<!-- BEGIN outreach/questionnaire/general.tt -->
<div class="indent">
<h4 class="blue">General assessment:</h4>
<table class="xborders">
<tr>
<td class="title" align="right" valign="top">Recent hospital referral:</td>
<td valign="top">
Yes <input type="radio" name="hospital_referral" value="Y"
[% 'checked' IF questionnaire.hospital_referral == 'Y' %] />
No <input type="radio" name="hospital_referral" value="N"
[% 'checked' UNLESS questionnaire.hospital_referral == 'Y' %] />
[% error_hospital_referral %]
</td>
<td>
<div class="bold">Details:</div>
<textarea name="hospital_referral_details" rows="1"
cols="40">[% questionnaire.details.hospital_referral %]</textarea>
[% error_hospital_referral_details %]
</td>
</tr>
<tr>
<td class="title" align="right" valign="top">New medication:</td>
<td valign="top">
Yes <input type="radio" name="new_medication" value="Y"
[% 'checked' IF questionnaire.new_medication == 'Y' %] />
No <input type="radio" name="new_medication" value="N"
[% 'checked' UNLESS questionnaire.new_medication == 'Y' %] />
[% error_new_medication %]
</td>
<td>
<div class="bold">Details:</div>
<textarea name="new_medication_details" rows="1"
cols="40">[% questionnaire.details.new_medication %]</textarea>
[% error_new_medication_details %]
</td>
</tr>
<tr>
<td class="title" align="right" valign="top">Serious infection:</td>
<td valign="top">
Yes <input type="radio" name="serious_infection" value="Y"
[% 'checked' IF questionnaire.serious_infection == 'Y' %] />
No <input type="radio" name="serious_infection" value="N"
[% 'checked' UNLESS questionnaire.serious_infection == 'Y' %] />
[% error_serious_infection %]
</td>
<td>
<div class="bold">Details:</div>
<textarea name="serious_infection_details" rows="1"
cols="40">[% questionnaire.details.serious_infection %]</textarea>
[% error_serious_infection_details %]
</td>
</tr>
<tr>
<td class="title" align="right" valign="top">Weight loss:</td>
<td valign="top">
Yes <input type="radio" name="weight_loss" value="Y"
[% 'checked' IF questionnaire.weight_loss == 'Y' %] />
No <input type="radio" name="weight_loss" value="N"
[% 'checked' UNLESS questionnaire.weight_loss == 'Y' %] />
[% error_weight_loss %]
</td>
<td>
[% IF error_weight %]
<div class="red">[% c.cfg('msg').require_one %] »</div>
[% END %]
[% class = error_weight ? 'input_error' : 'normal' %]
<span class="acronym" title="default value: 999"><b>Weight</b></span>
<input type="text" name="weight" value="[% questionnaire.weight %]"
class="[% class %]" size=5 /> kg <b>- OR -</b>
Stones: <input type="text" name="imperial_stones" class="[% class %]" size="5" />
Pounds: <input type="text" name="imperial_pounds" size="5" />
</td>
</tr>
<tr>
<td class="title" align="right" valign="top">Night sweats:</td>
<td valign="top">
<select name="night_sweats">
<option value="">--select one--</option>
[% FOREACH opt IN outreach.menu_options.sweats %]
<option value="[% opt %]"
[% 'selected' IF questionnaire.night_sweats == opt %]>
[% opt %]
</option>
[% END %]
</select>
[% error_night_sweats %]
</td>
<td>
<b>Persistent: </b>
Yes <input type="radio" name="persistent_night_sweats" value="Y"
[% 'checked' IF questionnaire.persistent_night_sweats == 'Y' %] />
No <input type="radio" name="persistent_night_sweats" value="N"
[% 'checked' UNLESS questionnaire.persistent_night_sweats == 'Y' %] />
[% error_persistent_night_sweats %]
</td>
</tr>
</table>
</div>
<!-- BEGIN outreach/questionnaire/general.tt -->