<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.4.1/jquery.min.js"></script>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css">
<head>
<style>
.tbl1 {
border: 2px solid black;
border-collapse: collapse;
font-weight: 800;
padding: 15px;
}
* {
text-transform: capitalize !important;
}
</style>
</head>
<div id="checkup_form_form" style="display:none">
<?php
include('includes/config/config.php');
include_once("includes/functions.php");
error_reporting(0);
$query = "select * from company_profile where company_id =5 ";
//echo $query;
$result = mysqli_query($conn, $query);
$row = mysqli_fetch_array($result);
@extract($row); ?>
<div style="margin-top:-20px">
<br>
<br>
<br>
<div style="margin-top: 20px">
<table width="100%" class="tbl3" id="form_header">
<tr>
<td colspan="2" align="center"><strong>(FORM - O)</strong></td>
</tr>
<tr>
<td colspan="2" align="center"><b>(See rule 29F(2) and 29L)</b></td>
</tr>
<tr>
<td colspan="2" align="center"><b>Report of medical examination under rule 29B</b></td>
</tr>
<tr>
<td colspan="2" align="center"><b>(To be Issued In Triplicate)**</b></td>
</tr>
</table>
<?php
$sql_section = "select checkup_form_section_ids from checkup_type where checkup_type_id=(select checkup_type_id from checkup_form where checkup_id='" . $_REQUEST['checkup_id'] . "')";
error_log("section query :" . $sql_section);
$result_section = mysqli_query($conn, $sql_section);
$row_section = mysqli_fetch_assoc($result_section);
$section_ids = explode(",", $row_section['checkup_form_section_ids']);
error_log("section ids : " . print_r($section_ids, true));
$data = array();
foreach ($section_ids as $sec_ids) {
$sql_value = "select cfk.checkup_form_key,cfk.checkup_form_value,cp.parameter_name,cp.checkup_form_section_id,cp.input_type from checkup_parameter cp left join checkup_form cf on cp.checkup_type_ids = cf.checkup_type_id left join checkup_form_key_value cfk on cfk.checkup_form_id=cf.checkup_id where cp.checkup_form_section_id='" . $sec_ids . "' and cf.checkup_id='" . $_REQUEST['checkup_id'] . "' and cfk.checkup_form_key=cp.`column_name`";
$result_val = mysqli_query($GLOBALS['conn'], $sql_value);
while ($row_val = mysqli_fetch_assoc($result_val)) {
if ($row_val['input_type'] == 'select') {
$data[$row_val['checkup_form_key']] = getFieldFromTable('parameter_value_name', 'checkup_parameter_value', 'parameter_value_id', $row_val['checkup_form_value']);
} else if ($row_val['input_type'] == 'multiselect') {
$data[$row_val['checkup_form_key']] = getCommaSeperatedValuesForInClause("select parameter_value_name from checkup_parameter_value", 'parameter_value_id', $row_val['checkup_form_value']);
} else {
$data[$row_val['checkup_form_key']] = $row_val['checkup_form_value'];
}
}
// error_log("value query for form o :" . $sql_value);
error_log("data array : " . print_r($data, true));
}
$sql_form_type_data = "select a.*,b.*,c.patient_name,c.identity,c.emp_photo,c.emp_sign,c.image_type,c.emp_image_type from form_data a inner join checkup_form b on a.checkup_id=b.checkup_id left join patient_master c on c.id = b.emp_id where a.checkup_id='" . $_REQUEST['checkup_id'] . "'";
