                  </tr> 
    373. 

  373.  
    374. 

  374.                  <tr> 
    375. 

  375.  
    376. 

  376.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    377. 

  377.  
    378. 

  378.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    379. 

  379.                          Eyes</td> 
    380. 

  380.  
    381. 

  381.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    382. 

  382.  
    383. 

  383.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    384. 

  384.   
    385. 

  385.  <table> 
    386. 

  386.   
    387. 

  387.  <tr><td class='text' > eyes positive</td> <td class='text' ><input type="text" name="_eyes_positive" value="<?php $result = chkdata_Txt($obj,"_eyes_positive"); echo $result;?>"></td></tr> 
    388. 

  388.   
    389. 

  389.  </table> 
    390. 

  390.                      </td> 
    391. 

  391.  
    392. 

  392.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    393. 

  393.  
    394. 

  394.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    395. 

  395.   
    396. 

  396.  <table> 
    397. 

  397.   
    398. 

  398.  <tr><td class='text' > eyes negative</td> <td class='text' ><input type="text" name="_eyes_negative" value="<?php $result = chkdata_Txt($obj,"_eyes_negative"); echo $result;?>"></td></tr> 
    399. 

  399.   
    400. 

  400.  </table> 
    401. 

  401.                      </td> 
    402. 

  402.                  </tr> 
    403. 

  403.  
    404. 

  404.                  <tr> 
    405. 

  405.  
    406. 

  406.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    407. 

  407.  
    408. 

  408.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    409. 

  409.                          Lymph</td> 
    410. 

  410.  
    411. 

  411.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    412. 

  412.  
    413. 

  413.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    414. 

  414.   
    415. 

  415.  <table> 
    416. 

  416.   
    417. 

  417.  <tr><td class='text' > lymph positive</td> <td class='text' ><input type="text" name="_lymph_positive" value="<?php $result = chkdata_Txt($obj,"_lymph_positive"); echo $result;?>"></td></tr> 
    418. 

  418.   
    419. 

  419.  </table> 
    420. 

  420.                      </td> 
    421. 

  421.  
    422. 

  422.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    423. 

  423.  
    424. 

  424.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    425. 

  425.   
    426. 

  426.  <table> 
    427. 

  427.   
    428. 

  428.  <tr><td class='text' > lymph negative</td> <td class='text' ><input type="text" name="_lymph_negative" value="<?php $result = chkdata_Txt($obj,"_lymph_negative"); echo $result;?>"></td></tr> 
    429. 

  429.   
    430. 

  430.  </table> 
    431. 

  431.                      </td> 
    432. 

  432.                  </tr> 
    433. 

  433.  
    434. 

  434.                  <tr> 
    435. 

  435.  
    436. 

  436.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    437. 

  437.  
    438. 

  438.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    439. 

  439.                          Resp</td> 
    440. 

  440.  
    441. 

  441.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    442. 

  442.  
    443. 

  443.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    444. 

  444.   
    445. 

  445.  <table> 
    446. 

  446.   
    447. 

  447.  <tr><td class='text' > resp positive</td> <td class='text' ><input type="text" name="_resp_positive" value="<?php $result = chkdata_Txt($obj,"_resp_positive"); echo $result;?>"></td></tr> 
    448. 

  448.   
    449. 

  449.  </table> 
    450. 

  450.                      </td> 
    451. 

  451.  
    452. 

  452.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    453. 

  453.  
    454. 

  454.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    455. 

  455.   
    456. 

  456.  <table> 
    457. 

  457.   
    458. 

  458.  <tr><td class='text' > resp negative</td> <td class='text' ><input type="text" name="_resp_negative" value="<?php $result = chkdata_Txt($obj,"_resp_negative"); echo $result;?>"></td></tr> 
    459. 

  459.   
    460. 

  460.  </table> 
    461. 

  461.                      </td> 
    462. 

  462.                  </tr> 
    463. 

  463.  
    464. 

  464.                  <tr> 
    465. 

  465.  
    466. 

  466.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    467. 

  467.  
    468. 

  468.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    469. 

  469.                          CV</td> 
    470. 

  470.  
    471. 

  471.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    472. 

  472.  
    473. 

