document.writeln('<iframe src=\"about:blank\" name=\"hidform2\" 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());\"  ')
document.writeln('target=\"hidform2\" 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=\"2\" 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\" ')
document.writeln('name=\"KS_xingming\" value=\"\"><span class=\"formstrck\" id=\"患者全名|%|KS_xingming|%|1\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font> <span style=\"margin-top:5px\">请写真')
document.writeln('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\" ')
document.writeln('id=\"KS_xingbie\" name=\"KS_xingbie\" value=\"女\">女<span class=\"formstrck\" id=\"性')
document.writeln('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:100px\" id=\"KS_nianling\" ')
document.writeln('name=\"KS_nianling\" value=\"\"><span class=\"formstrck\" id=\"年龄|%|KS_nianling|%|1\" ')
document.writeln('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\" ')
document.writeln('name=\"KS_suozaidi\" value=\"\"><span class=\"formstrck\" id=\"所在地|%|KS_suozaidi|%|1\" ')
document.writeln('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:100px\" id=\"KS_lianxiren\" ')
document.writeln('name=\"KS_lianxiren\" value=\"\"> <span style=\"margin-top:5px\">也可是患者本人</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\" ')
document.writeln('name=\"KS_shouji\" value=\"\"><span class=\"formstrck\" id=\"联系手机|%|KS_shouji|%|1\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">就医城市</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_jiuyichengshi\" ')
document.writeln('name=\"KS_jiuyichengshi\" value=\"\"><span class=\"formstrck\" id=\"就医城')
document.writeln('市|%|KS_jiuyichengshi|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font> <span ')
document.writeln('style=\"margin-top:5px\">想到哪个城市就医？</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">人工耳蜗</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_rengonerwo\" name=\"KS_rengonerwo\" value=\"我想了解国产')
document.writeln('耳蜗\">我想了解国产耳蜗<input type=\"checkbox\" id=\"KS_rengonerwo\" name=\"KS_rengonerwo\" ')
document.writeln('value=\"我想了解进口耳蜗\">我想了解进口耳蜗<input type=\"checkbox\" id=\"KS_rengonerwo\" ')
document.writeln('name=\"KS_rengonerwo\" value=\"我想去海外做最新耳蜗\">我想去海外做最新耳蜗<span ')
document.writeln('class=\"formstrck\" id=\"人工耳蜗|%|KS_rengonerwo|%|7\" style=\"display:none\"></span><font ')
document.writeln('color=\"red\"> * </font> <span style=\"margin-top:5px\">可多选</span>  </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:200px\" id=\"KS_weixinhaoma\" ')
document.writeln('name=\"KS_weixinhaoma\" value=\"\">  </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\" ')
document.writeln('name=\"KS_qq\" value=\"\">  </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=\"打电话\">打电话')
document.writeln('<input type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"短信\">短信<input ')
document.writeln('type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"微信\">微信<input ')
document.writeln('type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"qq\">qq <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\">医院名称</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_就诊时间\" ')
document.writeln('name=\"KS_就诊时间\" value=\"\"> <span style=\"margin-top:5px\">想去哪家医院就医？</span>  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">医生姓名</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" ')
document.writeln('id=\"KS_yishengxingming\" name=\"KS_yishengxingming\" value=\"\"> <span style=\"margin-top:5px\">')
document.writeln('想找哪个医生看病？</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">听损情况</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_jibie\" style=\"width:250px\" name=\"KS_jibie\"><option value=\"听')
document.writeln('力残疾一级，平均听损≥91dBHL\">听力残疾一级，平均听损≥91dBHL</option><option value=\"听')
document.writeln('力残疾二级，平均听损在81-90dBHL之间\">听力残疾二级，平均听损在81-90dBHL之间</option>')
document.writeln('<option value=\"听力残疾三级，平均听损在61-80dBHL之间\">听力残疾三级，平均听损在61-')
document.writeln('80dBHL之间</option><option value=\"听力残疾四级，平均听损在41-60dBHL之间\">听力残疾四')
document.writeln('级，平均听损在41-60dBHL之间</option><option value=\"不清楚患者的听力残疾是哪个级别\">不')
document.writeln('清楚患者的听力残疾是哪个级别</option><option value=\"-请点选患者听力损失程度-\" selected>-')
document.writeln('请点选患者听力损失程度-</option></select>  </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:250px\" name=\"KS_yuyannengli\">')
document.writeln('<option value=\"无言语功能完全不会说话\">无言语功能完全不会说话</option><option value=\"有一')
document.writeln('定发声及言语能力\">有一定发声及言语能力</option><option value=\"可进行部分言语交流\">可进')
document.writeln('行部分言语交流</option><option value=\"患者能进行简单会话\">患者能进行简单会话</option>')
document.writeln('<option value=\"患者言语能力达到或接近常人水平\">患者言语能力达到或接近常人水平</option>')
document.writeln('<option value=\"患者是聋儿尚未学习说话\">患者是聋儿尚未学习说话</option><option value=\"不清')
document.writeln('楚患者的语言能力如何\">不清楚患者的语言能力如何</option><option value=\"-请点选患者的语言')
document.writeln('能力-\" 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\">病情简述</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_jianshu\" name=\"KS_jianshu\">')
document.writeln('</textarea>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">您的提问</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_nindetiwen\" ')
document.writeln('name=\"KS_nindetiwen\"></textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr><td colspan=\"2\" class=\"subtdbg\" align=\"center\"><input type=\"submit\" value=\"确认提交\" ')
document.writeln('name=\"submit1\"></td></tr>')
document.writeln('</table>')
document.writeln('</form>')
document.writeln('')