<div id="snhospicewizard3" style="display:none">
	<cfform name="formstep3" id="formstep3">
		<div class="form-body">
			<div class="margin-top-10 text-center">
				<ul class="pagination nav_pagination" style="margin:0;">
					<cfloop index=ind from="1" to="4">
						<cfoutput>
							<li class="nav_snhospicewizard#ind# <cfif ind eq 1>active</cfif>" onClick="$('##snhospicewizard3').hide(); $('##snhospicewizard#ind#').show(); $('.pagination li').removeClass('active'); $('.nav_snhospicewizard#ind#').addClass('active');">
								<a href="javascript:;">#ind#</a>
							</li>
						</cfoutput>
					</cfloop>
				</ul>
			
				<div class="dashboard-stat2 progress_div" style="margin: 0px auto; padding-top: 0px; max-width: 320px;">
					<div class="progress-info">
						<div class="progress" style="height: 9px">
							<span class="progress-bar progress-bar-success green-sharp">
								<span class="sr-only ">0% progress</span>
							</span>
						</div>
						<div class="status">
							<div class="status-title"> progress </div>
							<div class="status-number"> <span class="progressBar">0%</span> </div>
						</div>
					</div>
				</div>
			</div>
			
			<div class="well">
			<input type="text" style="width:0px;height:0px;border:0" name="txtfocus1" id="txtfocus1" value=""/>
			<div class="row">
				<div class="col-md-6">
					<div class="form-group">
						<div class="label-stable">
							<label>Cardio-Respiratory-Hematology</label>
							<div id="Cardiodiv" class="checkbox-list">
								<cfoutput>
									<label>
									<input type="checkbox" name="Cardio"  value="Abnormal lab results" <cfif #AssForm.M0490_Assess# contains 'Abnormal lab results'>checked</cfif>  /> Abnormal lab results</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Breath Sounds not clear" <cfif #AssForm.M0490_Assess# contains 'Breath Sounds not clear'>checked</cfif>  /> Breath Sounds not clear</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Dependent Edema" <cfif #AssForm.M0490_Assess# contains 'Dependent Edema'>checked</cfif>  /> Dependent Edema</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Dizziness, Headaches" <cfif #AssForm.M0490_Assess# contains 'Dizziness, Headaches'>checked</cfif>  /> Dizziness, Headaches</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Dyspnea, Shortness of breath" <cfif #AssForm.M0490_Assess# contains 'Dyspnea, Shortness of breath'>checked</cfif>  /> Dyspnea, Shortness of breath</label>
									<label>
									<input type="checkbox" name="Cardio"  value="High Blood Pressure" <cfif #AssForm.M0490_Assess# contains 'High Blood Pressure'>checked</cfif>  /> High Blood Pressure</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Nosebleeds" <cfif #AssForm.M0490_Assess# contains 'Nosebleeds'>checked</cfif>  /> Nosebleeds</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Palpitations, Diaphoresis" <cfif #AssForm.M0490_Assess# contains 'Palpitations, Diaphoresis'>checked</cfif>  /> Palpitations, Diaphoresis</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Sputum not Clear, Scant, Watery" <cfif #AssForm.M0490_Assess# contains 'Sputum not Clear, Scant, Watery'>checked</cfif>  /> Sputum not Clear, Scant, Watery</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Weakness/Fatigue" <cfif #AssForm.M0490_Assess# contains 'Weakness/Fatigue'>checked</cfif>  /> Weakness/Fatigue</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Asymptomatic" <cfif #AssForm.M0490_Assess# contains 'Asymptomatic'>checked</cfif>  /> Asymptomatic</label>
									<label>
									<input type="checkbox" name="Cardio"  value="Other" <cfif #AssForm.M0490_Assess# contains 'Other'>checked</cfif>  /> Other</label>
								</cfoutput>
							</div>
						</div>
					</div>
				</div>
				<div class="col-md-6">
					<div class="form-group">
						<div class="label-stable">
							<label>Genitourinary/Catheter</label>
							<div id="Genidiv" class="checkbox-list">
								<cfoutput>
									<label>
									<input type="checkbox" name="Geni"  value="Abnormal Lab results" <cfif #AssForm.M0520_Assess# contains 'Abnormal Lab results'>checked</cfif>  /> Abnormal Lab results</label>
									<label>
									<input type="checkbox" name="Geni"  value="Abnormal Urine frequency" <cfif #AssForm.M0520_Assess# contains 'Abnormal Urine frequency'>checked</cfif>  /> Abnormal Urine frequency</label>
									<label>
									<input type="checkbox" name="Geni"  value="Excoriation of surrounding skin" <cfif #AssForm.M0520_Assess# contains 'Excoriation of surrounding skin'>checked</cfif>  /> Excoriation of surrounding skin</label>
									<label>
									<input type="checkbox" name="Geni"  value="Genital Discharge" <cfif #AssForm.M0520_Assess# contains 'Genital Discharge'>checked</cfif>  /> Genital Discharge</label>
									<label>
