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index.html
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<!DOCTYPE html>
<html>
<head>
<title> DoctorMate </title>
<meta name="x-blackberry-defaultHoverEffect" content="false" />
<meta name="viewport" content="initial-scale=1.0,width=device-width,user-scalable=no,target-densitydpi=device-dpi" />
<link href="css/jquery.mobile-1.2.0-alpha.1.min.css" rel="stylesheet" />
<!-- <link href="css/BethIsrael.min.css" rel="stylesheet" /> -->
<link href="css/app.css" rel="stylesheet" />
<script src="js/jquery-1.7.2.min.js"></script>
<script src="js/jquery.mobile-1.2.0-alpha.1.min.js"></script>
<script src="js/jSignature.min.js"></script>
<script src="js/jSignature.SignHere.js"></script>
</head>
<body onload="app.init()">
<div id="myPage" data-role="none" style="visibility:hidden">
<form id="form65" name="form65" class="wufoo topLabel page" autocomplete="off" enctype="multipart/form-data" method="post" novalidate action="complete.html">
<!-- Signature -->
<!-- NOTE: This needs to be created first, though it doesn't need to be default. -->
<div data-role="page" data-title="Signature" id="signoff" data-theme="a">
<div data-role="header" data-position="fixed" data-id="foo">
<h1 id="logo"> Signature </h1>
<a href="./index.html" data-icon="home" data-iconpos="notext" data-direction="reverse">Home</a>
</div>
<div data-role="content" data-role="none">
<div data-role="fieldcontain">
<div id="signatureparent" data-role="none">
<div id="signature" data-role="none"></div>
</div>
</div>
<fieldset class="ui-grid-a">
<div class="ui-block-a"> Physician's Full Name: <input type="text" /></div>
<div class="ui-block-b"> Beeper #: <input type="tel" /></div>
</fieldset>
<div data-role="fieldcontain"> Source of History: <input type="text"/></div>
<div>
<input id="saveForm" name="saveForm" class="btTxt submit" type="submit" value="Submit"/>
</div>
</div>
<div data-role="footer" data-id="nav" data-position="fixed"><div data-role="navbar"><ul>
<li><a href="#patient">Patient Info</a></li>
<li><a href="#history">History</a></li>
<li><a href="#systems">Systems</a></li>
<li><a href="#diagnostics">Diagnostics</a></li>
<li><a href="#signoff" class="ui-btn-active ui-state-persist">Signatures</a></li>
</ul></div></div>
</div>
<!-- Patient page -->
<div data-role="page" data-title="Patient Info" id="patient" data-theme="a">
<div data-role="header" data-position="fixed" data-id="foo">
<h1 id="patient_logo"> Patient Information </h1>
<a href="./index.html" data-icon="home" data-iconpos="notext" data-direction="reverse">Home</a>
</div>
<div style="text-align:center; margin: 5px 115px 0px 115px; padding-top:10px;border:5px solid #abc; border-radius:12px;background-color:#fff">
<img src="images/bethisrael_newark_logo.jpg"/>
</div>
<div data-role="content">
<fieldset class="ui-grid-a">
<div class="ui-block-a">
<label for="patient_id">Patient ID</label>
<input id="patient_id" name="patient_id" type="text" value="" size="8" tabindex="1" />
</div>
<div class="ui-block-b">
<label class="desc" id="title2" for="Field2"> Date </label>
<input id="Field2" name="Field2" type="date" value="" size="8" tabindex="2" />
</div>
</fieldset>
<div data-role="fieldcontain">
<label for="Field0">First Name</label> </span>
<input id="Field0" name="Field0" type="text" value="" size="8" tabindex="3" />
<label for="Field1">Last Name</label> </span>
<input id="Field1" name="Field1" type="text" value="" size="14" tabindex="4" />
</div>
<label id="title3" for="Field3"> Chief Complaint: </label>
<textarea class="ui-block-solo" id="Field3" name="Field3" class="field textarea small" spellcheck="true" rows="10" cols="50" tabindex="6" onkeyup=""></textarea>
</div>
<div data-role="footer" data-id="nav" data-position="fixed"><div data-role="navbar" ><ul>
<li><a href="#patient" class="ui-btn-active ui-state-persist">Patient Info</a></li>
<li><a href="#history">History</a></li>
<li><a href="#systems">Systems</a></li>
<li><a href="#diagnostics">Diagnostics</a></li>
<li><a href="#signoff">Signatures</a></li>
</div></div>
</div>
<!-- History page -->
<div data-role="page" data-title="History and Physical" id="history" data-theme="a">
<div data-role="header" data-position="fixed" data-id="foo">
<h1 id="logo"> Patient History and Physical </h1>
<a href="index.html" data-icon="home" data-iconpos="notext" data-direction="reverse">Home</a>
