fp/excel

[Painfree]

Maybe this wil help..it is the html for this form to give you an idea I am a
newbie without money for a real web preson!


<p> </p>
<p><strong>Please take a few seconds to fill out this
questionnaire...</strong></p>
<form method="POST" action="--WEBBOT-SELF--" onsubmit="return
FrontPage_Form1_Validator(this)" name="FrontPage_Form1" language="JavaScript">
<!--webbot bot="SaveResults" s-label-fields="TRUE"
b-reverse-chronology="FALSE" s-label-fields="TRUE"
b-reverse-chronology="FALSE" s-email-format="TEXT/PRE"
s-email-address="(e-mail address removed)" b-email-label-fields="TRUE"
b-email-subject-from-field="FALSE" s-email-subject="British Study"
s-builtin-fields="Date Time REMOTE_NAME REMOTE_USER HTTP_USER_AGENT"
u-file="_private/form_results.txt" s-format startspan --><input TYPE="hidden"
NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan
i-checksum="43374" --><p><b>Please enter your e-mail address:</b></p>
<p><input type="text" name="email" size="30"></p>
<p><strong>1. Do you have neck pain as the result of an auto
crash or accident?</strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="HaveNeckPain" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Yes, I have neck pain as a result of an auto
accident</option>
<option value="2">No, I don't have neck pain as a result of an
auto
accident</option>
</select></p>
<p><strong>2. If your vehicle was hit by another vehicle, what
was the direction of
the impact? </strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="Vector" size="1">
<option value="Click Here">Click Here</option>
<option value="Rear End (Another car hit the rear of my
car)">Rear End
(Another car hit the rear of my car)</option>
<option value="Side Impact">Side Impact</option>
<option value="Front Impact">Front Impact</option>
<option value="Other">Other</option>
<option value="Not sure...">Not sure...</option>
<option value="I wasn't hit by another vehicle...">I wasn't hit by
another vehicle...</option>
</select></p>
<p><strong>3. How long ago was your accident?</strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="PainDuration" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Less than 3 months ago</option>
<option value="2">3 months to 6 months</option>
<option value="3">6 months to 12 months</option>
<option value="4">1 year to 3 years</option>
<option value="5">More than 3 years</option>
</select></p>
<p><strong>4. Were you the driver or a passenger in the
vehicle?</strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="PositionInCar" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Driver</option>
<option value="2">Front Seat Passenger</option>
<option value="3">Other Passenger</option>
<option value="4">Not Sure</option>
<option value="5">Other</option>
</select></p>
<p><strong>5. Was the vehicle you were in at the time of the
accident left hand
drive (American Type Vehicle) or right hand drive (British Type
Vehicle)?</strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="SideOfSteeringWheel" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Left Hand Drive (American Type Vehicle)</option>
<option value="2">Right Hand Drive (British Type Vehicle)</option>
<option value="3">Not Sure</option>
</select></p>
<p><strong>6. Turn your head <u>right</u> then bring it back as
far as you can and
look at the ceiling, as shown below. Notice how much pain you have in
the back of
your neck. (Ignore any pain or pulling in the front of the neck).
</strong></p>
<p><img src="_borders/leftsi1.jpg" alt="wpe52.jpg (7301 bytes)"
width="198" height="198" align="left"><strong>Head back </strong></p>
<p><strong>and to the right.</strong></p>
<p> </p>
<p> </p>
<p> </p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="RightRotation" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Hurts more on the right...</option>
<option value="2">Hurts more on the left...</option>
<option value="3">Hurts equally on both sides...</option>
<option value="4">Neither side hurts much in the back...</option>
</select></p>
<p><strong>7. Then turn it <u>left</u> and bring it back as far
as you can and look
at the ceiling, as shown below. </strong></p>
<p><img src="_borders/leftsi2.jpg" alt="wpe53.jpg (7548 bytes)"
width="197" height="197" align="left"><strong>Head back </strong></p>
<p><strong>and to the left.</strong></p>
<p> </p>
<p> </p>
<p> </p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="LeftRotation" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Hurts more on the right...</option>
<option value="2">Hurts more on the left...</option>
<option value="3">Hurts equally on both sides...</option>
<option value="4">Neither side hurts much in the back...</option>
</select></p>
<p><strong>8. Do this a few times on each side, which side hurts
more in the back of the
neck?</strong></p>
<p>
<!--webbot bot="Validation" b-value-required="TRUE"
b-disallow-first-item="TRUE" --><select name="ComparePain" size="1">
<option value="Click Here">Click Here</option>
<option value="1">Hurts more on the right...</option>
<option value="2">Hurts more on the left...</option>
<option value="3">Hurts equally on both sides...</option>
<option value="4">Neither side hurts much in the back...</option>
</select></p>
<p><strong>Thanks for helping us understand whiplash better. When
you're done, press
the submit button below...</strong></p>
<p><input type="submit" value="Submit" name="B1"><input
type="reset" value="Reset" name="B2"></p>
</form>