Here is the code for the form.
Code:
<h3 class="AccordionHeader">History</h3>
<div class="AccordionPane">
<textarea name="History" id="History" cols="55" rows="8"><%=varHistory%></textarea>
</div>
<h3 class="AccordionHeader">Review of Systems</h3>
<div class="AccordionPane">
<table width="300" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="5" align="left" valign="top"> </td>
<td width="147" align="left" valign="top">
<input name="ROS_Constitutional" type="checkbox" value="1" >Constitutional<br>
<input name="ROS_Eyes" type="checkbox" value="1" >Eyes<br>
<input name="ROS_ENT" type="checkbox" value="1" >ENT<br>
<input name="ROS_CV" type="checkbox" value="1" >CV<br>
<input name="ROS_Respiratory" type="checkbox" value="1" >Respiratory<br>
<input name="ROS_GI" type="checkbox" value="1" >GI<br>
</td>
<td width="146" align="left" valign="top">
<input name="ROS_GU" type="checkbox" value="1" >GU<br>
<input name="ROS_MS" type="checkbox" value="1" >MS<br>
<input name="ROS_Skin" type="checkbox" value="1" >Skin<br>
<input name="ROS_Neuro" type="checkbox" value="1" >Neuro<br>
<input name="ROS_Psych" type="checkbox" value="1" >Psych<br>
</td>
</tr>
<tr>
<td width="5" align="left" valign="top"> </td>
<td width="147" align="center" valign="top"><a href="#" onclick="CheckAll()" >Check All</a></td>
<td width="146" align="center" valign="top"><a href="#" onclick="UncheckAll()" >Uncheck All</a></td>
</tr>
</table>
</div>
<h3 class="AccordionHeader">Past Medical History</h3>
<div class="AccordionPane">
<textarea name="Past_Medical_History" id="Past_Medical_History" cols="55" rows="8"><%=varPast_Medical_History%></textarea>
</div>
<h3 class="AccordionHeader">Family History</h3>
<div class="AccordionPane">
<textarea name="Family_History" id="Family_History" cols="55" rows="8"><%=varFamily_History%></textarea>
</div>
<h3 class="AccordionHeader">Social History</h3>
<div class="AccordionPane">
<textarea name="Social_History" id="Social_History" cols="55" rows="8"><%=varSocial_History%></textarea>
</div>
<h3 class="AccordionHeader">Physical Examination</h3>
<div class="AccordionPane">
<textarea name="Physical_Examination" id="Physical_Examination" cols="55" rows="8"><%=varPhysical_Examination%></textarea>
</div>
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