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<!-- BEGIN [% component.name %] -->
  <div class="indent">
    <h4 class="blue">General assessment:</h4>
    
    <table class="xborders">
	  <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.symptoms.weight_loss == 'Y' %] />
	      No <input type="radio" name="weight_loss" value="N"
	        [% 'checked' IF questionnaire.symptoms.weight_loss == 'N' %] />
	        [% error_weight_loss %]
      </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.symptoms.night_sweats == opt %]>
		      [% opt %]
		    </option>
          [% END %]          
		</select>
        [% error_night_sweats %]
	  </td>
	</tr> 
	</table>
  </div>
<!-- BEGIN [% component.name %] -->