</div>
<div data-role="content">
<div class="ui-grid-b">
<label data-mini="true" class="ui-block-a" style="width:40%;height:22px;padding:0" id="title4" for="Field4"> History of Present Illness: </label>
<fieldset class="ui-block-b" style="width:60%;position:relative;height:22px;top:-10px;padding:0" data-role="controlgroup" data-type="horizontal">
<button type="button" data-mini="true" data-role="button" data-icon="gear" data-iconpos="right" id="record">Record</button>
<button type="button" data-mini="true" data-role="button" data-icon="alert" data-iconpos="right" id="pause">Pause</button>
<button type="button" data-mini="true" data-role="button" data-icon="delete" data-iconpos="right" id="stop">Stop</button>
<button type="button" data-mini="true" data-role="button" data-icon="rarrow" data-iconpos="right" id="play">Play</button>
</fieldset>
</div>
<textarea style="padding:0" id="Field4" name="Field4" class="field textarea small" spellcheck="true" rows="10" cols="50" tabindex="6" onkeyup="">
</textarea>
<fieldset data-role="controlgroup" data-type="horizontal">
<legend id="title207" class="desc">Family History: <i>(check all that apply)</i></legend>
<input id="Field207" name="Field207" type="checkbox" class="field checkbox" value="Cancer" tabindex="16" />
<label class="choice" for="Field207">Cancer</label>
<input id="Field208" name="Field208" type="checkbox" class="field checkbox" value="HeartDisease" tabindex="17" />
<label class="choice" for="Field208">Heart Disease</label>
<input id="Field211" name="Field211" type="checkbox" class="field checkbox" value="Diabetes" tabindex="20" />
<label class="choice" for="Field211">Diabetes</label>
<input id="Field212" name="Field212" type="checkbox" class="field checkbox" value="HighCholesterol" tabindex="21" />
<label class="choice" for="Field212">High Cholesterol</label>
<input id="Field213" name="Field213" type="checkbox" class="field checkbox" value="HighBloodPressure" tabindex="22" />
<label class="choice" for="Field213">High Blood Pressure</label>
<input id="Field214" name="Field214" type="checkbox" class="field checkbox" value="Other" tabindex="23" />
<label class="choice" for="Field214">Other:</label>
<input id="Field215" name="Field215" type="text" class="field text fn" value="" size="20" tabindex="24" />
</fieldset>
<fieldset data-role="controlgroup" data-type="horizontal">
<legend id="title7" class="desc"> PMH: <i>(check if positive)</i></legend>
<input id="Field7" name="Field7" type="checkbox" class="field checkbox" value="AIDS" tabindex="7" />
<label class="choice" for="Field7">AIDS</label>
<input id="Field8" name="Field8" type="checkbox" class="field checkbox" value="Anemia" tabindex="8" />
<label class="choice" for="Field8">Anemia</label>
<span>
<input id="Field9" name="Field9" type="checkbox" class="field checkbox" value="Bleeding Disorders" tabindex="9" />
<label class="choice" for="Field9">Bleeding Disorders</label> </span>
<span>
<input id="Field10" name="Field10" type="checkbox" class="field checkbox" value="Cancer" tabindex="10" />
<label class="choice" for="Field10">Cancer</label> </span>
<span>
<input id="Field11" name="Field11" type="checkbox" class="field checkbox" value="Diabetes" tabindex="11" />
<label class="choice" for="Field11">Diabetes</label> </span>
<span>
<input id="Field12" name="Field12" type="checkbox" class="field checkbox" value="Hepatitis" tabindex="12" />
<label class="choice" for="Field12">Hepatitis</label> </span>
<span>
<input id="Field13" name="Field13" type="checkbox" class="field checkbox" value="Heart Disease" tabindex="13" />
<label class="choice" for="Field13">Heart Disease</label> </span>
<span>
<input id="Field14" name="Field14" type="checkbox" class="field checkbox" value="High Cholesterol" tabindex="14" />
<label class="choice" for="Field14">High Cholesterol</label> </span>
<span>
<input id="Field15" name="Field15" type="checkbox" class="field checkbox" value="Pneumonia" tabindex="15" />
<label class="choice" for="Field15">Pneumonia</label> </span>
<span>
<input id="Field16" name="Field16" type="checkbox" class="field checkbox" value="TB" tabindex="16" />
<label class="choice" for="Field16">TB</label> </span>
<span>
<input id="Field17" name="Field17" type="checkbox" class="field checkbox" value="Other" tabindex="16" />
<label class="choice" for="Field17">Other(s):</label>
