<? 
include "datainput.php"; 
include "Header.php";
$taal=$_POST['taal'];

//Nederlands
if ($taal=="Ned") {
$vraag_geslacht="Wat is uw geslacht?";
$antw_man="Man";
$antw_vrouw="Vrouw";
$antw_andere="Andere";
$vraag_leeftijd="Welk is uw geboortejaar?";
$antw_leeftijd="Geboortejaar...";
$vraag_land="In welk land woont u?";
$antw_land="Land...";
$antw_ja="Ja";
$antw_neen="Neen";

$vraag_hoesten="Moet u plots hoesten zonder duidelijke oorzaak?";
$vraag_dyspnoe="Bent u plots kortademig zonder duidelijke oorzaak?";
$vraag_pijn="Hebt u plots pijn op de borst zonder duidelijke oorzaak?";
$vraag_geur="Hebt u plots verlies van reukvermogen zonder duidelijke oorzaak?";
$vraag_smaak="Hebt u plots verlies van smaakvermogen zonder duidelijke oorzaak?";

$vraag_koorts="Hebt u koorts (38 graden of meer) zonder duidelijke oorzaak?";
$vraag_spier="Hebt u spierpijn zonder duidelijke oorzaak?";
$vraag_vermoeid="Bent u vermoeid zonder duidelijke oorzaak?";
$vraag_neus="Hebt u neusloop zonder duidelijke oorzaak?";
$vraag_keel="Hebt u keelpijn zonder duidelijke oorzaak?";
$vraag_hoofdpijn="Hebt u hoofdpijn zonder duidelijke oorzaak?";
$vraag_diarree="Hebt u waterige diarree zonder duidelijke oorzaak?";
$vraag_eetlust="Hebt u verminderde eetlust zonder duidelijke oorzaak?";
$vraag_verward="Bent u plots verward zonder duidelijke oorzaak?";
$vraag_vallen="Hebt u neiging om te vallen zonder duidelijke oorzaak?";

$vraag_luchtweg="Hebt u een chronische luchtwegaandoening (COPD, astma, chronische hoest…) en hebt u een verergering van de klachten?";


$vraag_slijm="Zijn er slijmen bij uw hoest?";
$vraag_adem="Hebt u plots ademhalingsmoeilijkheden?";

$vraag_china="Bent u gedurende de 14 dagen die aan de ziekte vooraf gingen in één van de volgende landen geweest:
China, Zuid-Korea, Iran of Noord Italië (regio’s van Lombardije, Veneto, Emilia-Romagna, Piemonte, Ligurië, Trentino,
Zuid-Tirol, Friuli-Venezia Giulia, Valle d’Aosta en Marche)?";

$vraag_contact2="Hebt u tekens van een ernstige acute luchtweginfectie en/of klinisch of radiologisch bewijs van longontsteking, 
die een ziekenhuisopname vereist, indien er geen aanwijzingen zijn van een bacteriële infectie.";

$vraag_contact="Hebt u gedurende de 14 dagen die aan de ziekte vooraf gingen nauw lichamelijk contact gehad met iemand met een bewezen corona-infectie?";

$vraag_risico="Hebt u een hartziekte, een longziekte zoals ernstig astma of COPD, een lever- of nierziekte, diabetes, een chronische spierziekte, 
of een verminderde weerstand door andere ziekten of door een medische behandeling?";

//archief
$vraag_hubei="Bent u in de Chinse provincie HUBEI geweest gedurende de 14 dagen die aan de klachten vooraf gingen?";
$vraag_landen="Bent u gedurende de 14 dagen die aan de ziekte vooraf gingen in één van de volgende landen geweest:
Singapore of Japan?";

$knop="Klik hier voor uw resultaat";
$link="evaluatie.php?taal=Ned";
$fout="U moet alle vragen beantwoorden";
}


//Frans
if ($taal=="Fra") {
$vraag_geslacht="Quel est votre sexe?";
$antw_man="Homme";
$antw_vrouw="Femme";
$antw_andere="Autre";
$vraag_leeftijd="Quelle est votre année de naissance?";
$antw_leeftijd="Année de naissance...";
$vraag_land="Dans quel pays habitez-vous?";
$antw_land="Pays...";
$antw_ja="Oui";
$antw_neen="Non";

