{literal} {/literal}

Review Of Systems

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