<input id="Field18" name="Field18" type="text" class="field text fn" value="" size="20" tabindex="17" />
</span>
</fieldset>
<label class="desc" id="title4" for="Field4"> Please list any medication allergies that you have : </label>
<textarea id="Field4" name="Field4" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="36" onkeyup="" ></textarea>
<label class="desc" id="title306" for="Field306"> Please list any medications you are currently taking (and dosage if known) : </label>
<textarea id="Field306" name="Field306" class="field textarea medium" spellcheck="true" rows="10" cols="50" tabindex="37" onkeyup="" ></textarea>
</div>
<div data-role="footer" data-id="nav" data-position="fixed"><div data-role="navbar"><ul>
<li><a href="#patient">Patient Info</a></li>
<li><a href="#history" class="ui-btn-active ui-state-persist">History</a></li>
<li><a href="#systems">Systems</a></li>
<li><a href="#diagnostics">Diagnostics</a></li>
<li><a href="#signoff">Signatures</a></li>
</div></div>
</div>
<!-- Systems page -->
<div data-role="page" data-title="Review of Systems" id="systems" data-theme="a">
<div data-role="header" data-position="fixed" data-id="foo">
<h1 id="logo"> Systems and Appearance </h1>
<a href="./index.html" data-icon="home" data-iconpos="notext" data-direction="reverse">Home</a>
</div>
<div data-role="content">
<legend id="title310" class="desc">REVIEW OF SYSTEMS: <i>(CHECK IF NEGATIVE)</i></legend>
<fieldset class="ui-grid-a" style="width:100%">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="b">
<h3>GENERAL:</h3>
<fieldset data-role="controlgroup" data-type="horizontal">
<label class="choice" for="systems_general_fever">Fever</label>
<input id="systems_general_fever" name="systems_general_fever" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_headache">Headache</label>
<input id="systems_general_headache" name="systems_general_headache" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_wloss">Weight Loss</label>
<input id="systems_general_wloss" name="systems_general_wloss" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_dizzy">Dizziness</label>
<input id="systems_general_dizzy" name="systems_general_dizzy" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_chills">Chills</label>
<input id="systems_general_chills" name="systems_general_chills" type="checkbox" class="field checkbox" />
</fieldset>
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="e">
<h3>HEENT:</h3>
<fieldset data-role="controlgroup" data-type="horizontal">
<label class="choice" for="systems_heent_blurry">Blurry Vision</label>
<input id="systems_heent_blurry" name="systems_heent_blurry" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_vloss">Vision Loss</label>
<input id="systems_heent_vloss" name="systems_heent_vloss" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_hloss">Hearing Loss</label>
<input id="systems_heent_hloss" name="systems_heent_hloss" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_hrloss">Hair Loss</label>
<input id="systems_heent_hrloss" name="systems_heent_hrloss" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_nbleed">Nosebleeds</label>
<input id="systems_heent_nbleed" name="systems_heent_nbleed" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_gbleed">Bleeding Gums</label>
<input id="systems_heent_gbleed" name="systems_heent_gbleed" type="checkbox" class="field checkbox" />
</fieldset>
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_heent_all">All Negative</label>
<input id="systems_heent_all" name="systems_heent_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_heent_hpi">See HPI</label>
<input id="systems_heent_hpi" name="systems_heent_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="b">
<h3>PULMONARY:</h3>
<fieldset data-role="controlgroup" data-type="horizontal">
<label class="choice" for="systems_pulm_cough">Cough</label>
<input id="systems_pulm_cough" name="systems_pulm_cough" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_pulm_sob">S.O.B.</label>
<input id="systems_pulm_sob" name="systems_pulm_sob" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_pulm_sputum">Productive Sputum</label>
<input id="systems_pulm_sputum" name="systems_pulm_sputum" type="checkbox" class="field checkbox" />
</fieldset>
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="e">
<h3>CARDIOVASCULAR:</h3>
More to come...
