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- VERSION 2.00
- Begin Form Form3
- BackColor = &H00C0C0C0&
- BorderStyle = 3 'Fixed Double
- Caption = "Medical Information"
- ClientHeight = 5880
- ClientLeft = 150
- ClientTop = 1290
- ClientWidth = 9255
- ControlBox = 0 'False
- Height = 6285
- Left = 90
- LinkMode = 1 'Source
- LinkTopic = "Form3"
- MaxButton = 0 'False
- MinButton = 0 'False
- ScaleHeight = 5880
- ScaleWidth = 9255
- Top = 945
- Width = 9375
- Begin SSPanel Panel3D1
- Alignment = 7 'Center - MIDDLE
- AutoSize = 0 'None
- BackColor = &H00C0C0C0&
- BevelInner = 1 'Inset
- BevelOuter = 0 'None
- BevelWidth = 3
- BorderWidth = 3
- FloodColor = &H00FF0000&
- FloodShowPct = -1 'True
- FloodType = 0 'None
- Font3D = 2 'Raised w/heavy shading
- ForeColor = &H00000000&
- Height = 1155
- Left = 2370
- Outline = 0 'False
- RoundedCorners = -1 'True
- ShadowColor = 0 'Dark Grey
- TabIndex = 35
- Top = 5715
- Width = 4335
- Begin SSCommand Command3D3
- AutoSize = 0 'None
- BevelWidth = 2
- Caption = "Return To First Page"
- Font3D = 3 'Inset w/light shading
- ForeColor = &H00000000&
- Height = 855
- Left = 1275
- Outline = -1 'True
- Picture = FORM3.FRX:0000
- RoundedCorners = -1 'True
- TabIndex = 36
- Top = 150
- Width = 1875
- End
- End
- Begin SSFrame Frame3D5
- Alignment = 0 'Left Justify
- Caption = "Misc. Questions:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1335
- Left = 120
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 23
- Top = 4290
- Width = 9060
- Begin PictureBox Picture6
- BackColor = &H00C0C0C0&
- BorderStyle = 0 'None
- Height = 180
- Left = 7560
- ScaleHeight = 180
- ScaleWidth = 1215
- TabIndex = 43
- Top = 1035
- Width = 1215
- Begin SSOption Option3D8
- Alignment = 0 'Text to the Right
- Caption = "No"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 675
- TabIndex = 45
- Top = 0
- Value = 0 'False
- Width = 570
- End
- Begin SSOption Option3D7
- Alignment = 0 'Text to the Right
- Caption = "Yes"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 0
- TabIndex = 44
- Top = 0
- Value = 0 'False
- Width = 630
- End
- End
- Begin PictureBox Picture7
- BackColor = &H00C0C0C0&
- BorderStyle = 0 'None
- Height = 180
- Left = 7560
- ScaleHeight = 180
- ScaleWidth = 1215
- TabIndex = 46
- Top = 810
- Width = 1215
- Begin SSOption Option3D10
- Alignment = 0 'Text to the Right
- Caption = "No"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 675
- TabIndex = 48
- Top = 0
- Value = 0 'False
- Width = 570
- End
- Begin SSOption Option3D9
- Alignment = 0 'Text to the Right
- Caption = "Yes"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 0
- TabIndex = 47
- Top = 0
- Value = 0 'False
- Width = 630
- End
- End
- Begin PictureBox Picture4
- BackColor = &H00C0C0C0&
- BorderStyle = 0 'None
- Height = 180
- Left = 7560
- ScaleHeight = 180
- ScaleWidth = 1215
- TabIndex = 40
- Top = 570
- Width = 1215
- Begin SSOption Option3D3
- Alignment = 0 'Text to the Right
- Caption = "No"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 675
- TabIndex = 42
- Top = 0
- Value = 0 'False
- Width = 570
- End
- Begin SSOption Option3D1
- Alignment = 0 'Text to the Right
- Caption = "Yes"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 0
- TabIndex = 41
- Top = 0
- Value = 0 'False
- Width = 615
- End
- End
- Begin PictureBox Picture3
- BackColor = &H00C0C0C0&
- BorderStyle = 0 'None
- Height = 180
- Left = 7560
- ScaleHeight = 180
- ScaleWidth = 1215
- TabIndex = 37
- Top = 330
- Width = 1215
- Begin SSOption Option3D2
- Alignment = 0 'Text to the Right
- Caption = "No"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 675
- TabIndex = 39
- Top = 0
- Value = 0 'False
- Width = 570
- End
- Begin SSOption Option3D4
- Alignment = 0 'Text to the Right
- Caption = "Yes"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 0
- TabIndex = 38
- Top = 0
- Value = 0 'False
- Width = 630
- End
- End
- Begin Label Label5
- BackColor = &H00C0C0C0&
- Caption = "Are you currently being treated for or taking medication for any condition or disease?"
