<cfset AssForm.Assessment_ID='#Session.CS.AssessmentID#' />
<cfquery name="GetP" datasource="#Application.DataSrc#">
    SELECT Patient_ID, Last_Name_M0040 AS Last_Name, First_Name_M0040 AS First_Name, Middle_Initial_M0040 AS Middle
    ,Payer_ID
    FROM  #Request.prefix_db_agency#.patient
    WHERE Patient_Id = '#session.cs.patientid#'
    AND   Agency_Id = '#session.AgencyId#'
</cfquery>

<cfquery name="AssForm" datasource="#Application.DataSrc#">
    select
    Assessment_ID,
    Start_of_Care_M0030,
    M0420_Assess,
    Pain1,
    Pain2,
    Pain3,
    pain4,
    Pain5,
    Inpatient_Discharge_Date_NA_M0180,
    Dress_Upper_M0650,
    Medical_or_Treatment_Change_M0200,
    Surgical_Wound_M0482,
    Hearing_M0400,
    Speech_M0410,
    Surgical_Wound_OB_M0484,
    Open_Wounds_M0440,
    Pressure_Ulcer_M0445,
    Pressure_Ulcer_a_M0450,
    Pressure_Ulcer_b_M0450,
    Pressure_Ulcer_c_M0450,
    Pressure_Ulcer_d_M0450,
    Vision_M0390,
    Eating_M0710,
    Eating_M0710p,
    Meal_Prep_M0720,
    Meal_Prep_M0720p,
    Pressure_Ulcer_Stage_M0460,
    Stasis_Ulcer_Num_M0470,
    Stasis_Ulcer_Hidden_M0474,
    Stasis_Ulcer_Status_M0476,
    Surgical_Wound_Status_M0488,
    Breathing_M0490,
    Urinary_INcont_M0520,
    Resp_Treatments_M0500,
    Freq_of_Pain_M0420,
    Transport_M0730,
    Transport_M0730p,
    Laundry_M0740,
    Laundry_M0740p,
    Housekeeping_M0750,
    Assessment_note,
    Record_Created_By,
    Transmission_status
    FROM #Request.prefix_db_agency#.Assessment_New
    where Assessment_ID='#session.cs.AssessmentId#'
</cfquery>
<cfquery name="Createdby" datasource="#Application.DataSrc#">
	select Last_Name,First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = '#AssForm.Record_Created_By#'
</cfquery>
<cfscript>
		pat = CreateObject("Component", "assessment");
		get_pain_que = pat.get_pain_ques('1 - Start of care - further visits planned','pain'); 
   </cfscript>
<div class="portlet box blue">
    <div class="portlet-title">
        <div class="caption">
            <i class="fa fa-gear"></i> <cfoutput> #DateFormat(AssForm.Start_of_Care_M0030,'mm/dd/yyyy')# - SN Pediatric Form </cfoutput>
        </div>
		<div class="tools">
		  <a href="javascript:;" class="collapse"></a>
		</div>
    </div>
    <div class="portlet-body form">
        <cfform name="otupdate" action="index.cfm?a=1&a=1&px=y&page=patient&px=y&cat=snpediatricformupdate" method="post" id="otupdate">
        	<div class="form-body">
			  <div class="well">
				<div class="row">
					<div class="col-md-6">
						<div class="form-group">
							<label>Other Services Involved (By Current Agency)</label>
							<textarea class="form-control" style="width:100%;max-width:100%;height:80px;" name="Other_Services" id="Other_Services" onBlur="ChangeBlur('otupdate','Other_Services')" rows="3"><cfoutput>#AssForm.Inpatient_Discharge_Date_NA_M0180#</cfoutput></textarea>
						</div>
					</div>
					<div class="col-md-6">
						<div class="form-group">
							<label>Other Agencies Involved</label>
							<textarea class="form-control" style="width:100%;max-width:100%;height:80px;" name="OtherAgencies" id="OtherAgencies" onBlur="ChangeBlur('otupdate','OtherAgencies')" rows="3"><cfoutput>#AssForm.Dress_Upper_M0650#</cfoutput></textarea>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Pertinent Medical History</label><br />
							<div class="label-stable">
								<div id="PatientHstrydiv" class="checkbox-list">
									<label>
									<input type="checkbox" name="PatientHstry1" value="Apnea" <cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Apnea'>checked</cfif>  /> apnea</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Asthma"  <cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Asthma'>checked</cfif> /> Asthma</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Bleeding problems"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Bleeding problems'>checked</cfif> /> Bleeding problems</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Burn(s)" <cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Burn(s)'>checked</cfif> /> Burn(s)</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Chickenpox"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Chickenpox'>checked</cfif> /> Chickenpox</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Conjunctivitis"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Conjunctivitis'>checked</cfif> /> Conjunctivitis</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Cradle cap"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Cradle cap'>checked</cfif> /> Cradle cap</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Croup"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Croup'>checked</cfif> /> Croup</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Fracture(s)"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Fracture(s)'>checked</cfif> /> Fracture(s)</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Frequent colds"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Frequent colds'>checked</cfif> /> Frequent colds</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Frequent ear infection"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Frequent ear infection'>checked</cfif> /> Frequent ear infection</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Frequent sore throat"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Frequent sore throat'>checked</cfif> /> Frequent sore throat</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Headaches"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Headaches'>checked</cfif> /> Headaches</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Hepatitis"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Hepatitis)'>checked</cfif> /> Hepatitis</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Hiv"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Hiv'>checked</cfif> /> Hiv</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Immunizations not up to date"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Immunizations not up to date'>checked</cfif> /> Immunizations not up to date</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Lead poisoning"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Lead poisoning'>checked</cfif> /> Lead poisoning</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Limb deficiencies"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Limb deficiencies'>checked</cfif> /> Limb deficiencies</label>
									<!---<label>
									<input type="checkbox" name="PatientHstry1" value="Hepatitis"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Hepatitis)'>checked</cfif> /> Hepatitis</label>
									<label>--->
									<input type="checkbox" name="PatientHstry1" value="Mongolian spots"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Mongolian spots'>checked</cfif> /> Mongolian spots</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Mumps"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Mumps'>checked</cfif> /> Mumps</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Nosebleeds"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Nosebleeds'>checked</cfif> /> Nosebleeds</label>
									<label>
									<input type="checkbox" name="PatientHstry1"  value="Otitis media"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Otitis media'>checked</cfif>/> Otitis media</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Pica"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Pica'>checked</cfif> /> Pica</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Pneumonia"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Pneumonia'>checked</cfif> /> Pneumonia</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Rheumatic Fever"<cfif #AssForm.Meal_Prep_M0720# contains 'Rheumatic Fever'>checked</cfif> /> Rheumatic Fever</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="RSU"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'RSU'>checked</cfif> /> RSU</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Rubella"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Rubella'>checked</cfif> /> Rubella</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Rubeolla"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Rubeolla'>checked</cfif> /> Rubeolla</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Scarlet Fever"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Scarlet Fever'>checked</cfif> /> Scarlet Fever</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Seizures - Grand Mal"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Seizures - Grand Mal'>checked</cfif> /> Seizures - Grand Mal</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Seizures - Petit Mall"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Seizures - Petit Mall'>checked</cfif> /> Seizures - Petit Mall</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Sickle Cell"<cfif #AssForm.Meal_Prep_M0720# contains 'Sickle Cell'>checked</cfif> /> Sickle Cell</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Sinusitis"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Sinusitis'>checked</cfif> /> Sinusitis</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Stork bites"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Stork bites'>checked</cfif> /> Stork bites</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Strep Throat"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Strep Throat'>checked</cfif> /> Strep Throat</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Thrush"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Thrush'>checked</cfif> /> Thrush</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Tonsillitis"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Tonsillitis'>checked</cfif> /> Tonsillitis</label>