// echo $sql_form_type_data;
$result_form_type_data = mysqli_query($conn, $sql_form_type_data);
$row_form_type_data = mysqli_fetch_assoc($result_form_type_data);
@extract($row_form_type_data);
// $certificate_no = $row_form_type_data['ticket_no'];
$patient_name = $row_form_type_data['patient_name'];
$identification_mark = $row_form_type_data['identity'];
?>
<div style="margin-top: 20px">
<table width="100%" class="tbl3" style="border-spacing: 10px;">
<tr>
<td>
<p><?= $para_one ?>
</p>
</td>
</tr>
<tr>
<td><?= $para_one_1 ?>
</td>
</tr>
<tr>
<td>
<p><?= $para_one_2 ?>
</p>
</td>
</tr>
<tr>
<td>
<p><?= $para_one_3 ?>
</p>
</td>
</tr>
<tr>
<td><?= $para_one_4 ?>
</td>
</tr>
<tr>
<td><?= $para_one_5 ?>
</td>
</tr>
<tr>
<td><?= $para_one_6 ?>
</td>
</tr>
<tr>
<td>
<p><?= $para_one_7 ?>
</p>
</td>
</tr>
</table>
<table class="tbl3" width="100%">
<tr>
<td>
<?php
$sql_image = "select * from patient_master where id='" . $row_form_type_data['emp_id'] . "'";
$result_image = mysqli_query($conn, $sql_image);
$row_image = mysqli_fetch_assoc($result_image);
@extract($row_image);
error_log("image query " . $sql_image);
?>
<img class="img-responsive" src="data:<?php echo $row_image['emp_image_type'] ?>;base64,<?php echo base64_encode($row_image['emp_photo']) ?>" style="display: block; width: 180px; height: 150px;" />
</td>
</tr>
</table>
<table width="100%" class="tbl3">
<?php
$doc_emp_id = $row_form_type_data['doc_attend'];
$doctor_name = getFieldfromTable('patient_name', 'patient_master', 'id', $doc_emp_id);
$sql_sign = "select * from employee_signature where emp_id='" . $doc_emp_id . "'";
$result_sign = mysqli_query($conn, $sql_sign);
$row_sign = mysqli_fetch_assoc($result_sign);
@extract($row_sign);
error_log("sign query " . $sql_sign);
?>
<tr>
<td colspan="3" align="right"><span class="profile-picture" id="profile-picture1"> <img src="data:<?php echo $row_sign['image_type'] ?>;base64,<?php echo base64_encode($row_sign['emp_sign']) ?>" style="width: 120px; height: 40px;" /></span></td>
</tr>
<tr>
<td align="left">Place:</span> SUTRAPADA</td>
<td colspan="3" align="right">Signature of examining authority</td>
</tr>
<tr>
<td align="left">Date: <?= date_format(date_create($row_form_type_data['approval_date']), "d-M-Y") ?></td>
<td colspan="3" align="right">Name and designation in block letter:</td>
</tr>
</table>
<table width="100%" style="margin-right: 20px">
<tr>
<td width="70%">
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
</td>
</tr>
</table>
<table width="100%" id="id_table" class="tbl3" style=" page-break-after: always;">
<tr>
<td align="left">* Delete whatever is not applicable</td>
</tr>
<tr>
<td>
**One copy of the certificate shall be handed over to the person concerned and another copy shall be send to the manager of the mine concerned by registered post; and the third copy shall be retained by the examining authority.