- FontBold = -1 'True
- FontItalic = 0 'False
- FontName = "Arial"
- FontSize = 8.25
- FontStrikethru = 0 'False
- FontUnderline = 0 'False
- Height = 195
- Left = 150
- TabIndex = 27
- Top = 1005
- Width = 7125
- End
- Begin Label Label3
- BackColor = &H00C0C0C0&
- Caption = "Had treatment or counseling for alcohol or drug dependency?"
- FontBold = -1 'True
- FontItalic = 0 'False
- FontName = "Arial"
- FontSize = 8.25
- FontStrikethru = 0 'False
- FontUnderline = 0 'False
- Height = 195
- Left = 150
- TabIndex = 25
- Top = 780
- Width = 5175
- End
- Begin Label Label4
- BackColor = &H00C0C0C0&
- Caption = "Been a patient in a hospital, sanitarium or other institution?"
- FontBold = -1 'True
- FontItalic = 0 'False
- FontName = "Arial"
- FontSize = 8.25
- FontStrikethru = 0 'False
- FontUnderline = 0 'False
- Height = 195
- Left = 150
- TabIndex = 26
- Top = 555
- Width = 4950
- End
- Begin Label Label2
- BackColor = &H00C0C0C0&
- Caption = "Had surgery or been advised to have surgery which was not done?"
- FontBold = -1 'True
- FontItalic = 0 'False
- FontName = "Arial"
- FontSize = 8.25
- FontStrikethru = 0 'False
- FontUnderline = 0 'False
- Height = 195
- Left = 150
- TabIndex = 24
- Top = 345
- Width = 5595
- End
- End
- Begin SSFrame Frame3D6
- Alignment = 0 'Left Justify
- Caption = "Immune System:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1770
- Left = 6285
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 28
- Top = 2430
- Width = 3075
- Begin SSCheck Check3D22
- Alignment = 0 'Text to the Right
- Caption = "S.T.D (ie. Gonorrhea, Syphilis)"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 33
- Top = 1455
- Value = 0 'False
- Width = 2865
- End
- Begin SSCheck Check3D12
- Alignment = 0 'Text to the Right
- Caption = "Cancer"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 32
- Top = 1185
- Value = 0 'False
- Width = 885
- End
- Begin SSCheck Check3D11
- Alignment = 0 'Text to the Right
- Caption = "Leukemia"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 31
- Top = 915
- Value = 0 'False
- Width = 1110
- End
- Begin SSCheck Check3D9
- Alignment = 0 'Text to the Right
- Caption = "Diabetes"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 30
- Top = 630
- Value = 0 'False
- Width = 1035
- End
- Begin SSCheck Check3D10
- Alignment = 0 'Text to the Right
- Caption = "Tumor"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 29
- Top = 345
- Value = 0 'False
- Width = 825
- End
- End
- Begin SSFrame Frame3D3
- Alignment = 0 'Left Justify
- Caption = "Nervous System:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1770
- Left = 3105
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 7
- Top = 2430
- Width = 3120
- Begin SSCheck Check3D18
- Alignment = 0 'Text to the Right
- Caption = "Other Brain Diseases/Disorders"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 15
- Top = 1290
- Value = 0 'False
- Width = 2940
- End
- Begin SSCheck Check3D19
- Alignment = 0 'Text to the Right
- Caption = "Mental Disorder"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 14
- Top = 990
- Value = 0 'False
- Width = 1635
- End
- Begin SSCheck Check3D20
- Alignment = 0 'Text to the Right
- Caption = "Epilepsy"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 13
- Top = 690
- Value = 0 'False
- Width = 975
- End
- Begin SSCheck Check3D21
- Alignment = 0 'Text to the Right
- Caption = "Convulsions"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 12
- Top = 375
- Value = 0 'False
- Width = 1305
- End
- End
- Begin SSFrame Frame3D2
- Alignment = 0 'Left Justify
- Caption = "Respiratory:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1770
- Left = 120
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 6
- Top = 2430
- Width = 2925
- Begin SSCheck Check3D13
- Alignment = 0 'Text to the Right
- Caption = "Other Lung Disease/Disorder"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 11
- Top = 1290
- Value = 0 'False
- Width = 2760
- End
- Begin SSCheck Check3D8
- Alignment = 0 'Text to the Right
- Caption = "Tuberculosis"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 10
- Top = 975
