document.writeln('<iframe src=\"about:blank\" name=\"hidform13\" style=\"width:0px;height:0px;display:none\">')
document.writeln('</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());\"  ')
document.writeln('target=\"hidform13\" 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=\"13\" 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\" ')
document.writeln('id=\"KS_huanzhexingming\" name=\"KS_huanzhexingming\" value=\"\"><span class=\"formstrck\" ')
document.writeln('id=\"患者全名|%|KS_huanzhexingming|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-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 ')
document.writeln('type=\"radio\" id=\"KS_xingbie\" name=\"KS_xingbie\" value=\"女\">女<span class=\"formstrck\" ')
document.writeln('id=\"性别|%|KS_xingbie|%|6\" style=\"display:none\"></span><font color=\"red\"> * </font>  ')
document.writeln('</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\" ')
document.writeln('id=\"KS_nianling\" name=\"KS_nianling\" value=\"\"><span class=\"formstrck\" id=\"年')
document.writeln('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\" ')
document.writeln('id=\"KS_suozaidi\" name=\"KS_suozaidi\" value=\"\"><span class=\"formstrck\" id=\"常驻')
document.writeln('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\" ')
document.writeln('id=\"KS_lianxiren\" name=\"KS_lianxiren\" value=\"\"><span class=\"formstrck\" id=\"联系人')
document.writeln('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\" ')
document.writeln('id=\"KS_shouji\" name=\"KS_shouji\" value=\"\"><span class=\"formstrck\" id=\"联系手')
document.writeln('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\">微信号码</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" ')
document.writeln('id=\"KS_weixin\" name=\"KS_weixin\" value=\"\"> <span style=\"margin-top:5px\">若有请务必填上')
document.writeln('</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_lianxi\" name=\"KS_lianxi\" value=\"打电话\">打电话')
document.writeln('<input type=\"checkbox\" id=\"KS_lianxi\" name=\"KS_lianxi\" value=\"发短信\">发短信<input ')
document.writeln('type=\"checkbox\" id=\"KS_lianxi\" name=\"KS_lianxi\" value=\"微信\">微信 <span style=\"margin-')
document.writeln('top:5px\">（可多选）</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">听力情况</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_tingli\" style=\"width:200px\" name=\"KS_tingli\">')
document.writeln('<option value=\"听损较轻只偶尔听不清说话\">听损较轻只偶尔听不清说话</option><option ')
document.writeln('value=\"中度听损要注意听才能听见\">中度听损要注意听才能听见</option><option value=\"听损较')
document.writeln('重需大声说才能听见\">听损较重需大声说才能听见</option><option value=\"听损很重接近全聋或')
document.writeln('已全聋\">听损很重接近全聋或已全聋</option><option value=\"不清楚患者有多少听力损失\">不清')
document.writeln('楚患者有多少听力损失</option><option value=\"-请点选患者的听力情况-\" selected>-请点选患')
document.writeln('者的听力情况-</option></select><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">语言能力</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_yuyannengli\" style=\"width:200px\" ')
document.writeln('name=\"KS_yuyannengli\"><option value=\"患者是聋儿，尚未学会说话\">患者是聋儿，尚未学会说话')
document.writeln('</option><option value=\"不会说话，言语能力已丧失\">不会说话，言语能力已丧失</option>')
document.writeln('<option value=\"说话很模糊，别人无法听懂\">说话很模糊，别人无法听懂</option><option ')
document.writeln('value=\"说话模糊，别人听懂有困难\">说话模糊，别人听懂有困难</option><option value=\"说话还')
document.writeln('可以，比较容易听懂\">说话还可以，比较容易听懂</option><option value=\"言语能力达到或者接')
document.writeln('近正常\">言语能力达到或者接近正常</option><option value=\"-请点选患者的语言能力-\" ')
document.writeln('selected>-请点选患者的语言能力-</option></select><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">服务项目</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_fuwuxiangmu\" style=\"width:200px\" ')
document.writeln('name=\"KS_fuwuxiangmu\"><option value=\"我是未植入者，想去海外做最新产品\">我是未植入者，想')
document.writeln('去海外做最新产品</option><option value=\"我是已植入者，想升级最新款体外机\">我是已植入')
document.writeln('者，想升级最新款体外机</option><option value=\"我是已植入者，想请专家帮我调机\">我是已植')
document.writeln('入者，想请专家帮我调机</option><option value=\"-请点选患者需要哪种服务-\" selected>-请点')
document.writeln('选患者需要哪种服务-</option></select><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_bingqingjianshu\" ')
document.writeln('name=\"KS_bingqingjianshu\"></textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr><td colspan=\"2\" class=\"subtdbg\" align=\"center\"><input type=\"submit\" value=\"确认')
document.writeln('提交\" name=\"submit1\"></td></tr>')
document.writeln('</table>')
document.writeln('</form>')