									<label>
									<input type="checkbox" name="PatientHstry1" value="Other"<cfif #AssForm.Medical_or_Treatment_Change_M0200# contains 'Other'>checked</cfif> /> Other...</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
						 <label>NUTRITION</label><br />
							<div class="label-stable">
							<div id="Feed" class="checkbox-list">
								<label>
								<input name="Fee"  type="checkbox"  value="0 - Absent teeth" <cfif #AssForm.Surgical_Wound_M0482# contains '0 - Absent teeth'>checked</cfif>/> 0 - Absent teeth</label>
								<label>
								<input name="Fee"  type="checkbox" value="1 - Anorexia" <cfif #AssForm.Surgical_Wound_M0482# contains '1 - Anorexia'>checked</cfif>/> 1 - Anorexia</label>
								<label>
								<input name="Fee" type="checkbox" value="2 - Apathetic" <cfif #AssForm.Surgical_Wound_M0482# contains '2 - Apathetic'>checked</cfif>/> 2 - Apathetic</label>
								<label>
								<input name="Fee" type="checkbox" value="3 - Cachectic" <cfif #AssForm.Surgical_Wound_M0482# contains '3 - Cachectic'>checked</cfif>/> 3 - Cachectic</label>
								<label>
								<input name="Fee" type="checkbox" value="4 - Dependent edema" <cfif #AssForm.Surgical_Wound_M0482# contains '4 - Dependent edema'>checked</cfif>/> 4 - Dependent edema</label>
								<label>
								<input name="Fee" type="checkbox" value="5 - Indigestion" <cfif #AssForm.Surgical_Wound_M0482# contains '5 - Indigestion'>checked</cfif>/> 5 - Indigestion</label>
								<label>
								<input name="Fee" type="checkbox" value="6 - Listless" <cfif #AssForm.Surgical_Wound_M0482# contains '6 - Listless'>checked</cfif>/> 6 - Listless</label>
								<label>
								<input name="Fee" type="checkbox" value="7 - Nails spoon-shaped" <cfif #AssForm.Surgical_Wound_M0482# contains '7 - Nails spoon-shaped'>checked</cfif>/> 7 - Nails spoon-shaped</label>
								<label>
								<input name="Fee" type="checkbox" value="8 - Overweight" <cfif #AssForm.Surgical_Wound_M0482# contains '8 - Overweight'>checked</cfif>/> 8 - Overweight</label>
								<label>
								<input name="Fee" type="checkbox" value="9 - Pal conjunctivae" <cfif #AssForm.Surgical_Wound_M0482# contains '9 - Pal conjunctivae'>checked</cfif>/> 9 - Pal conjunctivae</label>
								<label>
								<input name="Fee" type="checkbox" value="10 - Paresthesia" <cfif #AssForm.Surgical_Wound_M0482# contains '10 - Paresthesia'>checked</cfif>/> 10 - Absent teeth</label>
								<label>
								<input name="Fee" type="checkbox" value="11 - Poor muscle tone" <cfif #AssForm.Surgical_Wound_M0482# contains '11 - Poor muscle tone'>checked</cfif>/> 11 - Poor muscle tone</label>
								<label>
								<input name="Fee" type="checkbox" value="12 - Prominent scapula" <cfif #AssForm.Surgical_Wound_M0482# contains '12 - Prominent scapula'>checked</cfif>/> 12 - Prominent scapula</label>
								<label>
								<input name="Fee" type="checkbox" value="13 - Tongue swelling, beefy" <cfif #AssForm.Surgical_Wound_M0482# contains '13 - Tongue swelling, beefy'>checked</cfif>/> 13 - Tongue swelling, beefy</label>
								<label>
								<input name="Fee" type="checkbox" value="14 - Underweight" <cfif #AssForm.Surgical_Wound_M0482# contains '14 - Underweight'>checked</cfif>/> 14 - Underweight</label>
								<label>
								<input name="Fee" type="checkbox" value="15 - Asymptomatic" <cfif #AssForm.Surgical_Wound_M0482# contains '15 - Asymptomatic'>checked</cfif>/> 15 - Asymptomatic</label>
								<label>
								<input name="Fee" type="checkbox" value="Other" <cfif #AssForm.Surgical_Wound_M0482# contains 'Other'>checked</cfif>/> Other..</label>
							</div>
						</div>
						</div>
					</div>
				</div>
				<div class="form-group">
					<label>Medical Diagnoses (diagnosis lookup) <img name="imgbtnadd" id="imgbtnadd" src="../../images/icon_add.png" style="cursor:pointer" /></label>
				</div>
				<div class="well" id="DivSS" style="display:none;">
					<div class="form-group">
						<label>M1021/3/5 ICD and Severity Index: List up to 6 ICDs for which the patient is receiving home care and rate them using the severity index</label>
						<textarea name="M0230txtsearch" type="text" value=" " class="form-control"></textarea>
					</div>
					<input class="btn btn-sm blue" name="Search" type="button" value="Search" onClick="SearchClick();"  />
					<input class="btn btn-sm blue" name="btnSev" type="button" value="Redo Find" />
					<input class="btn btn-sm btn-default" name="btncancel" id="btncancel" type="button" value="Cancel" />
				</div>
				<cfinput name="tinput1" type="text" style="display:none" value="Test">
				<!---<cfdiv bind="url:#Application.siteURL#/patientadmin_new/sngrid.cfm?InputText={tinput1}" ID="theDiv"></cfdiv>--->
				<cfdiv bind="url:#Application.siteURL#/patientadmin_new/M0230Grid.cfm?InputText={tinput1}" ID="theDiv"></cfdiv>
				
				<div class="hidden">
				<div class="form-group">
					<label>Use Coding Expert? <img src="../../images/icon_help.png" alt="top" style="cursor:pointer" onClick="help();" /></label><br />
					<div class="label-stable">
						<div id="chkM1010YesColor1" class="checkbox-list">
							<label>
							<input type="checkbox" name="chkM1010Yes"onclick="chkReflect('1')" value="1"> Yes</label>
						</div>
					</div>
				</div>
				</div>
				
				
				<h4>Dietry Requirements</h4>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>for infants: bottle or bottle feed</label><br />
							<div class="label-stable">
								<div id="groomd" class="checkbox-list">
									<label>
									<input type="checkbox" name="groom" value="0 - OZ per day" <cfif #AssForm.Hearing_M0400# contains '0 - OZ per day'>checked</cfif> /> 0 - OZ per day</label>
									<label>
									<input type="checkbox" name="groom" value="1 - Frequency/duration" <cfif #AssForm.Hearing_M0400# contains '1 - Frequency/duration'>checked</cfif> /> 1 - Frequency/duration</label>
									<label>
									<input type="checkbox" name="groom"  value="2 - Weight pre-feed" <cfif #AssForm.Hearing_M0400# contains '2 - Weight pre-feed'>checked</cfif>/> 2 - Weight pre-feedt</label>
									<label>
									<input type="checkbox" name="groom"  value="3 - Weight post feed" <cfif #AssForm.Hearing_M0400# contains '3 - Weight post feed'>checked</cfif>/> 3 - Weight post feed</label>
									<label>
									<input type="checkbox" name="groom"  value="4 - Formula type" <cfif #AssForm.Hearing_M0400# contains '4 - Formula type'>checked</cfif>/> 4 - Formula type</label>
									<label>
									<input type="checkbox" name="groom"  value="5 - Suck/swallow/breath coordination" <cfif #AssForm.Hearing_M0400# contains '5 - Suck/swallow/breath coordination'>checked</cfif>/> 5 - Suck/swallow/breath coordination</label>
									<label>
									<input type="checkbox" name="groom"  value="6 - Cyanosis while feeding?" <cfif #AssForm.Hearing_M0400# contains '6 - Cyanosis while feeding?'>checked</cfif>/> 6 - Cyanosis while feeding?</label>
									<label>
									<input type="checkbox" name="groom"  value="7 - Caloric supplements" <cfif #AssForm.Hearing_M0400# contains '7 - Caloric supplements'>checked</cfif>/> 7 - Caloric supplements</label>
									<label>
									<input type="checkbox" name="groom"  value="8 - Disolvable solids" <cfif #AssForm.Hearing_M0400# contains '8 - Disolvable solids'>checked</cfif>/> 8 - Disolvable solids</label>
									<label>
									<input type="checkbox" name="groom" value="9 - Finger foods" <cfif #AssForm.Hearing_M0400# contains '9 - Finger foods'>checked</cfif> /> 9 - Finger foods</label>
									<label>
									<input type="checkbox" name="groom"  value="10 - G-tube/gavage" <cfif #AssForm.Hearing_M0400# contains '10 - G-tube/gavage'>checked</cfif>/> 10 - G-tube/gavage</label>
									<label>
									<input type="checkbox" name="groom"  value="11 - J-tube" <cfif #AssForm.Hearing_M0400# contains '11 - J-tube'>checked</cfif>/> 11 - J-tube</label>
									<label>
									<input type="checkbox" name="groom"  value="12 - Mechanical soft diet" <cfif #AssForm.Hearing_M0400# contains '12 - Mechanical soft diet'>checked</cfif>/> 12 - Mechanical soft diet</label>
									<label>
									<input type="checkbox" name="groom"  value="13 - Puree" <cfif #AssForm.Hearing_M0400# contains '13 - Puree'>checked</cfif>/> 13 - Puree</label>
									<label>
									<input type="checkbox" name="groom"  value="14 - Thickened liquids" <cfif #AssForm.Hearing_M0400# contains '14 - Thickened liquids'>checked</cfif>/> 14 - Thickened liquids</label>
									<label>
									<input type="checkbox" name="groom"  value="15 - TPN" <cfif #AssForm.Hearing_M0400# contains '15 - TPN'>checked</cfif>/> 15 - TPN</label>
									<label>
									<input type="checkbox" name="groom"  value="16 - Regular diet" <cfif #AssForm.Hearing_M0400# contains '16 - Regular diet'>checked</cfif>/> 16 - Regular diet</label>
									<label>
									<input type="checkbox" name="groom"  value="Other" <cfif #AssForm.Hearing_M0400# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Nutritional Therapies</label> <br />
