{php}html_header_show();{/php} {literal} {/literal}

{xl t="Review Of Systems"}

{xl t="Constitutional"}
{xl t="Weight Change"}: {html_radios name="weight_change" options=$form->get_options() selected=$form->get_weight_change() separator=""} {xl t="Weakness"}: {html_radios name="weakness" options=$form->get_options() selected=$form->get_weakness() separator=""} {xl t="Fatigue"}: {html_radios name="fatigue" options=$form->get_options() selected=$form->get_fatigue() separator=""}
{xl t="Anorexia"}: {html_radios name="anorexia" options=$form->get_options() selected=$form->get_anorexia() separator=""} {xl t="Fever"}: {html_radios name="fever" options=$form->get_options() selected=$form->get_fever() separator=""} {xl t="Chills"}: {html_radios name="chills" options=$form->get_options() selected=$form->get_chills() separator=""}
{xl t="Night Sweats"}: {html_radios name="night_sweats" options=$form->get_options() selected=$form->get_night_sweats() separator=""} {xl t="Insomnia"}: {html_radios name="insomnia" options=$form->get_options() selected=$form->get_insomnia() separator=""} {xl t="Irritability"}: {html_radios name="irritability" options=$form->get_options() selected=$form->get_irritability() separator=""}
{xl t="Heat or Cold"}: {html_radios name="heat_or_cold" options=$form->get_options() selected=$form->get_heat_or_cold() separator=""} {xl t="Intolerance"}: {html_radios name="intolerance" options=$form->get_options() selected=$form->get_intolerance() separator=""}
{xl t="Eyes"}
{xl t="Change in Vision"}: {html_radios name="change_in_vision" options=$form->get_options() selected=$form->get_weight_change() separator=""} {xl t="Family History of Glaucoma"}: {html_radios name="glaucoma_history" options=$form->get_options() selected=$form->get_glaucoma_history() separator=""} {xl t="Eye Pain"}: {html_radios name="eye_pain" options=$form->get_options() selected=$form->get_eye_pain() separator=""}
{xl t="Irritation"}: {html_radios name="irritation" options=$form->get_options() selected=$form->get_irritation() separator=""} {xl t="Redness"}: {html_radios name="redness" options=$form->get_options() selected=$form->get_redness() separator=""} {xl t="Excessive Tearing"}: {html_radios name="excessive_tearing" options=$form->get_options() selected=$form->get_excessive_tearing() separator=""}
{xl t="Double Vision"}: {html_radios name="double_vision" options=$form->get_options() selected=$form->get_double_vision() separator=""} {xl t="Blind Spots"}: {html_radios name="blind_spots" options=$form->get_options() selected=$form->get_blind_spots() separator=""} {xl t="Photophobia"}: {html_radios name="photophobia" options=$form->get_options() selected=$form->get_photophobia() separator=""}
{xl t="Ears"}, {xl t="Nose"}, {xl t="Mouth"}, {xl t="Throat"}
{xl t="Hearing Loss"}: {html_radios name="hearing_loss" options=$form->get_options() selected=$form->get_hearing_loss() separator=""} {xl t="Discharge"}: {html_radios name="discharge" options=$form->get_options() selected=$form->get_discharge() separator=""} {xl t="Pain"}: {html_radios name="pain" options=$form->get_options() selected=$form->get_pain() separator=""}
{xl t="Vertigo"}: {html_radios name="vertigo" options=$form->get_options() selected=$form->get_vertigo() separator=""} {xl t="Tinnitus"}: {html_radios name="tinnitus" options=$form->get_options() selected=$form->get_tinnitus() separator=""} {xl t="Frequent Colds"}: {html_radios name="frequent_colds" options=$form->get_options() selected=$form->get_frequent_colds() separator=""}
