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=\"myform21\" action=\"/plus/form/form.asp\" onSubmit=\"return(form_c(21));\"  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\" name=\"KS_xingming\" ')
document.writeln('value=\"\"><span class=\"formstrck21\" id=\"患者全名|%|KS_xingming|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-top:5px\">请勿填写小名</span>  </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=\"text\" maxlength=\"255\" class=\"upfile\" style=\"width:100px\" id=\"KS_huanzhexingbie\" ')
document.writeln('name=\"KS_huanzhexingbie\" value=\"\">  </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\" value=\"\">')
document.writeln('<span class=\"formstrck21\" id=\"患者年龄|%|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\">常驻省市</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=\"formstrck21\" id=\"常驻省市|%|KS_changzhudi|%|1\" style=\"display:none\"></span><font color=\"red\"> * ')
document.writeln('</font> <span style=\"margin-top:5px\">患者居住城镇</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=\"formstrck21\" 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 style=\"margin-top:5px\">通常微信联系您</span>  </td>')
document.writeln('</tr>')
document.writeln(' <tr class=\"tdbg\">')
document.writeln('  <td align=\"right\" class=\"lefttdbg\">听损情况</td>')
document.writeln('  <td><select class=\"upfile\" id=\"KS_tingshunqngkuang\" style=\"width:200px\" name=\"KS_tingshunqngkuang\"><option ')
document.writeln('value=\"不清楚患者的听力损失是多少\">不清楚患者的听力损失是多少</option><option value=\"')
document.writeln('听力残疾一级，平均听损≥91dBHL\">听力残疾一级，平均听损≥91dBHL</option><option value=\"')
document.writeln('听力残疾二级，平均听损在81-90dBHL之间\">听力残疾二级，平均听损在81-90dBHL之间</option><option value=\"')
document.writeln('听力残疾三级，平均听损在61-80dBHL之间\">听力残疾三级，平均听损在61-80dBHL之间</option><option value=\"')
document.writeln('听力残疾四级，平均听损在41-60dBHL之间\">听力残疾四级，平均听损在41-60dBHL之间</option><option value=\"')
document.writeln('请点选患者听力损失程度\" selected>请点选患者听力损失程度</option></select><font color=\"red\"> * </font>  </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:210px\" name=\"KS_yuyannengli\"><option value=\"')
document.writeln('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=\"无言语功能，基本不会说话\">')
document.writeln('无言语功能，基本不会说话</option><option value=\"有一定言语能力能进行简单会话\">有一定言语能力能进行简单会话')
document.writeln('</option><option value=\"患者言语能力达到或接近常人水平\">患者言语能力达到或接近常人水平</option><option value=\"')
document.writeln('请点选患者的语言能力\" selected>请点选患者的语言能力</option></select><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:220px;height:100px\" rows=\"5\" id=\"KS_bingqingjiansu\" name=\"KS_bingqingjiansu\"></textarea>  ')
document.writeln('</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:220px;height:100px\" rows=\"5\" id=\"KS_buchongshuoming\" name=\"KS_buchongshuoming\">')
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('')