  473.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    474. 

  474.   
    475. 

  475.  <table> 
    476. 

  476.   
    477. 

  477.  <tr><td class='text' > cv positive</td> <td class='text' ><input type="text" name="_cv_positive" value="<?php $result = chkdata_Txt($obj,"_cv_positive"); echo $result;?>"></td></tr> 
    478. 

  478.   
    479. 

  479.  </table> 
    480. 

  480.                      </td> 
    481. 

  481.  
    482. 

  482.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    483. 

  483.  
    484. 

  484.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    485. 

  485.   
    486. 

  486.  <table> 
    487. 

  487.   
    488. 

  488.  <tr><td class='text' > cv negative</td> <td class='text' ><input type="text" name="_cv_negative" value="<?php $result = chkdata_Txt($obj,"_cv_negative"); echo $result;?>"></td></tr> 
    489. 

  489.   
    490. 

  490.  </table> 
    491. 

  491.                      </td> 
    492. 

  492.                  </tr> 
    493. 

  493.  
    494. 

  494.                  <tr> 
    495. 

  495.  
    496. 

  496.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    497. 

  497.  
    498. 

  498.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    499. 

  499.                          GI</td> 
    500. 

  500.  
    501. 

  501.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    502. 

  502.  
    503. 

  503.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    504. 

  504.   
    505. 

  505.  <table> 
    506. 

  506.   
    507. 

  507.  <tr><td class='text' > gi positive</td> <td class='text' ><input type="text" name="_gi_positive" value="<?php $result = chkdata_Txt($obj,"_gi_positive"); echo $result;?>"></td></tr> 
    508. 

  508.   
    509. 

  509.  </table> 
    510. 

  510.                      </td> 
    511. 

  511.  
    512. 

  512.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    513. 

  513.  
    514. 

  514.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    515. 

  515.   
    516. 

  516.  <table> 
    517. 

  517.   
    518. 

  518.  <tr><td class='text' > gi negative</td> <td class='text' ><input type="text" name="_gi_negative" value="<?php $result = chkdata_Txt($obj,"_gi_negative"); echo $result;?>"></td></tr> 
    519. 

  519.   
    520. 

  520.  </table> 
    521. 

  521.                      </td> 
    522. 

  522.                  </tr> 
    523. 

  523.  
    524. 

  524.                  <tr> 
    525. 

  525.  
    526. 

  526.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    527. 

  527.  
    528. 

  528.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    529. 

  529.                          GU</td> 
    530. 

  530.  
    531. 

  531.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    532. 

  532.  
    533. 

  533.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    534. 

  534.   
    535. 

  535.  <table> 
    536. 

  536.   
    537. 

  537.  <tr><td class='text' > gu positive</td> <td class='text' ><input type="text" name="_gu_positive" value="<?php $result = chkdata_Txt($obj,"_gu_positive"); echo $result;?>"></td></tr> 
    538. 

  538.   
    539. 

  539.  </table> 
    540. 

  540.                      </td> 
    541. 

  541.  
    542. 

  542.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    543. 

  543.  
    544. 

  544.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    545. 

  545.   
    546. 

  546.  <table> 
    547. 

  547.   
    548. 

  548.  <tr><td class='text' > gu negative</td> <td class='text' ><input type="text" name="_gu_negative" value="<?php $result = chkdata_Txt($obj,"_gu_negative"); echo $result;?>"></td></tr> 
    549. 

  549.   
    550. 

  550.  </table> 
    551. 

  551.                      </td> 
    552. 

  552.                  </tr> 
    553. 

  553.  
    554. 

  554.                  <tr> 
    555. 

  555.  
    556. 

  556.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    557. 

  557.  
    558. 

  558.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    559. 

  559.                          Skin</td> 
    560. 

  560.  
    561. 

  561.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    562. 

  562.  
    563. 

  563.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    564. 

  564.   
    565. 

  565.  <table> 
    566. 

  566.   
    567. 

  567.  <tr><td class='text' > skin positive</td> <td class='text' ><input type="text" name="_skin_positive" value="<?php $result = chkdata_Txt($obj,"_skin_positive"); echo $result;?>"></td></tr> 
    568. 

  568.   
    569. 