{xl t="Sore Throat"}: {html_radios name="sore_throat" options=$form->get_options() selected=$form->get_sore_throat() separator=""} {xl t="Sinus Problems"}: {html_radios name="sinus_problems" options=$form->get_options() selected=$form->get_sinus_problems() separator=""} {xl t="Post Nasal Drip"}: {html_radios name="post_nasal_drip" options=$form->get_options() selected=$form->get_post_nasal_drip() separator=""}
{xl t="Nosebleed"}: {html_radios name="nosebleed" options=$form->get_options() selected=$form->get_nosebleed() separator=""} {xl t="Snoring"}: {html_radios name="snoring" options=$form->get_options() selected=$form->get_snoring() separator=""} {xl t="Apnea"}: {html_radios name="apnea" options=$form->get_options() selected=$form->get_apnea() separator=""}
{xl t="Breast"}
{xl t="Breast Mass"}: {html_radios name="breast_mass" options=$form->get_options() selected=$form->get_breast_mass() separator=""} {xl t="Discharge"}: {html_radios name="breast_discharge" options=$form->get_options() selected=$form->get_breast_discharge() separator=""} {xl t="Biopsy"}: {html_radios name="biopsy" options=$form->get_options() selected=$form->get_biopsy() separator=""}
{xl t="Abnormal Mammogram"}: {html_radios name="abnormal_mammogram" options=$form->get_options() selected=$form->get_abnormal_mammogram() separator=""}
{xl t="Respiratory"}
{xl t="Cough"}: {html_radios name="cough" options=$form->get_options() selected=$form->get_cough() separator=""} {xl t="Sputum"}: {html_radios name="sputum" options=$form->get_options() selected=$form->get_sputum() separator=""} {xl t="Shortness of Breath"}: {html_radios name="shortness_of_breath" options=$form->get_options() selected=$form->get_shortness_of_breath() separator=""}
{xl t="Wheezing"}: {html_radios name="wheezing" options=$form->get_options() selected=$form->get_wheezing() separator=""} {xl t="Hemoptysis"}: {html_radios name="hemoptsyis" options=$form->get_options() selected=$form->get_hemoptsyis() separator=""} {xl t="Asthma"}: {html_radios name="asthma" options=$form->get_options() selected=$form->get_asthma() separator=""}
{xl t="COPD"}: {html_radios name="copd" options=$form->get_options() selected=$form->get_copd() separator=""}
{xl t="Cardiovascular"}
{xl t="Chest Pain"}: {html_radios name="chest_pain" options=$form->get_options() selected=$form->get_chest_pain() separator=""} {xl t="Palpitation"}: {html_radios name="palpitation" options=$form->get_options() selected=$form->get_palpitation() separator=""} {xl t="Syncope"}: {html_radios name="syncope" options=$form->get_options() selected=$form->get_syncope() separator=""}
{xl t="PND"}: {html_radios name="pnd" options=$form->get_options() selected=$form->get_pnd() separator=""} {xl t="DOE"}: {html_radios name="doe" options=$form->get_options() selected=$form->get_doe() separator=""} {xl t="Orthopnea"}: {html_radios name="orthopnea" options=$form->get_options() selected=$form->get_orthopnea() separator=""}
{xl t="Peripheral"}: {html_radios name="peripheal" options=$form->get_options() selected=$form->get_peripheal() separator=""} {xl t="Edema"}: {html_radios name="edema" options=$form->get_options() selected=$form->get_edema() separator=""} {xl t="Leg Pain/Cramping"}: {html_radios name="legpain_cramping" options=$form->get_options() selected=$form->get_legpain_cramping() separator=""}
{xl t="History of Heart Murmur"}: {html_radios name="history_murmur" options=$form->get_options() selected=$form->get_history_murmur() separator=""} {xl t="Arrythmia"}: {html_radios name="arrythmia" options=$form->get_options() selected=$form->get_arrythmia() separator=""} {xl t="Heart Problem"}: {html_radios name="heart_problem" options=$form->get_options() selected=$form->get_heart_problem() separator=""}