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="b">
<h3>GASTROINTESTINAL:</h3>
More to come...
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="b" data-iconpos="right" data-theme="e">
<h3>GENITO-URINARY / GYN:</h3>
More to come...
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="b">
<h3>NEUROLOGY:</h3>
More to come...
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="e">
<h3>MUSCULOSKELITAL: </h3>
More to come...
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
<fieldset class="ui-grid-a">
<div class="ui-block-a" style="width:70%" data-role="collapsible" data-content-theme="a" data-iconpos="right" data-theme="b">
<h3>SKIN:</h3>
<ul>
<li id="foli311" class="notranslate ">
<fieldset data-role="controlgroup" data-type="horizontal">
<legend id="title311" class="desc">
Are you currently using or do you have a history of illegal drug use?
</legend>
<div>
<input id="radioDefault_311" name="Field311" type="hidden" value="" />
<span>
<input id="Field311_0" name="Field311" type="radio" class="field radio" value="Yes" tabindex="41" />
<label class="choice" for="Field311_0" > Yes</label> </span>
<span>
<input id="Field311_1" name="Field311" type="radio" class="field radio" value="No" tabindex="42" />
<label class="choice" for="Field311_1" > No</label> </span>
</div>
</fieldset>
</li>
<li id="foli313" class="notranslate ">
<fieldset data-role="controlgroup" data-type="horizontal">
<legend id="title313" class="desc">
Do you feel you are at risk for falls or falling injuries?
</legend>
<div>
<input id="radioDefault_313" name="Field313" type="hidden" value="" />
<span>
<input id="Field313_0" name="Field313" type="radio" class="field radio" value="Yes" tabindex="43" />
<label class="choice" for="Field313_0" > Yes</label> </span>
<span>
<input id="Field313_1" name="Field313" type="radio" class="field radio" value="No" tabindex="44" />
<label class="choice" for="Field313_1" > No</label> </span>
</div>
</fieldset>
</li>
<li id="foli312" class="notranslate ">
<fieldset data-role="controlgroup" data-type="horizontal">
<legend id="title312" class="desc">
Please describe your alcohol consumption :
</legend>
<div>
<input id="radioDefault_312" name="Field312" type="hidden" value="" />
<span>
<input id="Field312_0" name="Field312" type="radio" class="field radio" value="Daily" tabindex="45" />
<label class="choice" for="Field312_0" > Daily</label> </span>
<span>
<input id="Field312_1" name="Field312" type="radio" class="field radio" value="Weekly" tabindex="46" />
<label class="choice" for="Field312_1" > Weekly</label> </span>
<span>
<input id="Field312_2" name="Field312" type="radio" class="field radio" value="Monthly" tabindex="47" />
<label class="choice" for="Field312_2" > Monthly</label> </span>
<span>
<input id="Field312_3" name="Field312" type="radio" class="field radio" value="Occasionally" tabindex="48" />
<label class="choice" for="Field312_3" > Occasionally</label> </span>
<span>
<input id="Field312_4" name="Field312" type="radio" class="field radio" value="Rarely" tabindex="49" />
<label class="choice" for="Field312_4" > Rarely</label> </span>
<span>
<input id="Field312_5" name="Field312" type="radio" class="field radio" value="Never" tabindex="50" />
<label class="choice" for="Field312_5" > Never</label> </span>
</div>
</fieldset>
</li>
</ul>
</div>
<div class="ui-block-b" style="width:30%; padding-left:20px">
<fieldset data-role="controlgroup" data-type="horizontal" >
<label class="choice" for="systems_general_all">All Negative</label>
