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 $result = chkdata_Txt($obj, "note3"); echo $result; ?> </textarea></td></tr> </table> <input type="submit" name="submit form" value="submit form" /> </form> <a href='<?php echo $GLOBALS['webroot']; ?> /interface/patient_file/encounter/<?php echo $returnurl; ?> ' onclick='top.restoreSession()'> <?php
<tr><td> abdomen</td> <td><input type="text" name="_abdomen" value="<?php $result = chkdata_Txt($obj, "_abdomen"); echo $result; ?> "></td></tr> </table> </td> <td class='text' colspan="2" style="height: 21px"> <table> <tr><td> gi gu</td> <td><input type="text" name="_gi_gu" value="<?php $result = chkdata_Txt($obj, "_gi_gu"); echo $result; ?> "></td></tr> </table> </td> </tr> </table> <table></table><input type="submit" name="submit form" value="submit form" /> </form> <?php formFooter(); ?>
<tr><td class="text" > Subscriber ID #</td><td class="text" ><input type="text" name="_subscriber_id_number" value="<?php $result = chkdata_Txt($obj, "_subscriber_id_number"); echo $result; ?> "></td></tr> </table> </td> <td class="text" style="border:solid 1px #000000" > <table> <tr><td class="text" > Group #</td><td class="text" ><input type="text" name="_group_number" value="<?php $result = chkdata_Txt($obj, "_group_number"); echo $result; ?> "></td></tr> </table> </td> </tr> </table> </td> </tr>
<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> </table> </td> </tr> <tr> <td class="text" style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2"> <table> <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> </table> </td> </tr> <tr> <td class="text" style="border: solid 1px #000000" _checking_symptoms_of_nervous_systemscolspan="2"> <table> <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;
echo $result; ?> "></td></tr> </table> </td> <td class='text' valign="top"> <table> <tr><td class='text' > <?php xl("Reason", 'e'); ?> <input type="text" name="reason" value="<?php $result = chkdata_Txt($obj, "reason"); echo $result; ?> "></td></tr> </table> </td> </tr> </table> <table></table><input type="submit" name="submit form" value="submit form" /> </form> <?php formFooter(); ?>
?> "></td></tr> </table> </td> </tr> <tr><td class='text' colspan='3'> <table> <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> </table> </td></tr> </table> </td> </tr> </table> <table></table><input type="submit" name="submit form" value="submit form" />