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INSURE2.ZIP
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FORM3.FRM
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1993-07-22
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24KB
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671 lines
VERSION 2.00
Begin Form Form3
BackColor = &H00C0C0C0&
BorderStyle = 3 'Fixed Double
Caption = "Medical Information"
ClientHeight = 5880
ClientLeft = 150
ClientTop = 1290
ClientWidth = 9255
ControlBox = 0 'False
Height = 6285
Left = 90
LinkMode = 1 'Source
LinkTopic = "Form3"
MaxButton = 0 'False
MinButton = 0 'False
ScaleHeight = 5880
ScaleWidth = 9255
Top = 945
Width = 9375
Begin SSPanel Panel3D1
Alignment = 7 'Center - MIDDLE
AutoSize = 0 'None
BackColor = &H00C0C0C0&
BevelInner = 1 'Inset
BevelOuter = 0 'None
BevelWidth = 3
BorderWidth = 3
FloodColor = &H00FF0000&
FloodShowPct = -1 'True
FloodType = 0 'None
Font3D = 2 'Raised w/heavy shading
ForeColor = &H00000000&
Height = 1155
Left = 2370
Outline = 0 'False
RoundedCorners = -1 'True
ShadowColor = 0 'Dark Grey
TabIndex = 35
Top = 5715
Width = 4335
Begin SSCommand Command3D3
AutoSize = 0 'None
BevelWidth = 2
Caption = "Return To First Page"
Font3D = 3 'Inset w/light shading
ForeColor = &H00000000&
Height = 855
Left = 1275
Outline = -1 'True
Picture = FORM3.FRX:0000
RoundedCorners = -1 'True
TabIndex = 36
Top = 150
Width = 1875
End
End
Begin SSFrame Frame3D5
Alignment = 0 'Left Justify
Caption = "Misc. Questions:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1335
Left = 120
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 23
Top = 4290
Width = 9060
Begin PictureBox Picture6
BackColor = &H00C0C0C0&
BorderStyle = 0 'None
Height = 180
Left = 7560
ScaleHeight = 180
ScaleWidth = 1215
TabIndex = 43
Top = 1035
Width = 1215
Begin SSOption Option3D8
Alignment = 0 'Text to the Right
Caption = "No"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 675
TabIndex = 45
Top = 0
Value = 0 'False
Width = 570
End
Begin SSOption Option3D7
Alignment = 0 'Text to the Right
Caption = "Yes"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 0
TabIndex = 44
Top = 0
Value = 0 'False
Width = 630
End
End
Begin PictureBox Picture7
BackColor = &H00C0C0C0&
BorderStyle = 0 'None
Height = 180
Left = 7560
ScaleHeight = 180
ScaleWidth = 1215
TabIndex = 46
Top = 810
Width = 1215
Begin SSOption Option3D10
Alignment = 0 'Text to the Right
Caption = "No"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 675
TabIndex = 48
Top = 0
Value = 0 'False
Width = 570
End
Begin SSOption Option3D9
Alignment = 0 'Text to the Right
Caption = "Yes"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 0
TabIndex = 47
Top = 0
Value = 0 'False
Width = 630
End
End
Begin PictureBox Picture4
BackColor = &H00C0C0C0&
BorderStyle = 0 'None
Height = 180
Left = 7560
ScaleHeight = 180
ScaleWidth = 1215
TabIndex = 40
Top = 570
Width = 1215
Begin SSOption Option3D3
Alignment = 0 'Text to the Right
Caption = "No"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 675
TabIndex = 42
Top = 0
Value = 0 'False
Width = 570
End
Begin SSOption Option3D1
Alignment = 0 'Text to the Right
Caption = "Yes"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 0
TabIndex = 41
Top = 0
Value = 0 'False
Width = 615
End
End
Begin PictureBox Picture3
BackColor = &H00C0C0C0&
BorderStyle = 0 'None
Height = 180
Left = 7560
ScaleHeight = 180
ScaleWidth = 1215
TabIndex = 37
Top = 330
Width = 1215
Begin SSOption Option3D2
Alignment = 0 'Text to the Right
Caption = "No"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 675
TabIndex = 39
Top = 0
Value = 0 'False
Width = 570
End
Begin SSOption Option3D4
Alignment = 0 'Text to the Right
Caption = "Yes"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 0
TabIndex = 38
Top = 0
Value = 0 'False
Width = 630
End
End
Begin Label Label5
BackColor = &H00C0C0C0&
Caption = "Are you currently being treated for or taking medication for any condition or disease?"