{xl t="Gastrointestinal"}
{xl t="Dysphagia"}: {html_radios name="dysphagia" options=$form->get_options() selected=$form->get_dysphagia() separator=""} {xl t="Heartburn"}: {html_radios name="heartburn" options=$form->get_options() selected=$form->get_heartburn() separator=""} {xl t="Bloating"}: {html_radios name="bloating" options=$form->get_options() selected=$form->get_bloating() separator=""}
{xl t="Belching"}: {html_radios name="belching" options=$form->get_options() selected=$form->get_belching() separator=""} {xl t="Flatulence"}: {html_radios name="flatulence" options=$form->get_options() selected=$form->get_flatulence() separator=""} {xl t="Nausea"}: {html_radios name="nausea" options=$form->get_options() selected=$form->get_nausea() separator=""}
{xl t="Vomiting"}: {html_radios name="vomiting" options=$form->get_options() selected=$form->get_vomiting() separator=""} {xl t="Hematemesis"}: {html_radios name="hematemesis" options=$form->get_options() selected=$form->get_hematemesis() separator=""} {xl t="Pain"}: {html_radios name="gastro_pain" options=$form->get_options() selected=$form->get_gastro_pain() separator=""}
{xl t="Food Intolerance"}: {html_radios name="food_intolerance" options=$form->get_options() selected=$form->get_food_intolerance() separator=""} {xl t="H/O Hepatitis"}: {html_radios name="hepatitis" options=$form->get_options() selected=$form->get_hepatitis() separator=""} {xl t="Jaundice"}: {html_radios name="jaundice" options=$form->get_options() selected=$form->get_jaundice() separator=""}
{xl t="Hematochezia"}: {html_radios name="hematochezia" options=$form->get_options() selected=$form->get_hematochezia() separator=""} {xl t="Changed Bowel"}: {html_radios name="changed_bowel" options=$form->get_options() selected=$form->get_changed_bowel() separator=""} {xl t="Diarrhea"}: {html_radios name="diarrhea" options=$form->get_options() selected=$form->get_diarrhea() separator=""}
{xl t="Constipation"}: {html_radios name="constipation" options=$form->get_options() selected=$form->get_constipation() separator=""}
{xl t="Genitourinary"} {xl t="General"}
{xl t="Polyuria"}: {html_radios name="polyuria" options=$form->get_options() selected=$form->get_polyuria() separator=""} {xl t="Polydypsia"}: {html_radios name="polydypsia" options=$form->get_options() selected=$form->get_polydypsia() separator=""} {xl t="Dysuria"}: {html_radios name="dysuria" options=$form->get_options() selected=$form->get_dysuria() separator=""}
{xl t="Hematuria"}: {html_radios name="hematuria" options=$form->get_options() selected=$form->get_hematuria() separator=""} {xl t="Frequency"}: {html_radios name="frequency" options=$form->get_options() selected=$form->get_frequency() separator=""} {xl t="Urgency"}: {html_radios name="urgency" options=$form->get_options() selected=$form->get_urgency() separator=""}
{xl t="Incontinence"}: {html_radios name="incontinence" options=$form->get_options() selected=$form->get_incontinence() separator=""} {xl t="Renal Stones"}: {html_radios name="renal_stones" options=$form->get_options() selected=$form->get_renal_stones() separator=""} {xl t="UTIs"}: {html_radios name="utis" options=$form->get_options() selected=$form->get_utis() separator=""}
{xl t="Genitourinary"} {xl t="Male"}
{xl t="Hesitancy"}: {html_radios name="hesitancy" options=$form->get_options() selected=$form->get_hesitancy() separator=""} {xl t="Dribbling"}: {html_radios name="dribbling" options=$form->get_options() selected=$form->get_dribbling() separator=""} {xl t="Stream"}: {html_radios name="stream" options=$form->get_options() selected=$form->get_stream() separator=""}
