?>
></span>
<span class='width150'><label>Philhealth #:</label></span><input type='text' name='pin' <?php
echo "value='" . $result['philhealth_id'] . "'";
?>
>
<br /><span class='width70'><label>Name: </label></span>
<span class='width285'><input type='text' name='patientname' <?php
echo "value='" . $result['patient_lastname'] . ", " . $result['patient_firstname'] . "'";
?>
></span>
<span class='width150'><label>Age:</label></span><input type='text' size=4 name='age' <?php
echo "value='" . _getAge($result['patient_dob'], $result['serviceDATE']) . "'";
?>
>
<br /><span class='width70'><label>Gender:</label></span>
<span class='width285'><input type='radio' name='gender' value='Male' <?php
echo $result['patient_gender'] == 'M' ? "checked" : "";
?>
>Male
<input type='radio' name='gender' value='Female' <?php
echo $result['patient_gender'] == 'F' ? "checked" : "";
?>
>Female</span>
<span class='width150'><label>Membership:</label></span><input type='radio' name='membership' value='Member' <?php
if ($result['member_id'] == 1 || $result['member_id'] == 2 || $result['member_id'] == 3 || $result['member_id'] == 5) {
echo "value='" . $_SESSION['datanode']['name'] . "'";
?>
></h4>
<br />
</div>
<hr />
<br />
<h4 class='indent'>Part I</h4>
<div class='width750'>
<hr /><h4 class='center'>Personal Information</h4><hr />
<br /><span class='width70'><label>Name:</label></span><span class='width285'><input style='width: 263px;' type='text' name='patientname' <?php
echo "value='" . $result['patient_lastname'] . ", " . $result['patient_firstname'] . " " . $result['patient_middle'] . "'";
?>
></span>
<span class='width70'><label>Age:</label></span><span class='width150'><input type='text' name='age' style='width:50px;' <?php
echo "value='" . _getAge($result['patient_dob']) . "'";
?>
></span>
<span class='width70'><label>Sex:</label></span><select name='gender'><option value='M' <?php
if ($result["patient_gender"] == 'M') {
echo "selected";
}
?>
>Male</option><option value='F' <?php
if ($result["patient_gender"] == 'F') {
echo "selected";
}
?>
>Female</option></select>
<br /><br /><span class='width70'><label>Address:</label></span><textarea style='vertical-align: top' name='address' rows='2' cols='30'><?php
echo $result["address"] . ", " . $result["barangay_name"] . ", " . $_SESSION['lgu'] . ", " . $_SESSION['province'];
?>
>6-15 Year<br />
<input type='radio' name='yearAge' value='16-24' <?php
if (_getAge($result['patient_dob']) >= 16 && _getAge($result['patient_dob']) <= 24) {
echo "checked";
}
?>
>16-24 Year<br />
<input type='radio' name='yearAge' value='25-59' <?php
if (_getAge($result['patient_dob']) >= 25 && _getAge($result['patient_dob']) <= 59) {
echo "checked";
}
?>
>25-59 Year<br />
<input type='radio' name='yearAge' value='60' <?php
if (_getAge($result['patient_dob']) >= 60) {
echo "checked";
}
?>
>60 Years and Above<br />
</p>
<br />
<span class='width80'><label>Birthdate:</label></span>
<input type='text' size=8 name='personalinfodate' placeholder='(mm/dd/yyyy)' <?php
echo "value='" . date("m/d/Y", strtotime($result['patient_dob'])) . "'";
?>
><br /><br />
<span class='width80'><label>Sex:</label></span>
<select name='gender'><option value='M' <?php
if ($result["patient_gender"] == 'M') {