</td>
</tr>
<tr>
<td align="center">
<p><?= $para_two ?></p>
</td>
</tr>
<tr>
<td>
<p><?= $para_three ?></p>
</td>
</tr>
<tr>
<td>
<p><?= $para_four ?></p>
</td>
</tr>
</table>
<?php $sql_med = "select b.patient_name,b.identity ,a.doc_attend from checkup_form a left join patient_master b on a.emp_id = b.id where a.checkup_id = '" . $_REQUEST['checkup_id'] . "'";
error_log("DATA:" . $sql_med);
$result_med = mysqli_query($conn, $sql_med);
$row_med = mysqli_fetch_array($result_med);
@extract($row_med);
?>
<table width="100%" class="tbl3" style="page-break-after:always;">
<tr>
<td colspan="2" align="center"><b>Report of The Examining Authority</b></td>
</tr>
<tr>
<td colspan="2" align="center"><b>(To be filled in for every medical examination whether initial or periodical or re -examination or after cure/control of disability).</b></td>
</tr>
<tr>
<td align="left">Annexure to <?= $para_one ?></td>
<td align="center" style="margin-left: 10px;">as result of medical examination on <?= date_format(date_create($row_form_type_data['approval_date']), "d-M-Y") ?></td>
</tr>
<tr>
<td height="1%">Identification Mark: <?= $row_med['identity'] ?></td>
</tr>
<tr>
<td height="1%">1.General Development: <?= $data['general_development'] ?></td>
<td align="right"><span class="profile-picture" id="profile-picture1"> <img src="data:<?php echo $row_form_type_data['image_type'] ?>;base64,<?php echo base64_encode($row_form_type_data['emp_sign']) ?>" style="width: 120px; height: 40px;" /></span>
<br> Left Thumb Impression of the Candidate
</td>
</tr>
<tr>
<td height="1%">2.Height: <?= $data['height'] ?>cms</td>
</tr>
<tr>
<td height="1%">3.Weight: <?= $data['weight'] ?>kgs</td>
</tr>
<tr>
<td align="left">4. Eyes: (i) Visual Activity-Distant Vision (with or without glasses,)</td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">Right Eye: <?= $data['visual_acuity_distant_vision_rt_eye'] ?></span></td>
<td align="center">Left Eye: <?= $data['visual_acuity_distant_vision_lt_eye'] ?></td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">(ii) Any Organic Disease Of Eyes: </span><?= $data['any_organic_disease_of_eyes'] ?></span></td>
<td align="center">
(iii) Night Blindness: </span><?= $data['night_blindness'] ?></span>
</td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">(iv) Colour Blindness: </span><?= $data['colour_blindness'] ?></span></td>
<td align="center">(v) Squint: </span><?= $data['squint'] ?></td>
</tr>
<tr>
<td height="1%">5. Ears: (i) Hearing: </td>
</tr>
<tr>
<?php error_log("ear : " . $data['hearing_condition_rt_ear']); ?>
<td align="left"><span style="margin-left: 50px">Right Ear: <?= $data['hearing_condition_rt_ear'] ?> </span></td>
<td align="center">Left Ear: <?= $data['hearing_condition_lt_ear'] ?></td>
</tr>
<tr>
<td height="1%"><span style="margin-left: 50px">(ii) Any Organic Diseases: </span><?= $data['any_organic_disease'] ?></td>
</tr>
<tr>
<td height="1%">6. Respiratory System: </td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">(i) After Full Inspiration: <?= $data['after_full_inspiration'] ?> cms </span></td>
<td align="center">(ii) After Full Expiration: </span><?= $data['after_full_expiration'] ?> cms</td>
</tr>
<tr>
<td height="1%">7. Circulatory System:</td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">Blood Pressure: <?= $data['systolic_blood_pressure'] . "/" . $data['diastolic_blood_pressure'] ?> mm/Hg</span></td>
<td align="center">Pulse: <?= $data['pulse'] ?>/Min</td>
</tr>
<tr>
<td height="1%">8. Abdomen:</td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">Tenderness: <?= $data['tenderness'] ?></span></td>