							<div class="label-stable">
								<div id="Bathd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Bath" value="1 - Intravenous or infusion therapy (excludes TPN)" <cfif #AssForm.Speech_M0410# contains '1 - Intravenous or infusion therapy (excludes TPN)' >checked</cfif>/> 1 - Intravenous or infusion therapy (excludes TPN)</label>
									<label>
									<input type="checkbox" name="Bath" value="2 - Parenteral nutrition (TPN or liquids)" <cfif #AssForm.Speech_M0410# contains '2 - Parenteral nutrition (TPN or liquids)' >checked</cfif>/> 2 - Parenteral nutrition (TPN or liquids)</label>
									<label>
									<input type="checkbox" name="Bath" value="3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, etc)" <cfif #AssForm.Speech_M0410# contains '3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, etc)' >checked</cfif> /> 3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, etc)</label>
									<label>
									<input type="checkbox" name="Bath"  value="4 - None of the above" <cfif #AssForm.Speech_M0410# contains '4 - None of the above' >checked</cfif>/> 4 - None of the above</label>
								</div>
							</div>
						</div>
						<div class="form-group">
							<label>Endocrine</label><br />
							<div class="label-stable">
								<div id="Dressd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Dress" value="0 - Abnormal growth" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '0 - Abnormal growth'>checked</cfif>/> 0 - Abnormal growth</label>
									<label>
									<input type="checkbox" name="Dress" value="1 - Abnormal haire texture/distribution" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '1 - Abnormal haire texture/distribution'>checked</cfif> /> 1 - Abnormal haire texture/distribution</label>
									<label>
									<input type="checkbox" name="Dress"  value="2 - Abnormal sexual development" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '2 - Abnormal sexual development'>checked</cfif>/> 2 - Abnormal sexual development</label>
									<label>
									<input type="checkbox" name="Dress"  value="3 - Polyphagia" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '3 - Polyphagia'>checked</cfif>/> 3 - Polyphagia</label>
									<label>
									<input type="checkbox" name="Dress"  value="4 - Polyuria" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '4 - Polyuria'>checked</cfif>/> 4 - Polyuria</label>
									<label>
									<input type="checkbox" name="Dress"  value="5 - Asymptomatic" <cfif #AssForm.Surgical_Wound_OB_M0484# contains '5 - Asymptomatic'>checked</cfif>/> 5 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Dress"  value="Other" <cfif #AssForm.Surgical_Wound_OB_M0484# contains 'Other'>checked</cfif>/> Other</label>
								</div>
							</div>
						</div>
				   </div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Skin</label><br />
							<div class="label-stable">
								<div id="LDressd" class="checkbox-list">
									<label>
									<input type="checkbox" name="LDress" value="0 - acne" <cfif AssForm.Open_Wounds_M0440 contains '0 - acne'>checked</cfif>/> 0 - Acne</label>
									<label>
									<input type="checkbox" name="LDress" value="1 - Birthmarks" <cfif AssForm.Open_Wounds_M0440 contains '1 - Birthmarks'>checked</cfif>/> 1 - Birthmarks</label>
									<label>
									<input type="checkbox" name="LDress" value="2 - Bruise(s)" <cfif AssForm.Open_Wounds_M0440 contains '2 - Bruise(s)'>checked</cfif>/> 2 - Bruise(s)</label>
									<label>
									<input type="checkbox" name="LDress" value="3 - Color cyanotic" <cfif AssForm.Open_Wounds_M0440 contains '3 - Color cyanotic'>checked</cfif>/> 3 - Color cyanotic</label>
									<label>
									<input type="checkbox" name="LDress"  value="4 - Color jaundice" <cfif AssForm.Open_Wounds_M0440 contains '4 - Color jaundice'>checked</cfif>/> 4 - Color jaundice</label>
									<label>
									<input type="checkbox" name="LDress"  value="5 - Color pale" <cfif AssForm.Open_Wounds_M0440 contains '5 - Color pale'>checked</cfif>/> 5 - Color pale</label>
									<label>
									<input type="checkbox" name="LDress" value="6 - Dry skin" <cfif AssForm.Open_Wounds_M0440 contains '6 - Dry skin'>checked</cfif>/> 6 - Dry skin</label>
									<label>
									<input type="checkbox" name="LDress" value="7 - keloid(s)" <cfif AssForm.Open_Wounds_M0440 contains '7 - keloid(s)'>checked</cfif> /> 7 - keloid(s)</label>
									<label>
									<input type="checkbox" name="LDress"  value="8 - Lesions" <cfif AssForm.Open_Wounds_M0440 contains '8 - Lesions'>checked</cfif>/> 8 - Lesions</label>
									<label>
									<input type="checkbox" name="LDress" value="9 - Mole(s)" <cfif AssForm.Open_Wounds_M0440 contains '9 - Mole(s)'>checked</cfif>/> 9 - Mole(s)</label>
									<label>
									<input type="checkbox" name="LDress" value="10 - Poor skin turgor" <cfif AssForm.Open_Wounds_M0440 contains '10 - Poor skin turgor'>checked</cfif>/> 10 - Poor skin turgor</label>
									<label>
									<input type="checkbox" name="LDress" value="11 - rash(es)" <cfif AssForm.Open_Wounds_M0440 contains '11 - rash(es)'>checked</cfif>/> 11 - rash(es)</label>
									<label>
									<input type="checkbox" name="LDress"  value="12 - Sweaty skin" <cfif AssForm.Open_Wounds_M0440 contains '12 - Sweaty skin'>checked</cfif>/> 12 - Sweaty skin</label>
									<label>
									<input type="checkbox" name="LDress"  value="13 - Asymptomatic" <cfif AssForm.Open_Wounds_M0440 contains '13 - Asymptomatic'>checked</cfif>/> 13 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="LDress"  value="other" <cfif AssForm.Open_Wounds_M0440 contains 'other'>checked</cfif>/> other...</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">

						<div class="form-group">
							<label>Eyes</label><br />
							<div class="label-stable">
								<div id="DMEd" class="checkbox-list">
									<label>
									<input type="checkbox"  name="DME" value="0 - Bitots spots" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '0 - Bitots spots'>checked</cfif> /> 0 - Bitots spots</label>
									<label>
									<input type="checkbox" name="DME" value="1 - Drainage" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '1 - Drainage'>checked</cfif>/> 1 - Drainage</label>
									<label>
									<input type="checkbox"  name="DME" value="2 - Dull/soft cornea" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '2 - Dull/soft cornea'>checked</cfif>/> 2 - Dull/soft cornea</label>
									<label>
									<input type="checkbox" name="DME" value="3 - Entropion" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '3 - Entropion'>checked</cfif>/> 3 - Entropion</label>
									<label>
									<input type="checkbox"  name="DME" value="4 - Epicanthal folds" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '4 - Epicanthal folds'>checked</cfif>/> 4 - Epicanthal folds</label>
									<label>
									<input type="checkbox"  name="DME" value="5 - Misplaced position" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '5 - Misplaced position'>checked</cfif>/> 5 - Misplaced position</label>
									<label>
									<input type="checkbox"  name="DME" value="6 - Ptosis" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '6 - Ptosis'>checked</cfif>/> 6 - Ptosis</label>
									<label>
									<input type="checkbox"  name="DME" value="7 - Redness" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '7 - Redness'>checked</cfif>/> 7 - Redness</label>
									<label>
									<input type="checkbox"  name="DME" value="8 - Sunset sign" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '8 - Sunset sign'>checked</cfif>/> 8 - Sunset sign</label>
									<label>
									<input type="checkbox"  name="DME" value="9 - Swelling" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '9 - Swelling'>checked</cfif>/> 9 - Swelling</label>
									<label>
									<input type="checkbox"  name="DME" value="10 - Unable to follow objects with eyes" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '10 - Unable to follow objects with eyes'>checked</cfif>/> 10 - Unable to follow objects with eyes</label>
									<label>
									<input type="checkbox"  name="DME" value="11 - Wears glasses" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '11 - Wears glasses'>checked</cfif>/> 11 - Wears glasses</label>
									<label>
									<input type="checkbox" name="DME" value="12 - Asymptomatic" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains '12 - Asymptomatic'>checked</cfif>/> 12 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="DME" value="Other" <cfif #AssForm.Pressure_Ulcer_a_M0450# contains 'Other'>checked</cfif>/> Other</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<h4><b>HEAD & NECK </b></h4>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>--6 months and younger--</label><br />
							<div class="label-stable">
								<div id="Homemaked" class="checkbox-list">
									<label>
									<input type="checkbox" name="Homemake" value="0 - Bulging fontanel" <cfif AssForm.Pressure_Ulcer_M0445 contains '0 - Bulging fontanel'> checked</cfif>/> 0 - Bulging fontanel</label>
									<label>
									<input type="checkbox" name="Homemake" value="1 - Depressed fontanel" <cfif AssForm.Pressure_Ulcer_M0445 contains '1 - Depressed fontanel'> checked</cfif> /> 1 - Depressed fontanel</label>
									<label>