									<input type="checkbox" name="Geni"  value="Genital Inflamm" <cfif #AssForm.M0520_Assess# contains 'Genital Inflamm'>checked</cfif>  /> Genital Inflamm</label>
									<label>
									<input type="checkbox" name="Geni"  value="Genital Lesions" <cfif #AssForm.M0520_Assess# contains 'Genital Lesions'>checked</cfif>  /> Genital Lesions</label>
									<label>
									<input type="checkbox" name="Geni"  value="Urine color not Pale Yellow" <cfif #AssForm.M0520_Assess# contains 'Urine color not Pale Yellow'>checked</cfif>  /> Urine color not Pale Yellow</label>
									<label>
									<input type="checkbox" name="Geni"  value="Urine Odor not Faint" <cfif #AssForm.M0520_Assess# contains 'Urine Odor not Faint'>checked</cfif>  /> Urine Odor not Faint</label>
									<label>
									<input type="checkbox" name="Geni"  value="Asymptomatic" <cfif #AssForm.M0520_Assess# contains 'Asymptomatic'>checked</cfif>  /> Asymptomatic</label>
									<label>
									<input type="checkbox" name="Geni"  value="Other" <cfif #AssForm.M0520_Assess# contains 'Other'>checked</cfif>  /> Other</label>
								</cfoutput>
							</div>
						</div>
					</div>
				</div>
			</div>
			<div class="row">
				<div class="col-md-6">
					<div class="form-group">
						<div class="label-stable">
							<label>Gastrointestinal</label>
							<div id="Gastrodiv" class="checkbox-list">
								<cfoutput>
									<label>
									<input type="checkbox" name="Gastro"  value="Abnormal Stool Lab" <cfif #AssForm.M0540_Assess# contains 'Abnormal Stool Lab'>checked</cfif>  /> Abnormal Stool Lab</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Bowel Sounds not Soft Gurgling 5-35/min" <cfif #AssForm.M0540_Assess# contains 'Bowel Sounds not Soft Gurgling 5-35/min'>checked</cfif>  /> Bowel Sounds not Soft Gurgling 5-35/min</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Constipation" <cfif #AssForm.M0540_Assess# contains 'Constipation'>checked</cfif>  /> Constipation</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Diarrhea" <cfif #AssForm.M0540_Assess# contains 'Diarrhea'>checked</cfif>  /> Diarrhea</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Excoriation of Surrounding Skin" <cfif #AssForm.M0540_Assess# contains 'Excoriation of Surrounding Skin'>checked</cfif>  /> Excoriation of Surrounding Skin</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Asymptomatic" <cfif #AssForm.M0540_Assess# contains 'Asymptomatic'>checked</cfif>  /> Asymptomatic</label>
									<label>
									<input type="checkbox" name="Gastro"  value="Other" <cfif #AssForm.M0540_Assess# contains 'Other'>checked</cfif>  /> Other</label>
								</cfoutput>
							</div>
						</div>
					</div>
				</div>
				<div class="col-md-6">
					<div class="form-group">
						<div class="label-stable">
							<label>Ostomy</label>
							<div id="Ostomydiv" class="checkbox-list">
								<cfoutput>
									<label>
									<input type="checkbox" name="Ostomy"  value="Constipation" <cfif #AssForm.M0550_Assess# contains 'Constipation'>checked</cfif>  /> Constipation</label>
									<label>
									<input type="checkbox" name="Ostomy"  value="Diarrhea" <cfif #AssForm.M0550_Assess# contains 'Diarrhea'>checked</cfif>  /> Diarrhea</label>
									<label>
									<input type="checkbox" name="Ostomy"  value="Excoriation of Surrounding Skin" <cfif #AssForm.M0550_Assess# contains 'Excoriation of Surrounding Skin'>checked</cfif>  /> Excoriation of Surrounding Skin</label>
									<label>
									<input type="checkbox" name="Ostomy"  value="Flatulence" <cfif #AssForm.M0550_Assess# contains 'Flatulence'>checked</cfif>  /> Flatulence</label>
									<label>
									<input type="checkbox" name="Ostomy"  value="Asymptomatic" <cfif #AssForm.M0550_Assess# contains 'Asymptomatic'>checked</cfif>  /> Asymptomatic</label>
									<label>
									<input type="checkbox" name="Ostomy"  value="Other" <cfif #AssForm.M0550_Assess# contains 'Other'>checked</cfif>  /> Other</label>
								</cfoutput>
							</div>
						</div>
					</div>
				</div>
			</div>
			<div class="form-group">
				<label>Comments</label>
				<cfoutput><textarea class="form-control" name="txtComment" id="txtComment" onBlur="ChangeBlur('formstep3','txtComment')" rows="3">#AssForm.Assessment_Note#</textarea></cfoutput>
			</div>			
		</div>
		</div>
		
		<div class="form-actions">
			<input class="btn blue" type="button" value="Previous" onClick="$('#snhospicewizard3').hide(); $('#snhospicewizard2').show();$('.pagination li').removeClass('active'); $('.nav_snhospicewizard2').addClass('active'); $('html, body').animate({scrollTop: '0px'}, 300);">
			<input class="btn default" type="button" value="Cancel" onClick="StepClose('3');">
			<input class="btn green" type="button" value="Next" onClick="UpdateSoc(3);">	
		</div>
	</cfform>
</div>