document.writeln('<iframe src=\"about:blank\" name=\"hidform12\" style=\"width:0px;height:0px;display:none\"></iframe>')
document.writeln('<script src=\"/ks_inc/common.js\"></script>')
document.writeln('<script src=\"/ks_inc/form_ck.js\"></script>')
document.writeln('<form name=\"myform\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c());\"  target=\"hidform12\" method=\"post\"> ')
document.writeln('<table width=\"100%\" border=\"0\" cellspacing=\"2\" cellpadding=\"1\">')
document.writeln('<input type=\"hidden\" value=\"Save\" name=\"action\"/>')
document.writeln('<input type=\"hidden\" value=\"12\" name=\"id\"/>')
document.writeln('<input type=\"hidden\" value=\"0\" name=\"m\"/>')
document.writeln('<input type=\"hidden\" value=\"0\" name=\"d\"/>')
document.writeln('<input type=\"hidden\" value=\"{$ToUserName}\" id=\"tousername\" name=\"tousername\"/>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\" width=\"90px\">患者全名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_xingming\" name=\"KS_xingming\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"患者全名|%|KS_xingming|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font> <span style=\"margin-')
document.writeln('top:5px\">请写真名,勿填小名</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">性别：</td>')
document.writeln('  <td><input type=\"radio\" id=\"KS_xingbie\" name=\"KS_xingbie\" value=\"男\">男<input type=\"radio\" id=\"KS_xingbie\" name=\"KS_xingbie\" ')
document.writeln('value=\"女\">女<span class=\"formstrck\" id=\"性别|%|KS_xingbie|%|6\" style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">年龄：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_nianling\" name=\"KS_nianling\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">常驻地：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_suozaidi\" name=\"KS_suozaidi\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"常驻地|%|KS_suozaidi|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">联系人名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_lianxiren\" name=\"KS_lianxiren\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"联系人名|%|KS_lianxiren|%|1\" style=\"display:none\"></span> </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">联系手机</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_shouji\" name=\"KS_shouji\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"联系手机|%|KS_shouji|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">qq号码：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_qq\" name=\"KS_qq\" value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">微信号码</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_weixin\" name=\"KS_weixin\" value=\"\"> <span ')
document.writeln('style=\"margin-top:5px\">若有请务必填上</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">如何联系</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"打手机\">打手机<input type=\"checkbox\" ')
document.writeln('id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"短信\">短信<input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"微')
document.writeln('信\">微信<input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"qq\">qq <span style=\"margin-top:5px\">可多选</span>  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">何时耳聋</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_heshi\" name=\"KS_heshi\" value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">会说话吗</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_shuohua\" name=\"KS_shuohua\" value=\"\"><span ')
document.writeln('class=\"formstrck\" id=\"会说话吗|%|KS_shuohua|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">病情简述</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_bingqing\" name=\"KS_bingqing\"></textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr><td colspan=\"2\" class=\"subtdbg\" align=\"center\"><input type=\"submit\" value=\"确认提交\" name=\"submit1\"></td></tr>')
document.writeln('</table>')
document.writeln('</form>')
document.writeln('')