{xl t="Nocturia"}: {html_radios name="nocturia" options=$form->get_options() selected=$form->get_nocturia() separator=""} {xl t="Erections"}: {html_radios name="erections" options=$form->get_options() selected=$form->get_erections() separator=""} {xl t="Ejaculations"}: {html_radios name="ejaculations" options=$form->get_options() selected=$form->get_ejaculations() separator=""}
{xl t="Genitourinary"} {xl t="Female"}
{xl t="Female G"}: {html_radios name="g" options=$form->get_options() selected=$form->get_g() separator=""} {xl t="Female P"}: {html_radios name="p" options=$form->get_options() selected=$form->get_p() separator=""} {xl t="Female AP"}: {html_radios name="ap" options=$form->get_options() selected=$form->get_ap() separator=""}
{xl t="Female LC"}: {html_radios name="lc" options=$form->get_options() selected=$form->get_lc() separator=""} {xl t="Menarche"}: {html_radios name="mearche" options=$form->get_options() selected=$form->get_mearche() separator=""} {xl t="Menopause"}: {html_radios name="menopause" options=$form->get_options() selected=$form->get_menopause() separator=""}
{xl t="LMP"}: {html_radios name="lmp" options=$form->get_options() selected=$form->get_lmp() separator=""} {xl t="Frequency"}: {html_radios name="f_frequency" options=$form->get_options() selected=$form->get_f_frequency() separator=""} {xl t="Flow"}: {html_radios name="f_flow" options=$form->get_options() selected=$form->get_f_flow() separator=""}
{xl t="Symptoms"}: {html_radios name="f_symptoms" options=$form->get_options() selected=$form->get_f_symptoms() separator=""} {xl t="Abnormal Hair Growth"}: {html_radios name="abnormal_hair_growth" options=$form->get_options() selected=$form->get_abnormal_hair_growth() separator=""} {xl t="F/H Female Hirsutism/Striae"}: {html_radios name="f_hirsutism" options=$form->get_options() selected=$form->get_f_hirsutism() separator=""}
{xl t="Musculoskeletal"}
{xl t="Chronic Joint Pain"}: {html_radios name="joint_pain" options=$form->get_options() selected=$form->get_joint_pain() separator=""} {xl t="Swelling"}: {html_radios name="swelling" options=$form->get_options() selected=$form->get_swelling() separator=""} {xl t="Redness"}: {html_radios name="m_redness" options=$form->get_options() selected=$form->get_m_redness() separator=""}
{xl t="Warm"}: {html_radios name="m_warm" options=$form->get_options() selected=$form->get_m_warm() separator=""} {xl t="Stiffness"}: {html_radios name="m_stiffness" options=$form->get_options() selected=$form->get_m_stiffness() separator=""} {xl t="Muscle"}: {html_radios name="muscle" options=$form->get_options() selected=$form->get_muscle() separator=""}
{xl t="Aches"}: {html_radios name="m_aches" options=$form->get_options() selected=$form->get_m_aches() separator=""} {xl t="FMS"}: {html_radios name="fms" options=$form->get_options() selected=$form->get_fms() separator=""} {xl t="Arthritis"}: {html_radios name="arthritis" options=$form->get_options() selected=$form->get_arthritis() separator=""}
{xl t="Neurologic"}
{xl t="LOC"}: {html_radios name="loc" options=$form->get_options() selected=$form->get_loc() separator=""} {xl t="Seizures"}: {html_radios name="seizures" options=$form->get_options() selected=$form->get_seizures() separator=""} {xl t="Stroke"}: {html_radios name="stroke" options=$form->get_options() selected=$form->get_stroke() separator=""}
{xl t="TIA"}: {html_radios name="tia" options=$form->get_options() selected=$form->get_tia() separator=""} {xl t="Numbness"}: {html_radios name="n_numbness" options=$form->get_options() selected=$form->get_n_numbness() separator=""} {xl t="Weakness"}: {html_radios name="n_weakness" options=$form->get_options() selected=$form->get_n_weakness() separator=""}