FontBold = -1 'True
FontItalic = 0 'False
FontName = "Arial"
FontSize = 8.25
FontStrikethru = 0 'False
FontUnderline = 0 'False
Height = 195
Left = 150
TabIndex = 27
Top = 1005
Width = 7125
End
Begin Label Label3
BackColor = &H00C0C0C0&
Caption = "Had treatment or counseling for alcohol or drug dependency?"
FontBold = -1 'True
FontItalic = 0 'False
FontName = "Arial"
FontSize = 8.25
FontStrikethru = 0 'False
FontUnderline = 0 'False
Height = 195
Left = 150
TabIndex = 25
Top = 780
Width = 5175
End
Begin Label Label4
BackColor = &H00C0C0C0&
Caption = "Been a patient in a hospital, sanitarium or other institution?"
FontBold = -1 'True
FontItalic = 0 'False
FontName = "Arial"
FontSize = 8.25
FontStrikethru = 0 'False
FontUnderline = 0 'False
Height = 195
Left = 150
TabIndex = 26
Top = 555
Width = 4950
End
Begin Label Label2
BackColor = &H00C0C0C0&
Caption = "Had surgery or been advised to have surgery which was not done?"
FontBold = -1 'True
FontItalic = 0 'False
FontName = "Arial"
FontSize = 8.25
FontStrikethru = 0 'False
FontUnderline = 0 'False
Height = 195
Left = 150
TabIndex = 24
Top = 345
Width = 5595
End
End
Begin SSFrame Frame3D6
Alignment = 0 'Left Justify
Caption = "Immune System:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1770
Left = 6285
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 28
Top = 2430
Width = 3075
Begin SSCheck Check3D22
Alignment = 0 'Text to the Right
Caption = "S.T.D (ie. Gonorrhea, Syphilis)"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 33
Top = 1455
Value = 0 'False
Width = 2865
End
Begin SSCheck Check3D12
Alignment = 0 'Text to the Right
Caption = "Cancer"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 32
Top = 1185
Value = 0 'False
Width = 885
End
Begin SSCheck Check3D11
Alignment = 0 'Text to the Right
Caption = "Leukemia"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 31
Top = 915
Value = 0 'False
Width = 1110
End
Begin SSCheck Check3D9
Alignment = 0 'Text to the Right
Caption = "Diabetes"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 30
Top = 630
Value = 0 'False
Width = 1035
End
Begin SSCheck Check3D10
Alignment = 0 'Text to the Right
Caption = "Tumor"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 29
Top = 345
Value = 0 'False
Width = 825
End
End
Begin SSFrame Frame3D3
Alignment = 0 'Left Justify
Caption = "Nervous System:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1770
Left = 3105
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 7
Top = 2430
Width = 3120
Begin SSCheck Check3D18
Alignment = 0 'Text to the Right
Caption = "Other Brain Diseases/Disorders"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 15
Top = 1290
Value = 0 'False
Width = 2940
End
Begin SSCheck Check3D19
Alignment = 0 'Text to the Right
Caption = "Mental Disorder"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 14
Top = 990
Value = 0 'False
Width = 1635
End
Begin SSCheck Check3D20
Alignment = 0 'Text to the Right
Caption = "Epilepsy"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 13
Top = 690
Value = 0 'False
Width = 975
End
Begin SSCheck Check3D21
Alignment = 0 'Text to the Right
Caption = "Convulsions"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 12
Top = 375
Value = 0 'False
Width = 1305
End
End
Begin SSFrame Frame3D2
Alignment = 0 'Left Justify
Caption = "Respiratory:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1770
Left = 120
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 6
Top = 2430
Width = 2925
Begin SSCheck Check3D13
Alignment = 0 'Text to the Right
Caption = "Other Lung Disease/Disorder"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 11
Top = 1290
Value = 0 'False
Width = 2760
End
Begin SSCheck Check3D8
Alignment = 0 'Text to the Right
Caption = "Tuberculosis"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 10
