<!-- 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 %] &#187;</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 -->