$vraag_hoesten="Avez-vous soudainement une toux sans cause évidente?";
$vraag_dyspnoe="Êtes-vous soudainement essoufflé sans cause apparente?";
$vraag_pijn="Avez-vous soudainement des douleurs thoraciques sans raison apparente?";
$vraag_geur="Avez-vous soudainement une perte d'odorat sans raison apparente?";
$vraag_smaak="Avez-vous soudainement une perte de goût sans raison apparente?";

$vraag_koorts="Avez-vous de la fièvre (38 degrés ou plus) sans raison apparente?";
$vraag_spier="Avez-vous des douleurs musculaires sans raison apparente?";
$vraag_vermoeid="Êtes-vous fatigué sans raison apparente?";
$vraag_neus="Avez-vous le nez qui coule sans cause apparente?";
$vraag_keel="Avez-vous mal à la gorge sans cause évidente?";
$vraag_hoofdpijn="Avez-vous mal à la tête sans raison apparente?";
$vraag_diarree="Avez-vous une diarrhée aqueuse sans raison apparente?";
$vraag_eetlust="Avez-vous un appétit diminué sans raison apparente?";
$vraag_verward="Êtes-vous soudain confus sans raison apparente?";
$vraag_vallen="Avez-vous tendance à tomber sans raison apparente?";

$vraag_luchtweg="Avez-vous une maladie respiratoire chronique (MPOC, asthme, toux chronique ...)
et avez-vous une aggravation des plaintes?";

$knop="Cliquez ici pour votre résultat";
$link="evaluatie.php?taal=Fra";
$fout="Vous devez répondre à toutes les questions";
}


//Engels
if ($taal=="Eng") {
$vraag_geslacht="What is your gender?";
$antw_man="Man";
$antw_vrouw="Woman";
$antw_andere="Other";
$vraag_leeftijd="What is your year of birth?";
$antw_leeftijd="Year of birth...";
$vraag_land="In which country do you live?";
$antw_land="Country...";
$antw_ja="Yes";
$antw_neen="No";

$vraag_hoesten="Do you suddenly have a cough without an obvious cause?";
$vraag_dyspnoe="Are you suddenly short of breath with no apparent cause?";
$vraag_pijn="Do you suddenly have chest pain for no apparent reason?";
$vraag_geur="Do you suddenly have a loss of sense of smell for no apparent reason?";
$vraag_smaak="Do you suddenly have a loss of taste for no apparent reason?";

$vraag_koorts="Do you have a fever (38 degrees or more) for no apparent reason?";
$vraag_spier="Do you have muscle pain for no apparent reason?";
$vraag_vermoeid="Are you tired for no apparent reason?";
$vraag_neus="Do you have a runny nose with no apparent cause?";
$vraag_keel="Do you have a sore throat without an obvious cause?";
$vraag_hoofdpijn="Do you have a headache for no apparent reason?";
$vraag_diarree="Do you have watery diarrhea for no apparent reason?";
$vraag_eetlust="Do you have a decreased appetite for no apparent reason?";
$vraag_verward="Are you suddenly confused for no apparent reason?";
$vraag_vallen="Do you tend to fall for no apparent reason?";

$vraag_luchtweg="Do you have a chronic respiratory disease (COPD, asthma, chronic cough ...)
and do you have a worsening of the complaints?";

$knop="Click here for your result";
$link="evaluatie.php?taal=Eng";
$fout="You must answer all questions";
}


//Duits
if ($taal=="Deu") {
$vraag_geslacht="Was ist dein Geschlecht?";
$antw_man="Mann";
$antw_vrouw="Frau";
$antw_andere="Andere";
$vraag_leeftijd="Was ist dein Geburtsjahr?";
$antw_leeftijd="Geburtsjahr...";
$vraag_land="In welchem Land leben Sie?";
$antw_land="Land...";
$antw_ja="Ja";
$antw_neen="Nein";

$vraag_hoesten="Haben Sie plötzlich Husten ohne offensichtliche Ursache?";
$vraag_dyspnoe="Sind Sie plötzlich kurzatmig ohne erkennbaren Grund?";
$vraag_pijn="Haben Sie plötzlich Schmerzen in der Brust ohne ersichtlichen Grund?";
$vraag_geur="Haben Sie plötzlich einen Geruchssinnverlust ohne ersichtlichen Grund?";
$vraag_smaak="Haben Sie plötzlich einen Geschmacksverlust ohne ersichtlichen Grund?";