Top = 975
Value = 0 'False
Width = 1350
End
Begin SSCheck Check3D7
Alignment = 0 'Text to the Right
Caption = "Emphysema"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 9
Top = 660
Value = 0 'False
Width = 1260
End
Begin SSCheck Check3D6
Alignment = 0 'Text to the Right
Caption = "Asthma"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 8
Top = 360
Value = 0 'False
Width = 885
End
End
Begin PictureBox Picture1
AutoSize = -1 'True
BackColor = &H00C0C0C0&
BorderStyle = 0 'None
Height = 2205
Left = 8340
Picture = FORM3.FRX:0302
ScaleHeight = 2205
ScaleWidth = 1440
TabIndex = 34
Top = 600
Width = 1440
Begin PictureBox Picture2
AutoSize = -1 'True
BackColor = &H00FFFFFF&
BorderStyle = 0 'None
Height = 480
Left = 150
Picture = FORM3.FRX:1DBE
ScaleHeight = 480
ScaleWidth = 480
TabIndex = 49
Top = 315
Width = 480
End
End
Begin SSFrame Frame3D4
Alignment = 0 'Left Justify
Caption = "Diseases or Disorders of the:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1905
Left = 3570
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 17
Top = 480
Width = 4710
Begin SSCheck Check3D27
Alignment = 0 'Text to the Right
Caption = "Ears, Eyes, Nose or Sinuses"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 22
Top = 1560
Value = 0 'False
Width = 2805
End
Begin SSCheck Check3D26
Alignment = 0 'Text to the Right
Caption = "Blood, Glands or Skin"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 21
Top = 1275
Value = 0 'False
Width = 2190
End
Begin SSCheck Check3D25
Alignment = 0 'Text to the Right
Caption = "Spine, Joints, Skull or other Bones"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 20
Top = 975
Value = 0 'False
Width = 3285
End
Begin SSCheck Check3D24
Alignment = 0 'Text to the Right
Caption = "Kidney, Bladder, Genital Organs or Urinary Tract"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 19
Top = 675
Value = 0 'False
Width = 4440
End
Begin SSCheck Check3D23
Alignment = 0 'Text to the Right
Caption = "Liver, Gallbladder, Stomach, Intestines or Rectum"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 18
Top = 360
Value = 0 'False
Width = 4515
End
End
Begin SSFrame Frame3D1
Alignment = 0 'Left Justify
Caption = "Pulmonary:"
Font3D = 1 'Raised w/light shading
ForeColor = &H00000000&
Height = 1905
Left = 120
ShadowColor = 0 'Dark Grey
ShadowStyle = 0 'Inset
TabIndex = 0
Top = 480
Width = 3390
Begin SSCheck Check3D5
Alignment = 0 'Text to the Right
Caption = "Other Heart Diseases/Disorders"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 5
Top = 1575
Value = 0 'False
Width = 3030
End
Begin SSCheck Check3D4
Alignment = 0 'Text to the Right
Caption = "Heart Murmur"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 4
Top = 1275
Value = 0 'False
Width = 1425
End
Begin SSCheck Check3D3
Alignment = 0 'Text to the Right
Caption = "Rheumatic Fever"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 3
Top = 975
Value = 0 'False
Width = 1725
End
Begin SSCheck Check3D2
Alignment = 0 'Text to the Right
Caption = "Chest Pain or Pressure"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 2
Top = 660
Value = 0 'False
Width = 2235
End
Begin SSCheck Check3D1
Alignment = 0 'Text to the Right
Caption = "High Blood Pressure"
Font3D = 0 'None
ForeColor = &H00000000&
Height = 195
Left = 120
TabIndex = 1
Top = 345
Value = 0 'False
Width = 2010
End
End
Begin Label Label1
BackColor = &H00C0C0C0&
Caption = "Please Check All Below that Apply:"
FontBold = -1 'True
FontItalic = 0 'False
FontName = "Arial"
FontSize = 18
FontStrikethru = 0 'False
FontUnderline = 0 'False
Height = 450
Left = 1710
TabIndex = 16
Top = 60
Width = 6120
End
End
Sub Command1_Click ()
form2.Hide
form1.Show
End Sub
Sub Command3D3_Click ()
form1.Show
form3.Hide
End Sub
Sub Form_Load ()
form3.WindowState = 2
picture1.Width = 1020
picture1.Height = 1740
End Sub