									<input type="checkbox" name="Homemake"  value="2 - Flattened occiput" <cfif AssForm.Pressure_Ulcer_M0445 contains '2 - Flattened occiput'> checked</cfif>/> 2 - Flattened occiput</label>
									<label>
									<input type="checkbox" name="Homemake"  value="3 - Hydrocephaly" <cfif AssForm.Pressure_Ulcer_M0445 contains '3 - Hydrocephaly'> checked</cfif>/> 3 - Hydrocephaly</label>
									<label>
									<input type="checkbox" name="Homemake"  value="4 - Lesions present" <cfif AssForm.Pressure_Ulcer_M0445 contains '4 - Lesions present'> checked</cfif>/> 4 - Lesions present</label>
									<label>
									<input type="checkbox" name="Homemake"  value="5 - Microcephaly" <cfif AssForm.Pressure_Ulcer_M0445 contains '5 - Microcephaly'> checked</cfif>/> 5 - Microcephaly</label>
									<label>
									<input type="checkbox" name="Homemake"  value="6 - Separated sagittal suture" <cfif AssForm.Pressure_Ulcer_M0445 contains '6 - Separated sagittal suture'> checked</cfif>/> 6 - Separated sagittal suture</label>
									<label>
									<input type="checkbox" name="Homemake"  value="7 - Asymptomatic" <cfif AssForm.Pressure_Ulcer_M0445 contains '7 - Asymptomatic'> checked</cfif>/> 7 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Homemake"  value="8 - Head asymmetry" <cfif AssForm.Pressure_Ulcer_M0445 contains '8 - Head asymmetry'> checked</cfif>/> 8 - Head asymmetry</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>--Over 6 months--</label><br />
							<div class="label-stable">
								<div id="Homemaked" class="checkbox-list">
									<label>
									<input type="checkbox" name="Homemake" value="0 - Head lag" <cfif AssForm.Pressure_Ulcer_M0445 contains '0 - Head lag'> checked</cfif>/> 0 - Head lag</label>
									<label>
									<input type="checkbox" name="Homemake" value="1 - Enlarged head" <cfif AssForm.Pressure_Ulcer_M0445 contains '1 - Enlarged head'> checked</cfif> /> 1 - Enlarged head</label>
									<label>
									<input type="checkbox" name="Homemake"  value="2 - Neck pain/Resistance" <cfif AssForm.Pressure_Ulcer_M0445 contains '2 - Neck pain/Resistance'> checked</cfif>/> 2 - Neck pain/Resistance</label>
									<label>
									<input type="checkbox" name="Homemake"  value="3 - Neck swelling" <cfif AssForm.Pressure_Ulcer_M0445 contains '3 - Neck swelling'> checked</cfif>/> 3 - Neck swelling</label>
									<label>
									<input type="checkbox" name="Homemake"  value="4 - neck webbing" <cfif AssForm.Pressure_Ulcer_M0445 contains '4 - neck webbing'> checked</cfif>/> 4 - neck webbing</label>
									<label>
									<input type="checkbox" name="Homemake"  value="5 - Misaligned trachea" <cfif AssForm.Pressure_Ulcer_M0445 contains '5 - Misaligned trachea'> checked</cfif>/> 5 - Misaligned trachea</label>
									<label>
									<input type="checkbox" name="Homemake"  value="6 - Enlarged thyroid" <cfif AssForm.Pressure_Ulcer_M0445 contains '6 - Enlarged thyroid'> checked</cfif>/> 6 - Enlarged thyroid</label>
									<label>
									<input type="checkbox" name="Homemake"  value="7 - Enlarged lymphnodes" <cfif AssForm.Pressure_Ulcer_M0445 contains '7 - Enlarged lymphnodes'> checked</cfif>/> 7 - Enlarged lymphnodes</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="form-group">
					<label>EARS</label><br />
					<div class="label-stable">
						<div id="Toiletd" class="checkbox-list">
							<label>
							<input type="checkbox" name="Toilet" value="0 - Does not respond to sounds/voices" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '0 - Does not respond to sounds/voices'>checked</cfif> /> 0 - Does not respond to sounds/voices</label>
							<label>
							<input type="checkbox" name="Toilet" value="1 - Excessive cerumen" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '1 - Excessive cerumen'>checked</cfif> /> 1 - Excessive cerumen</label>
							<label>
							<input type="checkbox" name="Toilet"  value="2 - External canal inflamed" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '2 - External canal inflamed'>checked</cfif>/> 2 - External canal inflamed</label>
							<label>
							<input type="checkbox" name="Toilet"  value="3 - Gross hearing impaired" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '3 - Gross hearing impaired'>checked</cfif>/> 3 - Gross hearing impaired</label>
							<label>
							<input type="checkbox" name="Toilet"  value="4 - Low placement" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '4 - Low placement'>checked</cfif>/> 4 - Low placement</label>
							<label>
							<input type="checkbox"  name="Toilet"  value="5 - Myringotomy tubes" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '5 - Myringotomy tubes'>checked</cfif>/> 5 - Myringotomy tubes</label>
							<label>
							<input type="checkbox" name="Toilet"  value="6 - Pain" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '6 - Pain'>checked</cfif>/> 6 - Pain</label>
							<label>
							<input type="checkbox" name="Toilet"  value="7 - Tympanic membrane irregular" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '7 - Tympanic membrane irregular'>checked</cfif>/> 7 - Tympanic membrane irregular</label>
							<label>
							<input type="checkbox" name="Toilet"  value="8 - Uses hearing aid" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '8 - Uses hearing aid'>checked</cfif>/> 8 - Uses hearing aid</label>
							<label>
							<input type="checkbox" name="Toilet"  value="9 - Asymptomatic" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '9 - Asymptomatic'>checked</cfif>/> 9 - Asymptomatic</label>
							<label>
							<input type="checkbox" name="Toilet"  value="10 - Other" <cfif AssForm.Pressure_Ulcer_b_M0450 contains '10 - Other'>checked</cfif>/> 10 - Other</label>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Mouth & Throat</label><br />
							<div class="label-stable">
								<div id="Reachd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Reach" value="0 - Abnormal exudates"  <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '0 - Abnormal exudates'>checked</cfif>/> 0 - Abnormal exudates</label>
									<label>
									<input type="checkbox" name="Reach"  value="1 - Gingivitis" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '1 - Gingivitis'>checked</cfif>/> 1 - Gingivitis</label>
									<label>
									<input type="checkbox" name="Reach"  value="2 - Irregular tonsil size" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '2 - Irregular tonsil size'>checked</cfif>/> 2 - Irregular tonsil size</label>
									<label>
									<input type="checkbox" name="Reach"  value="3 - Lips not pink, smooth" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '3 - Lips not pink, smooth'>checked</cfif>/> 3 - Lips not pink, smooth</label>
									<label>
									<input type="checkbox" name="Reach"  value="4 - Malocclusion" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '4 - Malocclusion'>checked</cfif>/> 4 - Malocclusion</label>
									<label>
									<input type="checkbox" name="Reach"  value="5 - Sucking/swallowing deficit" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '5 - Sucking/swallowing deficit'>checked</cfif>/> 5 - Sucking/swallowing deficit</label>
									<label>
									<input type="checkbox" name="Reach"  value="6 - Teeth with caries, discolored, tartar" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '6 - Teeth with caries, discolored, tartar'>checked</cfif>/> 6 - Teeth with caries, discolored, tartar</label>
									<label>
									<input type="checkbox" name="Reach"  value="7 - TMJ" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '7 - TMJ'>checked</cfif>/> 7 - TMJ</label>
									<label>
									<input type="checkbox" name="Reach"  value="8 - Tongue swelling/redness" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '8 - Tongue swelling/redness'>checked</cfif>/> 8 - Tongue swelling/redness</label>
									<label>
									<input type="checkbox" name="Reach"  value="9 - Asymptomatic" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains '9 - Asymptomatic'>checked</cfif>/> 9 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Reach"  value="Other" <cfif #AssForm.Pressure_Ulcer_c_M0450# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">

						<div class="form-group">
							<label>Nose</label><br />
							<div class="label-stable">
								<div id="Mouthd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Mouth"  value="0 - Deviated septum" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '0 - Deviated septum'>checked</cfif>/> 0 - Deviated septum</label>
									<label>
									<input type="checkbox" name="Mouth"  value="1 - Inflamed/swollen nasal mucosa" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '1 - Inflamed/swollen nasal mucosa'>checked</cfif>/> 1 - Inflamed/swollen nasal mucosa</label>
									<label>
									<input type="checkbox" name="Mouth"  value="2 - Irregular turbinates" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '2 - Irregular turbinates'>checked</cfif>/> 2 - Irregular turbinates</label>
									<label>
									<input type="checkbox" name="Mouth"  value="3 - Nasal flaring" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '3 - Nasal flaring'>checked</cfif>/> 3 - Nasal flaring</label>
									<label>
									<input type="checkbox" name="Mouth"  value="4 - Nose bleeds" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '4 - Nose bleeds'>checked</cfif>/> 4 - Nose bleeds</label>