<td align="center">Liver: <?= $data['liver'] ?></td>
</tr>
<tr>
<td align="left"><span style="margin-left: 50px">Speen: <?= $data['spleen'] ?></span></td>
<td align="center">Tumour: <?= $data['tumour'] ?></td>
</tr>
<tr>
<td height="1%">9. Nervous System:</td>
</tr>
<tr>
<td align="left"><span style="margin-left: 100px">History Of Fits or Epilepsy: </span><?= $data['history_of_fits_or_epilepsy'] ?></td>
<td align="center">Paralysis: </span><?= $data['paralysis'] ?></td>
</tr>
<tr>
<td align="left"><span style="margin-left: 100px">Mental Health: </span><?= $data['mental_health'] ?></td>
</tr>
<tr>
<td height="1%">10. Locomotory System: <?= $data['locomotory_system'] ?></td>
</tr>
<tr>
<td height="1%">11. Skin: <?= $data['skin'] ?></td>
</tr>
<tr>
<td height="1%">12. Hydrocele: <?= $data['hydrocele'] ?></td>
</tr>
<tr>
<td height="1%">13. Hernia: <?= $data['hernea'] ?></td>
</tr>
<tr>
<td height="1%">14. Any Other Abnormality: <?= $data['any_other_abnormality'] ?></td>
</tr>
<tr>
<td height="1%">15. Urine: Reaction: <?= $data['reaction'] ?></td>
</tr>
<tr>
<td height="1%"><span style="margin-left: 60px">Albumin: </span><?= $data['albumin'] ?></td>
<td align="center"> Sugar: </span><?= $data['sugar'] ?></td>
</tr>
<tr>
<td align="left">16. Skiagram Of Chest:</td>
<td align="center"><?= $data['skiagram_of_chest'] ?></td>
</tr>
<tr>
<td align="left">17. Any other test considered necessary by the examining authority.</td>
<td align="center"><?= $data['any_other_test_considered_necessary_by_the_examining_authority'] ?></td>
</tr>
<tr height="2%">
<td align="left">18. Any opinion of specialist considered necessary. </td>
<td align="center"><?= $data['any_opinion_of_specialist_considered_necessary'] ?></td>
</tr>
<br>
<tr>
<td colspan="2" align="right"> <span class="profile-picture" id="profile-picture1"> <img src="data:<?php echo $row_sign['image_type'] ?>;base64,<?php echo base64_encode($row_sign['emp_sign']) ?>" style="width: 120px; height: 40px;" /></span></td>
</tr>
<tr>
<td>PLACE: GHCL LTD SUTRAPADA</td>
<td colspan="2" align="right">Signature of the examining authority</td>
</tr>
<tr>
<td align="left">NAME:<?= getFieldFromTable('patient_name', 'patient_master', 'id', $row_med['doc_attend']); ?>
<td align="right">
DESIGNATION :<?= getFieldFromTable('designation_name', 'designation', 'designation_id', getFieldFromTable('designation_id', 'patient_master', 'id', $row_med['doc_attend'])); ?>
</td>
</td>
</tr>
<tr>
<td align="left">
CITY / TOWN : <?= getFieldFromTable('village', 'patient_master', 'id', $row_med['doc_attend']); ?>
</td>
<td align="right">
DISTRICT : <?= getFieldFromTable('district', 'patient_master', 'id', $row_med['doc_attend']); ?>
</td>
</tr>
<tr>
<td align="left">
PH / MOB: <?= getFieldFromTable('primary_phone', 'patient_master', 'id', $row_med['doc_attend']); ?>
</td>
<td align="right">
EMAIL ADDRESS: <?= getFieldFromTable('offial_email_id', 'patient_master', 'id', $row_med['doc_attend']); ?>
</td>
</tr>
<tr>
<td align="left">PLACE OF POSTING : <?= getFieldFromTable('post', 'patient_master', 'id', $row_med['doc_attend']); ?> </td>
<td align="right">PO. : SUTRAPADA STATE: <?= getFieldFromTable('state', 'patient_master', 'id', $row_med['doc_attend']); ?></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td colspan="2" align="center"><b>Report of medical examination under mines rule 29-B</b></td>
</tr>
<tr>
<td colspan="2" align="center"><b>(To be issued in continuation with Form O)</b></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td>
<p><?= $para_one ?>
</p>
</td>
</tr>
<tr>
<td>
Name: <?= $patient_name ?>
</td>
</tr>