<input id="systems_general_all" name="systems_general_all" type="checkbox" class="field checkbox" />
<label class="choice" for="systems_general_hpi">See HPI</label>
<input id="systems_general_hpi" name="systems_general_hpi" type="checkbox" class="field checkbox" />
</fieldset>
</div>
</fieldset>
</div>
<div data-role="footer" data-id="nav" data-position="fixed"><div data-role="navbar"><ul>
<li><a href="#patient">Patient Info</a></li>
<li><a href="#history">History</a></li>
<li><a href="#systems" class="ui-btn-active ui-state-persist">Systems</a></li>
<li><a href="#diagnostics">Diagnostics</a></li>
<li><a href="#signoff">Signatures</a></li>
</ul></div></div>
</div>
<!-- Diagnostics -->
<div data-role="page" data-title="Diagnostics" id="diagnostics" data-theme="e">
<div data-role="header" data-position="fixed" data-id="foo">
<h1 id="logo"> Diagnostics </h1>
<a href="./index.html" data-icon="home" data-iconpos="notext" data-direction="reverse">Home</a>
</div>
<div data-role="content">
<div data-role="fieldcontain">
<label for="textarea"><b>DIAGNOSTIC RESULTS:</b></label>
<textarea name="textarea" id="textarea">
</textarea>
</div>
<div data-role="fieldcontain">
<label for="textarea"><b>ASSESSMENT:</b> <i>(differential Diagnosis)</i></label>
<textarea name="textarea" id="textarea">
</textarea>
</div>
<div data-role="fieldcontain">
<label for="textarea"><b>PLAN:</b></label>
<textarea name="textarea" id="textarea">
</textarea>
</div>
<fieldset data-role="controlgroup" data-type="horizontal">
<legend class="desc">Smoking Cessation:</legend>
<div>
<input id="radioDefault_314" name="Field314" type="hidden" value="" />
<span>
<input id="Field314_0" name="Field314" type="radio" class="field radio" value="Counseled" tabindex="39" />
<label class="choice" for="Field314_0" > Counseled </label> </span>
<span>
<input id="Field314_1" name="Field314" type="radio" class="field radio" value="NotNeeded" tabindex="40" />
<label class="choice" for="Field314_1" > Not Needed</label> </span>
</div>
</fieldset>
<fieldset data-role="controlgroup" data-type="horizontal">
<legend class="desc">Pain Management::</legend>
<div>
<select id="Field315" name="Field315" class="field select medium" tabindex="38" >
<option value="Not Needed" > Not Needed </option>
<option value="Oral" > Oral </option>
<option value="IV_PCA"> IV Incl. PCA </option>
<option value="Non_Pharma"> Non Pharmacological </option>
</select>
</div>
</fieldset>
<fieldset data-role="controlgroup" data-type="horizontal">
<legend class="desc">Vaccine:</legend>
<div>
<input id="radioDefault_316" name="Field316" type="hidden" value="" />
<span>
<input id="Field316_0" name="Field316" type="radio" class="field radio" value="Pneumovax" tabindex="39" />
<label class="choice" for="Field316_0" > Pneumovax To Be Given </label> </span>
<span>
<input id="Field316_1" name="Field316" type="radio" class="field radio" value="Influenza" tabindex="40" />
<label class="choice" for="Field316_1" > Influenza To Be Given (if Applicable) </label> </span>
</div>
</fieldset>
</div>
<div data-role="footer" data-id="nav" data-position="fixed"><div data-role="navbar"><ul>
<li><a href="#patient">Patient Info</a></li>
<li><a href="#history">History</a></li>
<li><a href="#systems">Systems</a></li>
<li><a href="#diagnostics" class="ui-btn-active ui-state-persist">Diagnostics</a></li>
<li><a href="#signoff">Signatures</a></li>
</ul></div></div>
</div>
</form>
</div> <!-- End of Page wrapper myPage -->
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</body>
</html>