document.writeln('<iframe src=\"about:blank\" name=\"hidform24\" 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=\"myform24\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(24));\"  target=\"hidform24\" 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=\"24\" 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_huanzhequanming\" ')
document.writeln('name=\"KS_huanzhequanming\" value=\"\"><span class=\"formstrck24\" id=\"患者全名|%|KS_huanzhequanming|%|1\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font> <span style=\"margin-top:5px\">请填真名，勿写小名</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\" id=\"KS_xingbie\" ')
document.writeln('name=\"KS_xingbie\" value=\"女\">女  </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\" name=\"KS_nianling\" value=\"\">')
document.writeln('<span class=\"formstrck24\" id=\"年龄|%|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\">常住地：</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_changzhudi\" name=\"KS_changzhudi\" ')
document.writeln('value=\"\"><span class=\"formstrck24\" id=\"常住地|%|KS_changzhudi|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-top:5px\">填省份和城市即可</span>  </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\" name=\"KS_lianxiren\" ')
document.writeln('value=\"\"> <span style=\"margin-top:5px\"> 患者家长或亲友姓名</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:100px\" id=\"KS_shouji\" name=\"KS_shouji\" value=\"\">')
document.writeln('<span class=\"formstrck24\" id=\"联系手机|%|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\" id=\"KS_weixin\" name=\"KS_weixin\" value=\"\">')
document.writeln('<span class=\"formstrck24\" id=\"微信号码|%|KS_weixin|%|1\" style=\"display:none\"></span><font color=\"red\"> * </font> <span ')
document.writeln('style=\"margin-top:5px\">若无微信请填 “0”</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">何时耳聋</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_heshierlong\" name=\"KS_heshierlong\" ')
document.writeln('value=\"\">  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">会说话吗</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:200px\" id=\"KS_huishuohuama\" ')
document.writeln('name=\"KS_huishuohuama\" value=\"\"><span class=\"formstrck24\" id=\"会说话吗|%|KS_huishuohuama|%|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\">病情简述</td>')
document.writeln('  <td><textarea style=\"width:250px;height:100px\" rows=\"5\" id=\"KS_bingqingjianshu\" name=\"KS_bingqingjianshu\">')
document.writeln('</textarea>  </td>')
document.writeln('</tr>')
document.writeln('<tr><td colspan=\"2\" class=\"subtdbg\" align=\"center\"><input type=\"submit\" value=\"确认提交\" name=\"submit1\"></td></tr>')
document.writeln('</table>')
document.writeln('</form>')
document.writeln('')