<tr>
<td>
Identifiction Mark: <?= $identification_mark ?>
</td>
</tr>
<tr>
<td align="center">
<b>Result of Lung Function Test (Spirometry)</b>
</td>
</tr>
</table>
<br>
<br>
<table width="100%" cellspacing="0" class="tbl3" border="1">
<tr>
<th>Parameters</th>
<th>Predicted Value</th>
<th>Performed Value</th>
<th>% Of Predicted</th>
</tr>
<tr>
<td>Forced Vital Capacity (FEV)</td>
<td><?= $data['forced_vital_capacity_fev_predicted_value'] ?></td>
<td><?= $data['forced_vital_capacity_fev_parformed_value'] ?></td>
<td><?= $data['forced_vital_capacity_of_predicted'] ?></td>
</tr>
<tr>
<td>Forced Vital Capacity FEV1</td>
<td><?= $data['forced_vital_capacity1_predicted_value'] ?></td>
<td><?= $data['forced_vital_capacity1_fev1_parformed_value'] ?></td>
<td><?= $data['forced_vital_capacity1_fev1_of_predicted'] ?></td>
</tr>
<tr>
<td>FEV1/FVC</td>
<td><?= $data['fev_fvc_predicted_value'] ?></td>
<td><?= $data['fev_fvc_parformed_value'] ?></td>
<td><?= $data['fev_fvc_of_predicted'] ?></td>
</tr>
<tr>
<td>Peak expiratory flow</td>
<td><?= $data['peak_expiratory_flow_predicted_value'] ?></td>
<td><?= $data['peak_expiratory_flow_parformed_value'] ?></td>
<td><?= $data['peak_expiratory_flow_of_predicted'] ?></td>
</tr>
</table>
<table width="100%" class="tbl3" style="page-break-after: always;">
<tr>
<td>Spirometry Report Enclosed</td>
</tr>
<tr>
<td colspan="2" align="right"><span class="profile-picture" id="profile-picture1"> <img src="data:<?php echo $row_sign['image_type'] ?>;base64,<?php echo base64_encode($row_sign['emp_sign']) ?>" style="width: 120px; height: 40px;" /></span></td>
</tr>
<tr>
<td align="right">Signature of examination authority</td>
</tr>
</table>
<br>
<br>
<table width="100%" class="tbl3">
<tr>
<td colspan="2" align="center"><b>Report of Medical Examination as per the recommendations of National Safety Conferences in Mines</b></td>
</tr>
<tr>
<td colspan="2" align="center"><b>(To be issued in continuation with Form O)</b></td>
</tr>
</table>
<br>
<br>
<table width="100%" class="tbl3">
<tr>
<td>
<p><?= $para_one ?>
</p>
</td>
</tr>
<tr>
<td>
Name: <?= $patient_name ?>
</td>
</tr>
<tr>
<td>
Identifiction Mark: <?= $identification_mark ?>
</td>
</tr>
<tr>
<td>
<b>1. Cardiological Assessment</b>
</td>
</tr>
</table>
<br>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<td rowspan="3" width="30%">
Ausculation
</td>
<td width="30%">
S1
</td>
<td width="40%">
<?= $data['auscultation_s1'] ?>
</td>
</tr>
<tr>
<td width="30%">
S2
</td>
<td width="40%">
<?= $data['auscultation_s2'] ?>
</td>
</tr>
<tr>
<td width="30%">
Additional Sould
</td>
<td width="40%">
<?= $data['auscultation_additional_sould'] ?>
</td>
</tr>
<tr>
<td colspan="2">
Electrocardiogram (12 leads) findings:
</td>
<td>
<?= $data['electrocardiogram_12_leads_findings'] ?>
</td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td>Enclosed ECG</td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td><b>2. Neurological assessment</b></td>
</tr>
</table>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<th>Findings</th>
<th>Normal/abnormal</th>
</tr>
<tr>
<td>Superficial reflexes</td>
<td><?= $data['superficial_reflexes'] ?></td>
</tr>
<tr>
<td>Deep Reflexes</td>
<td><?= $data['deep_reflexes'] ?></td>
</tr>
<tr>
<td>Peripheral Circulation</td>
<td><?= $data['peripheral_circulation'] ?></td>
</tr>
<tr>
<td>Vibrational Syndromes</td>
<td><?= $data['vibrational_syndromes'] ?></td>
</tr>
</table>
<br>
<br>
<br>
<table width="100%" class="tbl3">
<tr>
<td><b>3. ILO Classification Of Chest Rediograph:</b></td>
</tr>
</table>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<th>Profusion Of Pneumoconiotic Opacities</th>
