echo $result;
?>
> <?php
xl("Cholecystectomy (possible)", 'e');
?>
</label></td></tr><tr><td></td><td>
<label class="text"><input type="checkbox" name="recommendations[]" value="EGD Esophagogastroduodenoscopy" <?php
$result = chkdata_CB($obj, "recommendations", "EGD Esophagogastroduodenoscopy");
echo $result;
?>
> <?php
xl("EGD (Esophagogastroduodenoscopy)", 'e');
?>
</label></td><td>
<label class="text"><input type="checkbox" name="recommendations[]" value="Colonoscopy" <?php
$result = chkdata_CB($obj, "recommendations", "Colonoscopy");
echo $result;
?>
> <?php
xl("Colonoscopy", 'e');
?>
</label></td></tr>
</table>
<table>
<tr>
<td align="left" colspan="2"> </td>
</tr>
<tr><td align="right" width="150"></td> <td><textarea name="note3" rows="4" cols="60"><?php
echo $result;
?>
<?php
xl(">Milk of Magnesia", 'e');
?>
</label>
<label><input type="checkbox" name="_non_prescription_medications[]" value="Pepto Bismol" <?php
$result = chkdata_CB($obj, "_non_prescription_medications", "Pepto Bismol");
echo $result;
?>
<?php
xl(">Pepto Bismol", 'e');
?>
</label>
<label><input type="checkbox" name="_non_prescription_medications[]" value="Sudafed" <?php
$result = chkdata_CB($obj, "_non_prescription_medications", "Sudafed");
echo $result;
?>
<?php
xl(">Sudafed", 'e');
?>
</label></td></tr>
</table>
</td>
</tr>
</table>
<table width="100%">
<tr>
<td class="text" style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2">
<table>
<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>
<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>
</table> </td>
</tr>
</table> </td>
</tr>
</table>
<table></table><input type="submit" name="submit form" value="submit form" /> <a href='<?php
echo $result;
?>
<?php
xl(">Automobile", 'e');
?>
</label>
<label><input type="checkbox" name="_nature_of_accident[]" value="slip and fall" <?php
$result = chkdata_CB($obj, "_nature_of_accident", "slip and fall");
echo $result;
?>
<?php
xl(">slip and fall", 'e');
?>
</label>
<label><input type="checkbox" name="_nature_of_accident[]" value="work related" <?php
$result = chkdata_CB($obj, "_nature_of_accident", "work related");
echo $result;
?>
<?php
xl(">work related", 'e');
?>
</label></td></tr>
</table>
<table>
<tr><td class="text" > Other</td><td class="text" ><input type="text" name="_other" value="<?php
$result = chkdata_Txt($obj, "_other");
echo $result;
?>
echo $result;
?>
<?php
xl(">Sister", 'e');
?>
</label>
<label><input type="checkbox" name="_cancer[]" value="Child" <?php
$result = chkdata_CB($obj, "_cancer", "Child");
echo $result;
?>
<?php
xl(">Child", 'e');
?>
</label>
<label><input type="checkbox" name="_cancer[]" value="None" <?php
$result = chkdata_CB($obj, "_cancer", "None");
echo $result;
?>
<?php
xl(">None", 'e');
?>
</label></td></tr>
</table>
</td></tr>
<tr>
<td class='text' colspan="3" style="border: 1px #000000 solid;">
<h3>
Hospitalizations: </h3>