$vraag_koorts="Haben Sie ohne ersichtlichen Grund Fieber (38 Grad oder mehr)?";
$vraag_spier="Haben Sie ohne ersichtlichen Grund Muskelschmerzen?";
$vraag_vermoeid="Bist du ohne ersichtlichen Grund müde??";
$vraag_neus="Haben Sie eine laufende Nase ohne erkennbaren Grund??";
$vraag_keel="Haben Sie Halsschmerzen ohne offensichtliche Ursache?";
$vraag_hoofdpijn="Haben Sie ohne ersichtlichen Grund Kopfschmerzen?";
$vraag_diarree="Haben Sie wässrigen Durchfall ohne ersichtlichen Grund?";
$vraag_eetlust="Haben Sie ohne ersichtlichen Grund einen verminderten Appetit?";
$vraag_verward="Sind Sie plötzlich ohne ersichtlichen Grund verwirrt?";
$vraag_vallen="Neigen Sie dazu, ohne ersichtlichen Grund zu fallen?";

$vraag_luchtweg="Haben Sie eine chronische Atemwegserkrankung (COPD, Asthma, chronischer Husten ...)
und haben Sie eine Verschlechterung der Beschwerden?";

$knop="Klicken Sie hier für Ihr Ergebnis";
$link="evaluatie.php?taal=Deu";
$fout="Sie müssen alle Fragen beantworten";
}


//Spaans
if ($taal=="Spa") {
$vraag_geslacht="¿Cuál es su género?";
$antw_man="Hombre";
$antw_vrouw="Mujer";
$antw_andere="Otros";
$vraag_leeftijd="¿Cuál es tu año de nacimiento?";
$antw_leeftijd="Año de nacimiento...";
$vraag_land="¿En que país vives?";
$antw_land="Pais...";
$antw_ja="Si";
$antw_neen="No";

$vraag_hoesten="¿De repente tiene tos sin razón aparente?";
$vraag_dyspnoe="¿De repente te falta el aliento sin razón aparente?";
$vraag_pijn="¿De repente tiene dolor en el pecho sin razón aparente?";
$vraag_geur="¿De repente tiene pérdida del olfato sin razón aparente?";
$vraag_smaak="¿De repente tiene pérdida de gusto sin razón aparente?";

$vraag_koorts="¿Tiene fiebre (38 grados o más) sin razón aparente?";
$vraag_spier="¿Tienes dolor muscular sin razón aparente?";
$vraag_vermoeid="¿Estás cansado sin razón aparente?";
$vraag_neus="¿Tienes secreción nasal sin causa aparente?";
$vraag_keel="¿Tienes dolor de garganta sin razón aparente?";
$vraag_hoofdpijn="¿Tienes dolor de cabeza sin razón aparente?";
$vraag_diarree="¿Tienes diarrea acuosa sin razón aparente?";
$vraag_eetlust="¿Tiene disminución del apetito sin razón aparente?";
$vraag_verward="¿De repente estás confundido sin razón aparente?";
$vraag_vallen="¿Tiende a caer sin razón aparente?";

$vraag_luchtweg="¿Tiene una enfermedad respiratoria crónica (EPOC, asma, tos crónica ...)
y tienes un empeoramiento de las quejas?";


$knop="Haga clic aquí para obtener su resultado";
$link="evaluatie.php?taal=Spa";
$fout="Debes responder todas las preguntas";
}

?>

<script language="JavaScript">
<!--
function SymError()
{
  return true;
}

window.onerror = SymError;
//-->
</script>
<SCRIPT LANGUAGE=JAVASCRIPT TYPE="TEXT/JAVASCRIPT">
		function validForm(Form) {
			if ((Form.geslacht[0].checked == false) && (Form.geslacht[1].checked == false) && (Form.geslacht[2].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
         if( Form.geboortejaar.value == "-1" ) {
            alert( "<? echo $fout; ?>" );
            return false;
         }
         if( Form.land.value == "-1" ) {
            alert( "<? echo $fout; ?>" );
            return false;
         }
			if ((Form.hoesten[0].checked == false) && (Form.hoesten[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.dyspnoe[0].checked == false) && (Form.dyspnoe[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.pijn[0].checked == false) && (Form.pijn[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.geur[0].checked == false) && (Form.geur[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.smaak[0].checked == false) && (Form.smaak[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}