									<label>
									<input type="checkbox" name="Mouth"  value="5 - Perforated septum" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '5 - Perforated septum'>checked</cfif>/> 5 - Perforated septum</label>
									<label>
									<input type="checkbox" name="Mouth"  value="6 - Asymptomatic" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '6 - Asymptomatic'>checked</cfif>/> 6 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Mouth"  value="7 - Other" <cfif #AssForm.Pressure_Ulcer_d_M0450# contains '7 - Other'>checked</cfif>/> 7 - Other</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Mood</label><br />
							<div class="label-stable">
								<div id="Headd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Head" value="0 - Aggressive"  <cfif #AssForm.Vision_M0390# contains '0 - Aggressive'>checked</cfif>/> 0 - Aggressive</label>
									<label>
									<input type="checkbox" name="Head" value="1 - Hyperactive" <cfif #AssForm.Vision_M0390# contains '1 - Hyperactive'>checked</cfif> /> 1 - Hyperactive</label>
									<label>
									<input type="checkbox" name="Head"  value="2 - Hypoactive" <cfif #AssForm.Vision_M0390# contains '2 - Hypoactive'>checked</cfif>/> 2 - Hypoactive</label>
									<label>
									<input type="checkbox" name="Head"  value="3 - Impaired parent/child bonding" <cfif #AssForm.Vision_M0390# contains '3 - Impaired parent/child bonding'>checked</cfif>/> 3 - Impaired parent/child bonding</label>
									<label>
									<input type="checkbox" name="Head"  value="4 - Limited/no eye contact" <cfif #AssForm.Vision_M0390# contains '4 - Limited/no eye contact'>checked</cfif>/> 4 - Limited/no eye contact</label>
									<label>
									<input type="checkbox" name="Head"  value="5 - Short attention span" <cfif #AssForm.Vision_M0390# contains '5 - Short attention span'>checked</cfif>/> 5 - Short attention span</label>
									<label>
									<input type="checkbox" name="Head"  value="6 - Withdrawn" <cfif #AssForm.Vision_M0390# contains '6 - Withdrawn'>checked</cfif>/> 6 - Withdrawn</label>
									<label>
									<input type="checkbox" name="Head"  value="7 - Stable Mood" <cfif #AssForm.Vision_M0390# contains '7 - Stable Mood'>checked</cfif>/> 7 - Stable Mood</label>
									<label>
									<input type="checkbox" name="Head"  value="Other" <cfif #AssForm.Vision_M0390# contains 'Other'>checked</cfif>/> other...</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Short term memory</label><br />
							<div class="label-stable">
								<div id="Backd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Back"   value="0 - Impaired" <cfif #AssForm.Eating_M0710# contains '0 - Impaired'>checked</cfif>/> 0 - Impaired</label>
									<label>
									<input type="checkbox" name="Back"  name="Back"  value="1 - Appropriate for age" <cfif #AssForm.Eating_M0710# contains '1 - Appropriate for age'>checked</cfif>/> 1 - Appropriate for age</label>
								</div>
							</div>
						</div>
						<div class="form-group">
							<label>long term memory</label><br />
							<div class="label-stable">
								<div id="long_Backd" class="checkbox-list">
									<label>
									<input type="checkbox" name="long_Back"  value="0 - Impaired" <cfif #AssForm.Eating_M0710p# contains '0 - Impaired'>checked</cfif>/> 0 - Impaired</label>
									<label>
									<input type="checkbox" name="long_Back"  value="1 - Appropriate for age" <cfif #AssForm.Eating_M0710p# contains '1 - Appropriate for age'>checked</cfif>/> 1 - Appropriate for age</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-12">
						<h4><b>Cognition</b></h4>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Orientation</label><br />
							<div class="label-stable">
								<div id="Oriend" class="checkbox-list">
									<label>
									<input type="checkbox" name="Orien"  value="0 - Impaired" <cfif #AssForm.Meal_Prep_M0720# contains '0 - Impaired'>checked</cfif>/> 0 - Impaired</label>
									<label>
									<input type="checkbox" name="Orien"  value="1 - Appropriate for age" <cfif #AssForm.Meal_Prep_M0720# contains '1 - Appropriate for age'>checked</cfif>/> 1 - Appropriate for age</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Attention Span</label><br />
							<div class="label-stable">
								<div id="Attention_Spand" class="checkbox-list">
									<label>
									<input type="checkbox" name="Attention_Span"  value="0 - Impaired" <cfif #AssForm.Meal_Prep_M0720p# contains '0 - Impaired'>checked</cfif>/> 0 - Impaired</label>
									<label>
									<input type="checkbox" name="Attention_Span"  value="1 - Appropriate for age" <cfif #AssForm.Meal_Prep_M0720p# contains '1 - Appropriate for age'>checked</cfif>/> 1 - Appropriate for age</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Gastrointestinal</label><br />
							<div class="label-stable">
								<div id="Sided" class="checkbox-list">
									<label>
									<input type="checkbox" name="Side"  value="0 - Abdominal discoloration" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '0 - Abdominal discoloration'>checked</cfif>/> 0 - Abdominal discoloration</label>
									<label>
									<input type="checkbox" name="Side"  value="1 - Abdominal masses" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '1 - Abdominal masses'>checked</cfif>/> 1 - Abdominal masses</label>
									<label>
									<input type="checkbox" name="Side"  value="2 - Abdominal swelling" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '2 - Abdominal swelling'>checked</cfif>/> 2 - Abdominal swelling</label>
									<label>
									<input type="checkbox" name="Side"  value="3 - Abnormal bowel sounds" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '3 - Abnormal bowel sounds'>checked</cfif>/> 3 - Abnormal bowel sounds</label>
									<label>
									<input type="checkbox" name="Side"  value="4 - Abnormal labs" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '4 - Abnormal labs'>checked</cfif>/> 4 - Abnormal labs</label>
									<label>
									<input type="checkbox" name="Side"  value="5 - Bloody stools" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '5 - Bloody stools'>checked</cfif>/> 5 - Bloody stools</label>
									<label>
									<input type="checkbox" name="Side"  value="6 - Constipation" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '6 - Constipation'>checked</cfif>/> 6 - Constipation</label>
									<label>
									<input type="checkbox" name="Side"  value="7 - Diarrhea" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '7 - Diarrhea'>checked</cfif>/> 7 - Diarrhea</label>
									<label>
									<input type="checkbox" name="Side"  value="8 - Excessive stools per day" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '8 - Excessive stools per day'>checked</cfif>/> 8 - Excessive stools per day</label>
									<label>
									<input type="checkbox" name="Side"  value="9 - Gastric reflux" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '9 - Gastric reflux'>checked</cfif>/> 9 - Gastric reflux</label>
									<label>
									<input type="checkbox" name="Side"  value="10 - Hemorrhoids" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '10 - Hemorrhoids'>checked</cfif>/> 10 - Hemorrhoids</label>
									<label>
									<input type="checkbox" name="Side"  value="11 - Hernia" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '11 - Hernia'>checked</cfif>/> 11 - Hernia</label>
									<label>
									<input type="checkbox" name="Side"  value="12 - Nausea/vomiting" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '12 - Nausea/vomiting'>checked</cfif>/> 12 - Nausea/vomiting</label>
									<label>
									<input type="checkbox" name="Side"  value="13 - Pain" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '13 - Pain'>checked</cfif>/> 13 - Pain</label>
									<label>
									<input type="checkbox" name="Side"  value="14 - Perirectal lesions" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '14 - Perirectal lesions'>checked</cfif>/> 14 - Perirectal lesions</label>
									<label>
									<input type="checkbox" name="Side"  value="15 - Perirectal masses" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '15 - Perirectal masses'>checked</cfif>/> 15 - Perirectal masses</label>
									<label>
									<input type="checkbox" name="Side"  value="16 - Umbilical cord abnormalities" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '16 - Umbilical cord abnormalities'>checked</cfif>/> 16 - Umbilical cord abnormalities</label>
									<label>
									<input type="checkbox" name="Side"  value="17 - Asymptomatic" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains '17 - Asymptomatic'>checked</cfif>/> 17 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Side"  value="Other" <cfif #AssForm.Pressure_Ulcer_Stage_M0460# contains 'Other'>checked</cfif>/> Other...</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Genito-Urinary</label><br />
							<div class="label-stable">
								<div id="Coordinationd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Coordination"  value="0 - Abnormal urine frequency"  <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '0 - Abnormal urine frequency'>checked</cfif>/> 0 - Abnormal urine frequency</label>
									<label>
									<input type="checkbox" name="Coordination"  value="1 - Maximum assist" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '1 - Maximum assist'>checked</cfif>/> 1 - Maximum assist</label>