<th>Grades</th>
<th>Types</th>
</tr>
<tr>
<td><?= $data['profusional_of_pneumoconiotic_opacities'] ?></td>
<td><?= $data['grades'] ?></td>
<td><?= $data['types'] ?></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td>Enclosed chest radiograph</td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td><b>4. Audiometry Findings</b></td>
</tr>
</table>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<th>Conduction type</th>
<th>Left Ear</th>
<th>Right Ear</th>
</tr>
<tr>
<td>Air Conduction</td>
<?php error_log("air cond ear : " . $data['left_ear_1']); ?>
<td><?= $data['left_ear_1'] ?></td>
<td><?= $data['right_ear_1'] ?></td>
</tr>
<tr>
<td>Bone Conduction</td>
<?php error_log("air cond ear : " . $data['left_ear']); ?>
<td><?= $data['left_ear'] ?></td>
<td><?= $data['right_ear'] ?></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td>Enclosed audiometry report</td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td><b>5. Pathological/Microbiological Investigations</b></td>
</tr>
</table>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<th>S.No.</th>
<th>Tests</th>
<th>Findings</th>
</tr>
<tr>
<td>1.</td>
<td>Blood-TLC,DLC,Hb,ESR,Platelets</td>
<td><?= $data['blood_tc_dc_hb_esr_platelets'] ?></td>
</tr>
<tr>
<td>2.</td>
<td>Blood sugar - fasting & P.P.</td>
<td><?= $data['blood_sugar_fasting_pp'] ?></td>
</tr>
<tr>
<td>3.</td>
<td>Lipid profile</td>
<td><?= $data['lipid_profile'] ?></td>
</tr>
<tr>
<td>4.</td>
<td>Blood Urea,Creatinine</td>
<td><?= $data['blood_urea_creatinine'] ?></td>
</tr>
<tr>
<td>5.</td>
<td>Urine routine</td>
<td><?= $data['urine_routine'] ?></td>
</tr>
<tr>
<td>6.</td>
<td>Stool routine</td>
<td><?= $data['stool_routine'] ?></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td>Enclosed investigation report</td>
</tr>
</table>
<br><br>
<table width="100%" class="tbl3">
<tr>
<td><b>6. Special Test For M<span style="text-transform: lowercase;"></span>n exposure</b></td>
</tr>
</table>
<br>
<table width="100%" cellspacing="0" border="1" class="tbl3">
<tr>
<th>Behavioural Disturbances</th>
<th colspan="2">Present/Not present</th>
</tr>
<tr>
<td rowspan="4">Neurological Disturbances</td>
<td>Speech Defect</td>
<td><?= $data['neurological_disturbances_speech_defect'] ?></td>
</tr>
<tr>
<td>Tremor</td>
<td><?= $data['neurological_disturbances_tremor'] ?></td>
</tr>
<tr>
<td>Adiadocskinesia</td>
<td><?= $data['neurological_disturbances_adiadocokinesia'] ?></td>
</tr>
<tr>
<td>Emotional Changes</td>
<td><?= $data['neurological_disturbances_emotional_change'] ?></td>
</tr>
</table>
<table width="100%" class="tbl3">
<tr>
<td>Enclosed report</td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td><b>7. Any Other Special Tests Required :</b> <?= $data['any_other_tests_required'] ?></td>
</tr>
</table>
<br>
<table width="100%" class="tbl3">
<tr>
<td align="right"><span class="profile-picture" id="profile-picture1"> <img src="data:<?php echo $row_sign['image_type'] ?>;base64,<?php echo base64_encode($row_sign['emp_sign']) ?>" style="width: 120px; height: 40px;" /></span></td>
</tr>
<tr>
<td align="right">Signature of examination authority</td>
</tr>
</table>
</div>
</div>
</div>
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<input type="hidden" name="htmlText" id="htmlText" />
</form>
</div>
<script>
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document.forms['checkup_form_form_pdf'].action = "pdf_dynamic.php";
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document.forms['checkup_form_form_pdf'].submit();
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