document.writeln('<iframe src=\"about:blank\" name=\"hidform21\" 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=\"hidform21\" 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=\"21\" 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\">请写真名,勿填小名</span>  ')
document.writeln('</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=\"性别|%|KS_xingbie|%|6\" ')
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\">年龄：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" 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_changzhudi\" ')
document.writeln('name=\"KS_changzhudi\" value=\"\"><span class=\"formstrck\" id=\"常驻地|%|KS_changzhudi|%|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=\"就医城市|%|KS_jiuyichengshi|%|1\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font> <span ')
document.writeln('style=\"margin-top:5px\">想到哪个城市手术？</span>  </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\">微信号码</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_weixin\" ')
document.writeln('name=\"KS_weixin\" 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=\"发短信\">发短信<input ')
document.writeln('type=\"checkbox\" id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"qq\">qq<input type=\"checkbox\" ')
document.writeln('id=\"KS_ruhelianxi\" name=\"KS_ruhelianxi\" value=\"微信\">微信 <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\">语言能力</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_yuyannengli\" style=\"width:200px\" name=\"KS_yuyannengli\">')
document.writeln('<option value=\"-请点选患者的语言能力-\" selected>-请点选患者的语言能力-</option><option ')
document.writeln('value=\"患者是聋儿，尚未学会说话\">患者是聋儿，尚未学会说话</option><option value=\"不会说话，言语能力已丧')
document.writeln('失\">不会说话，言语能力已丧失</option><option value=\"说话很模糊，别人无法听懂\">说话很模糊，别人无法听懂')
document.writeln('</option><option 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近正常\">言语能力')
document.writeln('达到或者接近正常</option></select><font color=\"red\"> * </font>  </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_tinliqingkuang\" style=\"width:200px\" ')
document.writeln('name=\"KS_tinliqingkuang\"><option value=\"-请点选患者的听力情况-\" selected>-请点选患者的听力情况-</option>')
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 value=\"中度听损要注意听')
document.writeln('才能听见\">中度听损要注意听才能听见</option><option value=\"听损较重需大声说才能听见\">听损较重需大声说才')
document.writeln('能听见</option><option value=\"听损很重接近全聋或已全聋\">听损很重接近全聋或已全聋</option><option ')
document.writeln('value=\"不清楚自己有多少听力损失\">不清楚自己有多少听力损失</option></select>  </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 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('')