									<label>
									<input type="checkbox" name="Coordination"  value="2 - Excessive wet diapers" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '2 - Excessive wet diapers'>checked</cfif>/> 2 - Excessive wet diapers</label>
									<label>
									<input type="checkbox" name="Coordination"  value="3 - Excoriation of surrounding skin" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '3 - Excoriation of surrounding skin'>checked</cfif>/> 3 - Excoriation of surrounding skin</label>
									<label>
									<input type="checkbox" name="Coordination"  value="4 - Foul urine odor" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '4 - Foul urine odor'>checked</cfif>/> 4 - Foul urine odor</label>
									<label>
									<input type="checkbox" name="Coordination"  value="5 - Severe urge to urinate, distended bladder, restlessness" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '5 - Severe urge to urinate, distended bladder, restlessness'>checked</cfif>/> 5 - Severe urge to urinate, distended bladder, restlessness</label>
									<label>
									<input type="checkbox" name="Coordination"  value="6 - Tanner stage inconsistent with age" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '6 - Tanner stage inconsistent with age'>checked</cfif>/> 6 - Tanner stage inconsistent with age</label>
									<label>
									<input type="checkbox" name="Coordination"  value="7 - Urine color dark" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '7 - Urine color dark'>checked</cfif>/> 7 - Urine color dark</label>
									<label>
									<input type="checkbox" name="Coordination"  value="8 - Asymptomatic" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains '8 - Asymptomatic'>checked</cfif>/> 8 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Coordination"  value="Other" <cfif #AssForm.Stasis_Ulcer_Num_M0470# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
						<div class="form-group">
							<label>Female</label><br />
							<div class="label-stable">
								<div id="Graspd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Grasp" value="0 - Non-menstrual bleeding" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '0 - Non-menstrual bleeding'>checked</cfif> /> 0 - Non-menstrual bleeding</label>
									<label>
									<input type="checkbox"  name="Grasp" value="1 - Pelvic pain" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '1 - Pelvic pain'>checked</cfif>/> 1 - Pelvic pain</label>
									<label>
									<input type="checkbox" name="Grasp" value="2 - Vaginal discharge" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '2 - Vaginal discharge'>checked</cfif>/> 2 - Vaginal discharge</label>
									<label>
									<input type="checkbox"  name="Grasp" value="3 - Vaginal lesions" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '3 - Vaginal lesions'>checked</cfif>/> 3 - Vaginal lesions</label>
									<label>
									<input type="checkbox"  name="Grasp" value="4 - Vaginal masses" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '4 - Vaginal masses'>checked</cfif>/> 4 - Vaginal masses</label>
									<label>
									<input type="checkbox"  name="Grasp" value="5 - Asymptomatic" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains '5 - Asymptomatic'>checked</cfif>/> 5 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Grasp" value="Other" <cfif #AssForm.Stasis_Ulcer_Hidden_M0474# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Male</label><br />
							<div class="label-stable">
								<div id="UPPER_Reachd" class="checkbox-list">
									<label>
									<input type="checkbox" name="UPPER_Reach" value="0 - Circumsized"  <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '0 - Circumsized'>checked</cfif> /> 0 - Circumsized</label>
									<label>
									<input type="checkbox" name="UPPER_Reach" value="1 - Cysts" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '1 - Cysts'>checked</cfif> /> 1 - Cysts</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="2 - Discharge" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '2 - Discharge'>checked</cfif>/> 2 - Discharge</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="3 - Edema" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '3 - Edema'>checked</cfif>/> 3 - Edema</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="4 - Erythemas" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '4 - Erythemas'>checked</cfif>/> 4 - Erythemas</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="5 - Hydrocele" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '5 - Hydrocele'>checked</cfif>/> 5 - Hydrocele</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="6 - Inguinal hernia" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '6 - Inguinal hernia'>checked</cfif>/> 6 - Inguinal hernia</label>
									<label>
									<input type="checkbox" name="UPPER_Reach" value="7 - Lesions"  <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '7 - Lesions'>checked</cfif>/> 7 - Lesions</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="8 - Phimosis" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '8 - Phimosis'>checked</cfif>/> 8 - Phimosis</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="9 - Ulcerations" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '9 - Ulcerations'>checked</cfif>/> 9 - Ulcerations</label>
									<label>
									<input type="checkbox" name="UPPER_Reach" value="10 - Undescended testes"  <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '10 - Undescended testes'>checked</cfif>/> 10 - Undescended testes</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="11 - Asymptomatic" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains '11 - Asymptomatic'>checked</cfif>/> 11 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="UPPER_Reach"  value="Other" <cfif #AssForm.Stasis_Ulcer_Status_M0476# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Musculo-Skeletal</label><br />
							<div class="label-stable">
								<div id="UPPER_Mouthd" class="checkbox-list">
									<label>
									<input type="checkbox" name="UPPER_Mouth" value="0 - Abnormal gait and station" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '0 - Abnormal gait and station'>checked</cfif> /> 0 - Abnormal gait and station</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth" value="1 - Deformities" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '1 - Deformities'>checked</cfif>/> 1 - Deformities</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth" value="2 - Hands to midline" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '2 - Hands to midline'>checked</cfif> /> 2 - Hands to midline</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="3 - Impaired coordination" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '3 - Impaired coordination'>checked</cfif>/> 3 - Impaired coordination</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="4 - Kyphosis" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '4 - Kyphosis'>checked</cfif>/> 4 - Kyphosis</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="5 - Limited muscle strength" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '5 - Limited muscle strength'>checked</cfif>/> 5 - Limited muscle strength</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="6 - Limited range of motion" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '6 - Limited range of motion'>checked</cfif>/> 6 - Limited range of motion</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="7 - multiple falls in the" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '7 - multiple falls in the'>checked</cfif>/> 7 - multiple falls in the</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="8 - Scoliosis" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '8 - Scoliosis'>checked</cfif>/> 8 - Scoliosis</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="9 - Simian crease" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '9 - Simian crease'>checked</cfif>/> 9 - Simian crease</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="10 - sydney palm crease" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '10 - sydney palm crease'>checked</cfif>/> 10 - sydney palm crease</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="11 - Trendelenburg gait" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '11 - Trendelenburg gait'>checked</cfif>/> 11 - Trendelenburg gait</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="12 - Weakness" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '12 - Weakness'>checked</cfif>/> 12 - Weakness</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="13 - Asymptomatic" <cfif #AssForm.Surgical_Wound_Status_M0488# contains '13 - Asymptomatic'>checked</cfif>/> 13 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="UPPER_Mouth"  value="Other" <cfif #AssForm.Surgical_Wound_Status_M0488# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Cardiac</label><br />
							<div class="label-stable">
								<div id="UPPER_Headd" class="checkbox-list">
									<label>
									<input type="checkbox" name="UPPER_Head"  value="0 - Diminished heart sounds" <cfif #AssForm.Breathing_M0490# contains '0 - Diminished heart sounds'>checked</cfif>/> 0 - Diminished heart sounds</label>
									<label>
