document.writeln('<iframe src=\"about:blank\" name=\"hidform30\" 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=\"myform30\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(30));\"  target=\"hidform30\" ')
document.writeln('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=\"30\" 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_quanming\" ')
document.writeln('name=\"KS_quanming\" value=\"\"><span class=\"formstrck30\" id=\"患者全名|%|KS_quanming|%|1\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font> <span style=\"margin-top:5px\">请写全名,勿填小名</span>  ')
document.writeln('</td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">患者性别</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\">患者年龄</td>')
document.writeln('  <td><input type=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_nianling\" name=\"KS_nianling\" ')
document.writeln('value=\"\"><span class=\"formstrck30\" id=\"患者年龄|%|KS_nianling|%|1\" style=\"display:none\"></span><font ')
document.writeln('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:200px\" id=\"KS_changzhudi\" ')
document.writeln('name=\"KS_changzhudi\" value=\"\"><span class=\"formstrck30\" id=\"常住地|%|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\" name=\"KS_lianxiren\" ')
document.writeln('value=\"\"> <span style=\"margin-top:5px\">亲友或患者本人</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:100px\" id=\"KS_shouji\" name=\"KS_shouji\" ')
document.writeln('value=\"\"><span class=\"formstrck30\" id=\"联系手机|%|KS_shouji|%|1\" style=\"display:none\"></span><font color=\"red\"> ')
document.writeln('* </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\" ')
document.writeln('value=\"\"><span class=\"formstrck30\" id=\"微信号码|%|KS_weixin|%|1\" style=\"display:none\"></span><font color=\"red\"> ')
document.writeln('* </font> <span 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\">人工耳蜗：</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_rengongerwo\" name=\"KS_rengongerwo\" value=\"想做国产\">想做国产<input ')
document.writeln('type=\"checkbox\" id=\"KS_rengongerwo\" name=\"KS_rengongerwo\" value=\"想做进口\">想做进口<input ')
document.writeln('type=\"checkbox\" id=\"KS_rengongerwo\" name=\"KS_rengongerwo\" value=\"皆可考虑\">皆可考虑  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">手术地点</td>')
document.writeln('  <td><input type=\"checkbox\" id=\"KS_shoushudidian\" name=\"KS_shoushudidian\" value=\"上海\">上海<input ')
document.writeln('type=\"checkbox\" id=\"KS_shoushudidian\" name=\"KS_shoushudidian\" value=\"安徽\">安徽<input type=\"checkbox\" ')
document.writeln('id=\"KS_shoushudidian\" name=\"KS_shoushudidian\" value=\"江西\">江西<input type=\"checkbox\" id=\"KS_shoushudidian\" ')
document.writeln('name=\"KS_shoushudidian\" value=\"山东\">山东<span class=\"formstrck30\" id=\"手术地点|%|KS_shoushudidian|%|7\" ')
document.writeln('style=\"display:none\"></span><font color=\"red\"> * </font> <span style=\"margin-top:5px\"></span>  </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 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_tiwen\" name=\"KS_tiwen\"></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>')
document.writeln('</tr>')
document.writeln('</table>')
document.writeln('</form>')
document.writeln('')