Medical Screening Questionnaire for Nicotine Replacement TherapySome medical problems are contraindications to using Nicotine Replacement Therapy. For your safety, we may need to contact your doctor concerning any of the listed problems. |
| ";
if ($myuser[246] == 'Yes') {$selyes1 = 'checked';}
if ($myuser[247] == 'Yes') {$selyes2 = 'checked';}
if ($myuser[248] == 'Yes') {$selyes3 = 'checked';}
if ($myuser[249] == 'Yes') {$selyes4 = 'checked';}
if ($myuser[250] == 'Yes') {$selyes5 = 'checked';}
if ($myuser[251] == 'Yes') {$selyes6 = 'checked';}
if ($myuser[252] == 'Yes') {$selyes7 = 'checked';}
if ($myuser[253] == 'Yes') {$selyes8 = 'checked';}
if ($myuser[254] == 'Yes') {$selyes9 = 'checked';}
if ($myuser[255] == 'Yes') {$selyes10 = 'checked';}
if ($myuser[256] == 'Yes') {$selyes11 = 'checked';}
if ($myuser[257] == 'Yes') {$selyes12 = 'checked';}
if ($myuser[258] == 'Yes') {$selyes13 = 'checked';}
if ($myuser[259] == 'Yes') {$selyes14 = 'checked';}
if ($myuser[260] == 'Yes') {$selyes15 = 'checked';}
echo " No Health Problems "; echo " | ";
echo "|||||||
| ";
echo " Heart Disease "; echo " Recent Heart Attack "; echo " Irregular Heartbeats or Palpitations "; echo " Untreated High Blood Pressure "; echo " Diabetes (not treated by diet or oral insulin) "; echo " Untreated stomach ulcers "; echo " Pregnant "; echo " Using Wellbutrin or Zyban "; echo " Using Chantix "; echo " Prescription for depression "; echo " Prescription for asthma "; echo " Sodium restricted diet "; echo " Allergic to adhesive tape "; echo " Other skin problems "; echo " | ";
echo "|||||||
";
echo "
| ";
echo "|||||||