									<input type="checkbox" name="UPPER_Head" value="1 - Edema" <cfif #AssForm.Breathing_M0490# contains '1 - Edema'>checked</cfif> /> 1 - Edema</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="2 - Irregular heart rate" <cfif #AssForm.Breathing_M0490# contains '2 - Irregular heart rate'>checked</cfif>/> 2 - Irregular heart rate</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="3 - Loud heart sounds" <cfif #AssForm.Breathing_M0490# contains '3 - Loud heart sounds'>checked</cfif>/> 3 - Loud heart sounds</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="4 - Murmurs, clicks or rubs" <cfif #AssForm.Breathing_M0490# contains '4 - Murmurs, clicks or rubs'>checked</cfif>/> 4 - Murmurs, clicks or rubs</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="5 - Poor capillary refill" <cfif #AssForm.Breathing_M0490# contains '5 - Poor capillary refill'>checked</cfif>/> 5 - Poor capillary refill</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="6 - Weak femoral pulse" <cfif #AssForm.Breathing_M0490# contains '6 - Weak femoral pulse'>checked</cfif>/> 6 - Weak femoral pulse</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="7 - Asymptomatic" <cfif #AssForm.Breathing_M0490# contains '7 - Asymptomatic'>checked</cfif>/> 7 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="UPPER_Head"  value="Other" <cfif #AssForm.Breathing_M0490# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Respiratory</label><br />
							<div class="label-stable">
								<div id="Respiratoryd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Respiratory"  value="0 - Cyanosis" <cfif #AssForm.Urinary_INcont_M0520# contains '0 - Cyanosis'>checked</cfif>/> 0 - Cyanosis</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="1 - Dullness on percussion" <cfif #AssForm.Urinary_INcont_M0520# contains '1 - Dullness on percussion'>checked</cfif>/> 1 - Dullness on percussion</label>
									<label>
									<input type="checkbox" name="Respiratory" value="2 - Excessive respiratory effort" <cfif #AssForm.Urinary_INcont_M0520# contains '2 - Excessive respiratory effort'>checked</cfif> /> 2 - Excessive respiratory effort</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="3 - Expiratory wheezes, rales and/or rhonchi" <cfif #AssForm.Urinary_INcont_M0520# contains '3 - Expiratory wheezes, rales and/or rhonchi'>checked</cfif>/> 3 - Expiratory wheezes, rales and/or rhonchi</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="4 - Inspiratory wheezes, rales and/or rhonchi" <cfif #AssForm.Urinary_INcont_M0520# contains '4 - Inspiratory wheezes, rales and/or rhonchi'>checked</cfif>/> 4 - Inspiratory wheezes, rales and/or rhonchi</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="5 - Irregular heart rate" <cfif #AssForm.Urinary_INcont_M0520# contains '5 - Irregular heart rate'>checked</cfif>/> 5 - Irregular heart rate</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="6 - Irregular lung sounds" <cfif #AssForm.Urinary_INcont_M0520# contains '6 - Irregular lung sounds'>checked</cfif>/> 6 - Irregular lung sounds</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="7 - Retractions" <cfif #AssForm.Urinary_INcont_M0520# contains '7 - Retractions'>checked</cfif>/> 7 - Retractions</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="8 - Asymptomatic" <cfif #AssForm.Urinary_INcont_M0520# contains '8 - Asymptomatic'>checked</cfif>/> 8 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Respiratory"  value="Other" <cfif #AssForm.Urinary_INcont_M0520# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				<div class="row">
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
						<div class="form-group">
							<label>Neurological</label><br />
							<div class="label-stable">
								<div id="Impairedd" class="checkbox-list">
									<label>
									<input type="checkbox" name="Impaired"  value="0 - Impaired smelling CN 1" <cfif #AssForm.Resp_Treatments_M0500# contains '0 - Impaired smelling CN 1'>checked</cfif>/> 0 - Impaired smelling CN 1</label>
									<label>
									<input type="checkbox" name="Impaired"  value="1 - Reduced visual acuity CN 2" <cfif #AssForm.Resp_Treatments_M0500# contains '1 - Reduced visual acuity CN 2'>checked</cfif>/> 1 - Reduced visual acuity CN 2</label>
									<label>
									<input type="checkbox" name="Impaired" value="2 - Abnormal pupil response CN 3" <cfif #AssForm.Resp_Treatments_M0500# contains '2 - Abnormal pupil response CN 3'>checked</cfif> /> 2 - Abnormal pupil response CN 3</label>
									<label>
									<input type="checkbox" name="Impaired"  value="3 - Abnormal up/down diagonal gaze CN 4" <cfif #AssForm.Resp_Treatments_M0500# contains '3 - Abnormal up/down diagonal gaze CN 4'>checked</cfif>/> 3 - Abnormal up/down diagonal gaze CN 4</label>
									<label>
									<input type="checkbox" name="Impaired"  value="4 - Absent corneal reflex, cant clench teeth CN 5" <cfif #AssForm.Resp_Treatments_M0500# contains '4 - Absent corneal reflex, cant clench teeth CN 5'>checked</cfif>/> 4 - Absent corneal reflex, can't clench teeth CN 5</label>
									<label>
									<input type="checkbox" name="Impaired"  value="5 - Abnormal lateral gaze CN 6" <cfif #AssForm.Resp_Treatments_M0500# contains '5 - Abnormal lateral gaze CN 6'>checked</cfif>/> 5 - Abnormal lateral gaze CN 6</label>
									<label>
									<input type="checkbox" name="Impaired"  value="6 - Asymm. smile, blinking, facial move., tasting CN 7" <cfif #AssForm.Resp_Treatments_M0500# contains '6 - Asymm. smile, blinking, facial move., tasting CN 7'>checked</cfif>/> 6 - Asymm. smile, blinking, facial move., tasting CN 7</label>
									<label>
									<input type="checkbox" name="Impaired"  value="7 - Impaired hearing CN 8" <cfif #AssForm.Resp_Treatments_M0500# contains '7 - Impaired hearing CN 8'>checked</cfif>/> 7 - Impaired hearing CN 8</label>
									<label>
									<input type="checkbox" name="Impaired"  value="8 - Impaired taste, absent gag reflex CN 9" <cfif #AssForm.Resp_Treatments_M0500# contains '8 - Impaired taste, absent gag reflex CN 9'>checked</cfif>/> 8 - Impaired taste, absent gag reflex CN 9</label>
									<label>
									<input type="checkbox" name="Impaired"  value="9 - Abnormal soft palate or uvula rise CN 10" <cfif #AssForm.Resp_Treatments_M0500# contains '9 - Abnormal soft palate or uvula rise CN 10'>checked</cfif>/> 9 - Abnormal soft palate or uvula rise CN 10</label>
									<label>
									<input type="checkbox" name="Impaired"  value="10 - can shrug against resistance CN 11" <cfif #AssForm.Resp_Treatments_M0500# contains '10 - can shrug against resistance CN 11'>checked</cfif>/> 10 - can shrug against resistance CN 11</label>
									<label>
									<input type="checkbox" name="Impaired"  value="11 - tongue deviation CN 12" <cfif #AssForm.Resp_Treatments_M0500# contains '11 - tongue deviation CN 12'>checked</cfif>/> 11 - tongue deviation CN 12</label>
									<label>
									<input type="checkbox" name="Impaired"  value="12 - Absent reflexes" <cfif #AssForm.Resp_Treatments_M0500# contains '12 - Absent reflexes'>checked</cfif>/> 12 - Absent reflexes</label>
									<label>
									<input type="checkbox" name="Impaired"  value="13 - Atnr reflex not present" <cfif #AssForm.Resp_Treatments_M0500# contains '13 - Atnr reflex not present'>checked</cfif>/> 13 - Atnr reflex not present</label>
									<label>
									<input type="checkbox" name="Impaired"  value="14 - babinksi reflex not present" <cfif #AssForm.Resp_Treatments_M0500# contains '14 - babinksi reflex not present'>checked</cfif>/> 14 - babinksi reflex not present</label>
									<label>
									<input type="checkbox" name="Impaired"  value="15 - Dizziness" <cfif #AssForm.Resp_Treatments_M0500# contains '15 - Dizziness'>checked</cfif>/> 15 - Dizziness</label>
									<label>
									<input type="checkbox" name="Impaired"  value="16 - Fixed or unequal pupils" <cfif #AssForm.Resp_Treatments_M0500# contains '16 - Fixed or unequal pupils'>checked</cfif>/> 16 - Fixed or unequal pupils</label>
									<label>
									<input type="checkbox" name="Impaired"  value="17 - Headaches" <cfif #AssForm.Resp_Treatments_M0500# contains '17 - Headaches'>checked</cfif>/> 17 - Headaches</label>
									<label>
									<input type="checkbox" name="Impaired"  value="18 - Hyperactive reflexes" <cfif #AssForm.Resp_Treatments_M0500# contains '18 - Hyperactive reflexes'>checked</cfif>/> 18 - Hyperactive reflexes</label>
									<label>
									<input type="checkbox" name="Impaired"  value="19 - Protective reflexes not present" <cfif #AssForm.Resp_Treatments_M0500# contains '19 - Protective reflexes not present'>checked</cfif>/> 19 - Protective reflexes not present</label>
									<label>
									<input type="checkbox" name="Impaired"  value="20 - Seizures" <cfif #AssForm.Resp_Treatments_M0500# contains '20 - Seizures'>checked</cfif>/> 20 - Seizures</label>
									<label>
									<input type="checkbox" name="Impaired"  value="21 - Spasms" <cfif #AssForm.Resp_Treatments_M0500# contains '21 - Spasms'>checked</cfif>/> 21 - Spasms</label>
									<label>
									<input type="checkbox" name="Impaired"  value="22 - Stepping reflex not present" <cfif #AssForm.Resp_Treatments_M0500# contains '22 - Stepping reflex not present'>checked</cfif>/> 22 - Stepping reflex not present</label>
									<label>
									<input type="checkbox" name="Impaired"  value="23 - Tremors" <cfif #AssForm.Resp_Treatments_M0500# contains '23 - Tremors'>checked</cfif>/> 23 - Tremors</label>
