<!-- BEGIN outreach/questionnaire/pain.tt -->
    <div class="indent">
      <h4 class="blue">Pain assessment:</h4>
    
    <table class="xborders">
		<tr> 
			<td class="title" align="right" valign="top">Bone pain, ribs:</td> 
			<td valign="top"> 
				<select name="rib_pain"> 
					<option value="">--select one--</option> 
          [% FOREACH opt IN outreach.menu_options.pain %]
					<option value="[% opt %]"
              [% 'selected' IF questionnaire.rib_pain == opt %]>
            [% opt %]
          </option>
          [% END %]          
				</select>
                [% error_rib_pain %]
			</td>
      
			<td> 
				<b>Persistent: </b>            
        Yes <input type="radio" name="persistent_rib_pain" value="Y"
          [% 'checked' IF questionnaire.persistent_rib_pain == 'Y' %] />
        No <input type="radio" name="persistent_rib_pain" value="N"
          [% 'checked' UNLESS questionnaire.persistent_rib_pain == 'Y' %] />
          [% error_persistent_rib_pain %]
      </td> 
		</tr> 

		<tr> 
			<td class="title" align="right" valign="top">Bone pain, back:</td> 
			<td valign="top"> 
				<select name="back_pain"> 
					<option value="">--select one--</option> 
          [% FOREACH opt IN outreach.menu_options.pain %]
					<option value="[% opt %]"
              [% 'selected' IF questionnaire.back_pain == opt %]>
            [% opt %]
          </option>
          [% END %]          
				</select>
                [% error_back_pain %]
			</td>
      
			<td> 
				<b>Persistent: </b>            
        Yes <input type="radio" name="persistent_back_pain" value="Y"
          [% 'checked' IF questionnaire.persistent_back_pain == 'Y' %] />
        No <input type="radio" name="persistent_back_pain" value="N"
          [% 'checked' UNLESS questionnaire.persistent_back_pain == 'Y' %] />
          [% error_persistent_back_pain %]
      </td> 
		</tr> 

		<tr> 
			<td class="title" align="right" valign="top">Bone pain, upper arm:</td> 
			<td valign="top"> 
				<select name="arm_pain"> 
					<option value="">--select one--</option> 
          [% FOREACH opt IN outreach.menu_options.pain %]
					<option value="[% opt %]"
              [% 'selected' IF questionnaire.arm_pain == opt %]>
            [% opt %]
          </option>
          [% END %]          
				</select>
            [% error_arm_pain %]
			</td>
      
			<td> 
				<b>Persistent: </b>            
        Yes <input type="radio" name="persistent_arm_pain" value="Y"
          [% 'checked' IF questionnaire.persistent_arm_pain == 'Y' %] />
        No <input type="radio" name="persistent_arm_pain" value="N"
          [% 'checked' UNLESS questionnaire.persistent_arm_pain == 'Y' %] />
        [% error_persistent_arm_pain %]
      </td> 
		</tr> 

		<tr> 
			<td class="title" align="right" valign="top">Bone pain, upper leg:</td> 
			<td valign="top"> 
				<select name="leg_pain"> 
					<option value="">--select one--</option> 
          [% FOREACH opt IN outreach.menu_options.pain %]
					<option value="[% opt %]"
              [% 'selected' IF questionnaire.leg_pain == opt %]>
            [% opt %]
          </option>
          [% END %]          
				</select>
            [% error_leg_pain %]
			</td>
      
			<td> 
				<b>Persistent: </b>            
        Yes <input type="radio" name="persistent_leg_pain" value="Y"
          [% 'checked' IF questionnaire.persistent_leg_pain == 'Y' %] />
        No <input type="radio" name="persistent_leg_pain" value="N"
          [% 'checked' UNLESS questionnaire.persistent_leg_pain == 'Y' %] />
        [% error_persistent_leg_pain %]
      </td> 
		</tr> 
	</table>
  </div>
<!-- BEGIN outreach/questionnaire/pain.tt -->