{xl t="Paralysis"}: {html_radios name="paralysis" options=$form->get_options() selected=$form->get_paralysis() separator=""} {xl t="Intellectual Decline"}: {html_radios name="intellectual_decline" options=$form->get_options() selected=$form->get_intellectual_decline() separator=""} {xl t="Memory Problems"}: {html_radios name="memory_problems" options=$form->get_options() selected=$form->get_memory_problems() separator=""}
{xl t="Dementia"}: {html_radios name="dementia" options=$form->get_options() selected=$form->get_dementia() separator=""} {xl t="Headache"}: {html_radios name="n_headache" options=$form->get_options() selected=$form->get_n_headache() separator=""}
{xl t="Skin"}
{xl t="Cancer"}: {html_radios name="s_cancer" options=$form->get_options() selected=$form->get_s_cancer() separator=""} {xl t="Psoriasis"}: {html_radios name="psoriasis" options=$form->get_options() selected=$form->get_psoriasis() separator=""} {xl t="Acne"}: {html_radios name="s_acne" options=$form->get_options() selected=$form->get_s_acne() separator=""}
{xl t="Other"}: {html_radios name="s_other" options=$form->get_options() selected=$form->get_s_other() separator=""} {xl t="Disease"}: {html_radios name="s_disease" options=$form->get_options() selected=$form->get_s_disease() separator=""}
{xl t="Psychiatric"}
{xl t="Psychiatric Diagnosis"}: {html_radios name="p_diagnosis" options=$form->get_options() selected=$form->get_p_diagnosis() separator=""} {xl t="Psychiatric Medication"}: {html_radios name="p_medication" options=$form->get_options() selected=$form->get_p_medication() separator=""} {xl t="Depression"}: {html_radios name="depression" options=$form->get_options() selected=$form->get_depression() separator=""}
{xl t="Anxiety"}: {html_radios name="anxiety" options=$form->get_options() selected=$form->get_anxiety() separator=""} {xl t="Social Difficulties"}: {html_radios name="social_difficulties" options=$form->get_options() selected=$form->get_social_difficulties() separator=""}
{xl t="Endocrine"}
{xl t="Thyroid Problems"}: {html_radios name="thyroid_problems" options=$form->get_options() selected=$form->get_thyroid_problems() separator=""} {xl t="Diabetes"}: {html_radios name="diabetes" options=$form->get_options() selected=$form->get_diabetes() separator=""} {xl t="Abnormal Blood Test"}: {html_radios name="abnormal_blood" options=$form->get_options() selected=$form->get_abnormal_blood() separator=""}
{xl t="Hematologic"}/{xl t="Allergic"}/{xl t="Immunologic"}
{xl t="Anemia"}: {html_radios name="anemia" options=$form->get_options() selected=$form->get_anemia() separator=""} {xl t="F/H Blood Problems"}: {html_radios name="fh_blood_problems" options=$form->get_options() selected=$form->get_fh_blood_problems() separator=""} {xl t="Bleeding Problems"}: {html_radios name="bleeding_problems" options=$form->get_options() selected=$form->get_bleeding_problems() separator=""}
{xl t="Allergies"}: {html_radios name="allergies" options=$form->get_options() selected=$form->get_allergies() separator=""} {xl t="Frequent Illness"}: {html_radios name="frequent_illness" options=$form->get_options() selected=$form->get_frequent_illness() separator=""} {xl t="HIV"}: {html_radios name="hiv" options=$form->get_options() selected=$form->get_hiv() separator=""}
{xl t="HAI Status"}: {html_radios name="hai_status" options=$form->get_options() selected=$form->get_hai_status() separator=""}
[{php} xl("Don't Save","e"); {/php}]