% url = Request.QueryString("name") name = Request.Form("name") gender = Request.Form("gender") age = Request.Form("age") martialstatus = Request.Form("martialstatus") noofissues = Request.Form("issues") profession = Request.Form("profession") street1 = Request.Form("street1") street2 = Request.Form("street2") city = Request.Form("city") state = Request.Form("state") zip = Request.Form("zip") country = Request.Form("country") telephone = Request.Form("telephone") fax = Request.Form("fax") email = Request.Form("email") hereditary=Request.Form("hereditary") bone=Request.Form("bone") thyroid=Request.Form("thyroid") kidney=Request.Form("kidney") diabetes=Request.Form("diabetes") cancer=Request.Form("cancer") stomach=Request.Form("stomach") polio=Request.Form("polio") immune=Request.Form("immune") liver=Request.Form("liver") aids=Request.Form("aids") std=Request.Form("std") neuro=Request.Form("neuro") mental=Request.Form("mental") vision=Request.Form("vision") weight=Request.Form("weight") bleeding=Request.Form("bleeding") bp=Request.Form("bp") tires=Request.Form("tires") chest=Request.Form("chest") heart=Request.Form("heart") heart1=Request.Form("heart1") diet=Request.Form("diet") cold=Request.Form("cold") eye=Request.Form("eye") asthama=Request.Form("asthama") tonsil=Request.Form("tonsil") allergy=Request.Form("allergy") medication=Request.Form("medication") operations=Request.Form("operations") healthcare=Request.Form("healthcare") menstrual=Request.Form("menstrual") pregnant=Request.Form("pregnant") yes = "" dis_name = "
| Any Hereditary problem or Birth defect: | " if not(hereditary = yes) then dis_name = dis_name & hereditary & " |
| Bone Fractures, any major accidents: | " if not(bone = yes) then dis_name = dis_name & bone & " |
| Endocrine or thyroid problems? | " if not(thyroid = yes) then dis_name = dis_name & thyroid & " |
| Kidney problems? | " if not(kidney = yes) then dis_name = dis_name & kidney & " |
| Do you have Diabetes? | " if not(diabetes = yes) then dis_name = dis_name & diabetes & " |
| Cancer or been treated for a tumor? | " if not(cancer = yes) then dis_name = dis_name & cancer & " |
| Stomach ulcer or hyperacidity? | " if not(stomach = yes) then dis_name = dis_name & stomach & " |
| Polio, mononucleosis, tuberculosis, pneumonia? | " if not(polio = yes) then dis_name = dis_name & polio & " |
| Problems of the immune system? | " if not(immune = yes) then dis_name = dis_name & immune & " |
| Hepatitis, jaundice or liver problem? | " if not(liver = yes) then dis_name = dis_name & liver & " |
| AIDS or HIV Positive? | " if not(aids = yes) then dis_name = dis_name & aids & " |
| Sexually transmitted disease? | " if not(std = yes) then dis_name = dis_name & std & " |
| Fainting spells, seizures, epilepsy or neurologic disease? | " if not(neuro = yes) then dis_name = dis_name & neuro & " |
| Mental health or behavioral problems? | " if not(mental = yes) then dis_name = dis_name & mental & " |
| Vision, hearing, tasting or speech difficulties? | " if not(vision = yes) then dis_name = dis_name & vision & " |
| Loss of weight recently, poor appetite? | " if not(weight = yes) then dis_name = dis_name & weight & " |
| Excessive bleeding, black and blue tendency, anemia or bleeding disorder? | " if not(bleeding = yes) then dis_name = dis_name & bleeding & " |
| High or low blood pressure? | " if not(bp = yes) then dis_name = dis_name & bp & " |
| Tires easily? | " if not(tires = yes) then dis_name = dis_name & tires & " |
| Chest pain, shortness of breath or swelling ankles? | " if not(chest = yes) then dis_name = dis_name & chest & " |
| Damaged heart valves or artificial heart valves, including heart murmur or rheumatic heart disease, scarlet fever, artificial joints? | " if not(heart = yes) then dis_name = dis_name & heart & " |
| Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke?) | " if not(heart1 = yes) then dis_name = dis_name & heart1 & " |
| Does patient have a normal and good diet? | " if not(diet = yes) then dis_name = dis_name & diet & " |
| Frequent headaches, colds or sore throat? | " if not(cold = yes) then dis_name = dis_name & cold & " |
| Eye, ear, nose, throat conditions? | " if not(eye = yes) then dis_name = dis_name & eye & " |
| Hayfever, asthma, sinus trouble, hives? | " if not(asthama = yes) then dis_name = dis_name & asthama & " |
| Tonsil or adenoid conditions? | " if not(tonsil = yes) then dis_name = dis_name & tonsil & " |
| Allergies or drug reactions? If so, what? | " if not(allergy = yes) then dis_name = dis_name & allergy & " |
| Is patient taking medication, nutrient supplements or nonprescription medicine? | " if not(medication = yes) then dis_name = dis_name & medication & " |
| Operations? (surgical procedures)? | " if not(operations = yes) then dis_name = dis_name & operations & " |
| Being treated by another health care professional? | " if not(healthcare = yes) then dis_name = dis_name & healthcare & " |
| Has patient started her menstrual period? If yes, at what age? | " if not(menstrual = yes) then dis_name = dis_name & menstrual & " |
| Is patient pregnant? | " if not(pregnant = yes) then dis_name = dis_name & pregnant & " |
| Patients Detail | ||
| Patient's Name : | " & name & " | |
| Patient's Gender : | " & gender & " | |
| Age : | " & age body = body & " | >|
| Marrital Status : | " & martialstatus & " if married no&of issues :" & noofissues & " | |
| Profession : | " & profession & " | >|
| Street1 : | " & street1 & " Street2 : " & street2 body = body & " | |
| City : | " & city & " | |
| State : | " & state & " | |
| Zip : | " & zip & " | |
| Country : | " & country body = body & " | |
| Telephone : | " & telephone & " | |
| Fax : | " & fax & " | |
| Email : | " & email & " | |
| Medical Health History | |
| " & dis_name &" |
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