- Value = 0 'False
- Width = 1350
- End
- Begin SSCheck Check3D7
- Alignment = 0 'Text to the Right
- Caption = "Emphysema"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 9
- Top = 660
- Value = 0 'False
- Width = 1260
- End
- Begin SSCheck Check3D6
- Alignment = 0 'Text to the Right
- Caption = "Asthma"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 8
- Top = 360
- Value = 0 'False
- Width = 885
- End
- End
- Begin PictureBox Picture1
- AutoSize = -1 'True
- BackColor = &H00C0C0C0&
- BorderStyle = 0 'None
- Height = 2205
- Left = 8340
- Picture = FORM3.FRX:0302
- ScaleHeight = 2205
- ScaleWidth = 1440
- TabIndex = 34
- Top = 600
- Width = 1440
- Begin PictureBox Picture2
- AutoSize = -1 'True
- BackColor = &H00FFFFFF&
- BorderStyle = 0 'None
- Height = 480
- Left = 150
- Picture = FORM3.FRX:1DBE
- ScaleHeight = 480
- ScaleWidth = 480
- TabIndex = 49
- Top = 315
- Width = 480
- End
- End
- Begin SSFrame Frame3D4
- Alignment = 0 'Left Justify
- Caption = "Diseases or Disorders of the:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1905
- Left = 3570
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 17
- Top = 480
- Width = 4710
- Begin SSCheck Check3D27
- Alignment = 0 'Text to the Right
- Caption = "Ears, Eyes, Nose or Sinuses"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 22
- Top = 1560
- Value = 0 'False
- Width = 2805
- End
- Begin SSCheck Check3D26
- Alignment = 0 'Text to the Right
- Caption = "Blood, Glands or Skin"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 21
- Top = 1275
- Value = 0 'False
- Width = 2190
- End
- Begin SSCheck Check3D25
- Alignment = 0 'Text to the Right
- Caption = "Spine, Joints, Skull or other Bones"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 20
- Top = 975
- Value = 0 'False
- Width = 3285
- End
- Begin SSCheck Check3D24
- Alignment = 0 'Text to the Right
- Caption = "Kidney, Bladder, Genital Organs or Urinary Tract"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 19
- Top = 675
- Value = 0 'False
- Width = 4440
- End
- Begin SSCheck Check3D23
- Alignment = 0 'Text to the Right
- Caption = "Liver, Gallbladder, Stomach, Intestines or Rectum"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 18
- Top = 360
- Value = 0 'False
- Width = 4515
- End
- End
- Begin SSFrame Frame3D1
- Alignment = 0 'Left Justify
- Caption = "Pulmonary:"
- Font3D = 1 'Raised w/light shading
- ForeColor = &H00000000&
- Height = 1905
- Left = 120
- ShadowColor = 0 'Dark Grey
- ShadowStyle = 0 'Inset
- TabIndex = 0
- Top = 480
- Width = 3390
- Begin SSCheck Check3D5
- Alignment = 0 'Text to the Right
- Caption = "Other Heart Diseases/Disorders"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 5
- Top = 1575
- Value = 0 'False
- Width = 3030
- End
- Begin SSCheck Check3D4
- Alignment = 0 'Text to the Right
- Caption = "Heart Murmur"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 4
- Top = 1275
- Value = 0 'False
- Width = 1425
- End
- Begin SSCheck Check3D3
- Alignment = 0 'Text to the Right
- Caption = "Rheumatic Fever"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 3
- Top = 975
- Value = 0 'False
- Width = 1725
- End
- Begin SSCheck Check3D2
- Alignment = 0 'Text to the Right
- Caption = "Chest Pain or Pressure"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 2
- Top = 660
- Value = 0 'False
- Width = 2235
- End
- Begin SSCheck Check3D1
- Alignment = 0 'Text to the Right
- Caption = "High Blood Pressure"
- Font3D = 0 'None
- ForeColor = &H00000000&
- Height = 195
- Left = 120
- TabIndex = 1
- Top = 345
- Value = 0 'False
- Width = 2010
- End
- End
- Begin Label Label1
- BackColor = &H00C0C0C0&
- Caption = "Please Check All Below that Apply:"
- FontBold = -1 'True
- FontItalic = 0 'False
- FontName = "Arial"
- FontSize = 18
- FontStrikethru = 0 'False
- FontUnderline = 0 'False
- Height = 450
- Left = 1710
- TabIndex = 16
- Top = 60
- Width = 6120
- End
- Sub Command1_Click ()
- form2.Hide
- form1.Show
- End Sub
- Sub Command3D3_Click ()
- form1.Show
- form3.Hide
- End Sub
- Sub Form_Load ()
- form3.WindowState = 2
- picture1.Width = 1020
- picture1.Height = 1740
- End Sub
-