  569.  </table> 
    570. 

  570.                      </td> 
    571. 

  571.  
    572. 

  572.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    573. 

  573.  
    574. 

  574.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    575. 

  575.   
    576. 

  576.  <table> 
    577. 

  577.   
    578. 

  578.  <tr><td class='text' > skin negative</td> <td class='text' ><input type="text" name="_skin_negative" value="<?php $result = chkdata_Txt($obj,"_skin_negative"); echo $result;?>"></td></tr> 
    579. 

  579.   
    580. 

  580.  </table> 
    581. 

  581.                      </td> 
    582. 

  582.                  </tr> 
    583. 

  583.  
    584. 

  584.                  <tr> 
    585. 

  585.  
    586. 

  586.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    587. 

  587.  
    588. 

  588.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    589. 

  589.                          MS</td> 
    590. 

  590.  
    591. 

  591.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    592. 

  592.  
    593. 

  593.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    594. 

  594.   
    595. 

  595.  <table> 
    596. 

  596.   
    597. 

  597.  <tr><td class='text' > ms positive</td> <td class='text' ><input type="text" name="_ms_positive" value="<?php $result = chkdata_Txt($obj,"_ms_positive"); echo $result;?>"></td></tr> 
    598. 

  598.   
    599. 

  599.  </table> 
    600. 

  600.                      </td> 
    601. 

  601.  
    602. 

  602.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    603. 

  603.  
    604. 

  604.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    605. 

  605.   
    606. 

  606.  <table> 
    607. 

  607.   
    608. 

  608.  <tr><td class='text' > ms negative</td> <td class='text' ><input type="text" name="_ms_negative" value="<?php $result = chkdata_Txt($obj,"_ms_negative"); echo $result;?>"></td></tr> 
    609. 

  609.   
    610. 

  610.  </table> 
    611. 

  611.                      </td> 
    612. 

  612.                  </tr> 
    613. 

  613.  
    614. 

  614.                  <tr> 
    615. 

  615.  
    616. 

  616.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    617. 

  617.  
    618. 

  618.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    619. 

  619.                          Psych</td> 
    620. 

  620.  
    621. 

  621.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    622. 

  622.  
    623. 

  623.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    624. 

  624.   
    625. 

  625.  <table> 
    626. 

  626.   
    627. 

  627.  <tr><td class='text' > psych positive</td> <td class='text' ><input type="text" name="_psych_positive" value="<?php $result = chkdata_Txt($obj,"_psych_positive"); echo $result;?>"></td></tr> 
    628. 

  628.   
    629. 

  629.  </table> 
    630. 

  630.                      </td> 
    631. 

  631.  
    632. 

  632.                      <td class='text'  align="center" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    633. 

  633.  
    634. 

  634.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    635. 

  635.   
    636. 

  636.  <table> 
    637. 

  637.   
    638. 

  638.  <tr><td class='text' > psych negative</td> <td class='text' ><input type="text" name="_psych_negative" value="<?php $result = chkdata_Txt($obj,"_psych_negative"); echo $result;?>"></td></tr> 
    639. 

  639.   
    640. 

  640.  </table> 
    641. 

  641.                      </td> 
    642. 

  642.                  </tr> 
    643. 

  643.  
    644. 

  644.                  <tr> 
    645. 

  645.  
    646. 

  646.                      <td class='text'   align="left" colspan="3" style="border-right: #000000 1px solid; border-top: #000000 1px solid; 
    647. 

  647.  
    648. 

  648.                          border-left: #000000 1px solid; border-bottom: #000000 1px solid; height: 15px"> 
    649. 

  649.   
    650. 

  650.  <table> 
    651. 

  651.   
    652. 

  652.  <tr><td class='text' > all other ros negative </td> <td class='text' ><textarea name="_all_other_ros_negative_"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"_all_other_ros_negative_"); echo $result;?></textarea></td></tr> 
    653. 

  653.   
    654. 

  654.  </table> 
    655. 

  655.                      </td> 
    656. 

  656.                  </tr> 
    657. 

  657.  
    658. 

  658.                   
    659. 

  659.  
    660. 

  660.                   
    661. 

  661.  
    662. 

  662.                   
    663. 