									<label>
									<input type="checkbox" name="Impaired"  value="24 - Weakness" <cfif #AssForm.Resp_Treatments_M0500# contains '24 - Weakness'>checked</cfif>/> 24 - Weakness</label>
									<label>
									<input type="checkbox" name="Impaired"  value="25 - Asymptomatic" <cfif #AssForm.Resp_Treatments_M0500# contains '25 - Asymptomatic'>checked</cfif>/> 25 - Asymptomatic</label>
									<label>
									<input type="checkbox" name="Impaired"  value="Others" <cfif #AssForm.Resp_Treatments_M0500# contains 'Others'>checked</cfif>/> Others..</label>
								</div>
							</div>
						</div>
					</div>
					<div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">

						<div class="form-group">
							<label> Home Safety</label><br />
							<div class="label-stable">
								<div id="ENVIRONMENTd" class="checkbox-list">
									<label>
									<input type="checkbox" name="ENVIRONMENT" value="Unsafe stairs and/or doorways" <cfif #AssForm.Housekeeping_M0750# contains 'Unsafe stairs and/or doorways'>checked</cfif>  /> Unsafe stairs and/or doorways</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Rugs, cords and/or furniture causing safety risk" <cfif #AssForm.Housekeeping_M0750# contains 'Rugs, cords and/or furniture causing safety risk'>checked</cfif>/> Rugs, cords and/or furniture causing safety risk</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT" value="Inadequate heating and/or cooling" <cfif #AssForm.Housekeeping_M0750# contains 'Inadequate heating and/or cooling'>checked</cfif>/> Inadequate heating and/or cooling</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT" value="Unsafe appliances" <cfif #AssForm.Housekeeping_M0750# contains 'Unsafe appliances'>checked</cfif>/> Unsafe appliances</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Inadequate sanitation and/or plumbing" <cfif #AssForm.Housekeeping_M0750# contains 'Inadequate sanitation and/or plumbing'>checked</cfif>/> Inadequate sanitation and/or plumbing</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Inadequate refrigeration" <cfif #AssForm.Housekeeping_M0750# contains 'Inadequate refrigeration'>checked</cfif>/> Inadequate refrigeration</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Presence of insects and/or rodents" <cfif #AssForm.Housekeeping_M0750# contains 'Presence of insects and/or rodents'>checked</cfif>/> Presence of insects and/or rodents</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Inadequate smoke detectors" <cfif #AssForm.Housekeeping_M0750# contains 'Inadequate smoke detectors'>checked</cfif>/> Inadequate smoke detectors</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT" value="O2 in use without precautions" <cfif #AssForm.Housekeeping_M0750# contains 'O2 in use without precautions'>checked</cfif>/> O2 in use without precautions</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT"  value="Home has no hazards" <cfif #AssForm.Housekeeping_M0750# contains 'Home has no hazards'>checked</cfif>/> Home has no hazards</label>
									<label>
									<input type="checkbox" name="ENVIRONMENT" value="Other" <cfif #AssForm.Housekeeping_M0750# contains 'Other'>checked</cfif>/> Other..</label>
								</div>
							</div>
						</div>
					</div>
				</div>
				 <!--- Pain Assessment start--->
											 <div class="portlet box green">
														<div class="portlet-title">
															<div class="caption">
																<i class="fa fa-gear"></i>
																<cfif AssForm.M0420_Assess EQ 'No Pain'>
																	No Pain
																<cfelseif AssForm.M0420_Assess NEQ "" AND AssForm.Pain1 NEQ "" AND AssForm.Pain2 NEQ "" AND AssForm.Pain3 NEQ "" AND AssForm.Pain4 NEQ "" AND AssForm.Pain5 NEQ "">
																	Pain Assessment
																<cfelse>
																	Pain assessment incomplete
																</cfif>
															</div>
															<div class="tools">
															 <a href="javascript:;" class="expand"></a>
															 </div>
														</div>
														<div class="portlet-body" style="display:none">
															 <cfoutput query="get_pain_que">
																			   <div class="col-lg-6 col-md-6 col-sm-6 col-xs-12">
																						  <label class="bold">#get_pain_que.questions#</label>
																							<cfscript>
																							   get_pain_anw = pat.get_pain_anw(#get_pain_que.id#); 
																							</cfscript>
																							<div class="form-group">
																							 <cfset  cheked_value = "AssForm."&get_pain_anw.answer_label />
																							<cfloop query="get_pain_anw">
																								<cfif answer_type EQ 'radio'>
																													   <div class="radio-list">
																															   <label> <input type="#answer_type#" name="#answer_label#" id="#answer_label#" value="#answer#" <cfif #Evaluate(Variables.cheked_value)#  EQ  #answer#>checked </cfif>><span>#answer#</span></label>
																														</div>
																										<cfelseif answer_type EQ 'checkbox'>
																														   <div class="checkbox-list">
																															  <label><input type="#answer_type#"  name="#answer_label#" id="#answer_label#" value="#answer#" <cfif #Evaluate(Variables.cheked_value)#  Contains  #answer#>checked</cfif>>#answer#
																															 </label>
																														</div>
																										</cfif>
																								</cfloop>
																							</div>
																					</div>
															</cfoutput>
																			  <table style="text-align:center;">
																					<tr>
																						<td width="10%">
																							<img src="../../images/smily0.gif" />
																						</td>
																						<td width="10%">
																							<img src="../../images/smily2.gif"/>
																						</td>
																						<td width="10%">
																							<img src="../../images/smily4.gif" />
																						</td>
																						<td width="10%">
																							<img src="../../images/smily6.gif"/>
																						</td>
																						<td width="10%">
																							<img src="../../images/smily8.gif" />
																						</td>
																						<td width="10%">
																							<img src="../../images/smily10.gif"/>
																						</td>
																					</tr>
																					<tr>
																						<td  width="10%">0</td>
																						<td width="10%">2</td>
																						<td width="10%">4</td>
																						<td width="10%">6</td>
																						<td width="10%">8</td>
																						<td width="10%">10</td>
																					</tr>
																				</table>
																				<p style="color:red">
																					<cfif AssForm.M0420_Assess NEQ "" AND AssForm.Pain1 NEQ "" AND AssForm.Pain2 NEQ "" AND AssForm.Pain3 NEQ "" AND AssForm.Pain4 NEQ "" AND AssForm.Pain5 NEQ "">
																						pain assessment indicates #AssForm.M0420_Assess# #AssForm.Pain2# requiring medication every as  needed pain relief resolves pain
																					<cfelse>
																						Pain assessment incomplete
																					</cfif>
																				</p>
																		<div class="form-actions">
																			 <input class="btn blue" type="button" name="pain" value="Update Pain Level" onclick="return other_assessment_validation('pain');">
																	 </div>
																	 </div>
												   </div>
									  <!---  Pain Assessment End--->
				<div class="form-group">
					<label>Comments</label>
					<textarea class="form-control" style="width:100%;max-width:100%;height:80px;" name="txtComment" id="txtComment" onBlur="ChangeBlur('otupdate','txtComment')" rows="3"><cfoutput>#AssForm.Assessment_note#</cfoutput></textarea>
				</div>
            </div>
			</div>
            <div class="form-actions">
                <cfoutput>
                    <input type="hidden" id="M1010Diagnosisid" name="M1010Diagnosisid" value=""/>
                    <input type="hidden" id="codetype" name="codetype" value=""/>
                    <input type="hidden" id="txtAssId" name="txtAssId" value="#AssForm.Assessment_ID#"/>
                    <input type="hidden" id="M1010updateF" name="M1010updateF" value=""/>
					<input type="hidden"  name="txtfocus1" id="txtfocus1" value=""/>
					<input type="hidden" name="tmp" id="tmp" value=""/>
                </cfoutput>
                <cfset Transmission_status=AssForm.Transmission_status />
                <cfif #UCASE(Transmission_status)# neq "DATASET HAS BEEN TRANSMITTED." AND #UCASE(Transmission_status)# neq "READY TO TRANSMIT">
                	<input class="btn blue" type="submit" name="Submit" value="Update" onClick="return check();">
                </cfif>
                <input class="btn default" type="button" name="Cancel" value="Cancel" onclick="window.location='index.cfm?page=patient&ID=<cfoutput>#Session.CS.PatientID#</cfoutput>&cat=Patient'" />
			</div>
        </cfform>
	</div>
</div>



<cfinclude template="/patientadmin_new/patient/M0230Diagnosis.cfm" />
<cfinclude template="/patientadmin_new/patient/vitaladd.cfm" />
<cfinclude template="/patientadmin_new/patient/woundsadd.cfm" />
<cfinclude template="/Scripts/assessment_form/snpediatricform.cfm">