  663.  
    664. 

  664.              </table> 
    665. 

  665.          </td> 
    666. 

  666.      </tr> 
    667. 

  667.  
    668. 

  668.       
    669. 

  669.  
    670. 

  670.       
    671. 

  671.  
    672. 

  672.        <tr> 
    673. 

  673.  
    674. 

  674.           <td class='text'  valign="top" style="border: 1px #000000 solid; height: 15px;"> 
    675. 

  675.  
    676. 

  676.              <table width="100%" cellpadding="0" cellspacing="0"> 
    677. 

  677.  
    678. 

  678.                  <tr> 
    679. 

  679.  
    680. 

  680.                      <td class='text'  colspan="3" align="center" style="border: 1px #000000 solid; height: 15px;">                       
    681. 

  681.   
    682. 

  682.  <table> 
    683. 

  683.   
    684. 

  684.  <tr><td class='text' > past famiy social history</td> <td class='text' ><textarea name="_past_famiy_social_history"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"_past_famiy_social_history"); echo $result;?></textarea></td></tr> 
    685. 

  685.   
    686. 

  686.  </table> 
    687. 

  687.                      </td> 
    688. 

  688.                  </tr> 
    689. 

  689.  
    690. 

  690.                   
    691. 

  691.  
    692. 

  692.                   <tr> 
    693. 

  693.  
    694. 

  694.                       
    695. 

  695.  
    696. 

  696.                      <td class='text'  style="border: 1px #000000 solid; height: 27px;"> 
    697. 

  697.   
    698. 

  698.  <table> 
    699. 

  699.   
    700. 

  700.  <tr><td class='text' > ph no change since</td> <td class='text' ><input type="text" name="_ph_no_change_since" value="<?php $result = chkdata_Txt($obj,"_ph_no_change_since"); echo $result;?>"></td></tr> 
    701. 

  701.   
    702. 

  702.  </table> 
    703. 

  703.                      </td> 
    704. 

  704.  
    705. 

  705.                      <td class='text'  style="border: 1px #000000 solid; height: 27px;"> 
    706. 

  706.   
    707. 

  707.  <table> 
    708. 

  708.   
    709. 

  709.  <tr><td class='text' > fh no change since</td> <td class='text' ><input type="text" name="_fh_no_change_since" value="<?php $result = chkdata_Txt($obj,"_fh_no_change_since"); echo $result;?>"></td></tr> 
    710. 

  710.   
    711. 

  711.  </table> 
    712. 

  712.                      </td> 
    713. 

  713.  
    714. 

  714.                       <td class='text'  style="border: 1px #000000 solid; height: 27px;"> 
    715. 

  715.   
    716. 

  716.  <table> 
    717. 

  717.   
    718. 

  718.  <tr><td class='text' > sh no change since</td> <td class='text' ><input type="text" name="_sh_no_change_since" value="<?php $result = chkdata_Txt($obj,"_sh_no_change_since"); echo $result;?>"></td></tr> 
    719. 

  719.   
    720. 

  720.  </table> 
    721. 

  721.                      </td> 
    722. 

  722.                  </tr>   
    723. 

  723.  
    724. 

  724.  <tr><td class='text'  colspan='3'> 
    725. 

  725.   
    726. 

  726.  <table> 
    727. 

  727.   
    728. 

  728.  <tr><td class='text' > <?php xl("Examination",'e') ?> </td> <td class='text' ><textarea name="examination"  rows="4" cols="40"><?php $result = chkdata_Txt($obj,"examination"); echo $result;?></textarea></td></tr> 
    729. 

  729.   
    730. 

  730.  </table> 
    731. 

  731.  </td></tr>             
    732. 

  732.  
    733. 

  733.                   
    734. 

  734.  
    735. 

  735.              </table> 
    736. 

  736.          </td> 
    737. 

  737.      </tr> 
    738. 

  738.  
    739. 

  739.  </table> 
    740. 

  740.  <table></table><input type="submit" name="submit form" value="submit form" /> 
    741. 

  741.   
    742. 

  742.  </form> 
    743. 

  743.  <?php 
    744. 

  744.  formFooter(); 
    745. 

  745.  ?>
    746.