			if ((Form.koorts[0].checked == false) && (Form.koorts[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.spier[0].checked == false) && (Form.spier[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.vermoeid[0].checked == false) && (Form.vermoeid[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.neus[0].checked == false) && (Form.neus[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.keel[0].checked == false) && (Form.keel[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.hoofdpijn[0].checked == false) && (Form.hoofdpijn[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.eetlust[0].checked == false) && (Form.eetlust[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.diarree[0].checked == false) && (Form.diarree[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.verward[0].checked == false) && (Form.verward[1].checked == false))
			{
			alert("<? echo $fout; ?>");
			return false;
			}
			if ((Form.vallen[0].checked == false) && (Form.vallen[1].checked == false))
			{
			alert("<? echo $fout; ?>");			
			return false;
			}
			if ((Form.luchtweg[0].checked == false) && (Form.luchtweg[1].checked == false))
			{
			alert("<? echo $fout; ?>");			
			return false;
			}
		return true;
		}
</SCRIPT>
<div align="center">
<font size="+1">
<FORM onsubmit="return validForm(this)" ACTION="<? echo $link; ?>" METHOD="POST">
<input name="uid" type="hidden" value="<? echo $uid; ?>">
<table width="100% align="center" border="0">
  	<tr><td width="50%" >
		<p><? echo $vraag_geslacht; ?></b></td><td width="70%" ><input name="geslacht" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_man; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;<input name="geslacht" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_vrouw; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;<input name="geslacht" type="radio" value="3"">&nbsp;&nbsp;<? echo $antw_andere; ?></p>
	</td></tr>
  	<tr><td>
		<p><? echo $vraag_leeftijd; ?></b></td><td>
			<select name="geboortejaar">
				<option value="-1"><? echo $antw_leeftijd; ?></option>
				<option value="1920">1920</option>
				<option value="1921">1921</option>
				<option value="1922">1922</option>
				<option value="1923">1923</option>
				<option value="1924">1924</option>
				<option value="1925">1925</option>
				<option value="1926">1926</option>
				<option value="1927">1927</option>
				<option value="1928">1928</option>
				<option value="1929">1929</option>
				<option value="1930">1930</option>
				<option value="1931">1931</option>
				<option value="1932">1932</option>
				<option value="1933">1933</option>
				<option value="1934">1934</option>
				<option value="1935">1935</option>
				<option value="1936">1936</option>
				<option value="1937">1937</option>
				<option value="1938">1938</option>
				<option value="1939">1939</option>
				<option value="1940">1940</option>
				<option value="1941">1941</option>
				<option value="1942">1942</option>
				<option value="1943">1943</option>
				<option value="1944">1944</option>
				<option value="1945">1945</option>
				<option value="1946">1946</option>
				<option value="1947">1947</option>
				<option value="1948">1948</option>
				<option value="1949">1949</option>
				<option value="1950">1950</option>
				<option value="1951">1951</option>
				<option value="1952">1952</option>
				<option value="1953">1953</option>
				<option value="1954">1954</option>
				<option value="1955">1955</option>
				<option value="1956">1956</option>
				<option value="1957">1957</option>
				<option value="1958">1958</option>
				<option value="1959">1959</option>
				<option value="1960">1960</option>
				<option value="1961">1961</option>
				<option value="1962">1962</option>
				<option value="1963">1963</option>
				<option value="1964">1964</option>
				<option value="1965">1965</option>
				<option value="1966">1966</option>
				<option value="1967">1967</option>
				<option value="1968">1968</option>
				<option value="1969">1969</option>
				<option value="1970">1970</option>
				<option value="1971">1971</option>
				<option value="1972">1972</option>
				<option value="1973">1973</option>
				<option value="1974">1974</option>
				<option value="1975">1975</option>
				<option value="1976">1976</option>
				<option value="1977">1977</option>
				<option value="1978">1978</option>
				<option value="1979">1979</option>
				<option value="1980">1980</option>
				<option value="1981">1981</option>
				<option value="1982">1982</option>
				<option value="1983">1983</option>
				<option value="1984">1984</option>
				<option value="1985">1985</option>
				<option value="1986">1986</option>
				<option value="1987">1987</option>
				<option value="1988">1988</option>
				<option value="1989">1989</option>
				<option value="1990">1990</option>
				<option value="1991">1991</option>
				<option value="1992">1992</option>
				<option value="1993">1993</option>
				<option value="1994">1994</option>
				<option value="1995">1995</option>
				<option value="1996">1996</option>
				<option value="1997">1997</option>
				<option value="1998">1998</option>
				<option value="1999">1999</option>
				<option value="2000">2000</option>
				<option value="2001">2001</option>
				<option value="2002">2002</option>
				<option value="2003">2003</option>
				<option value="2004">2004</option>
				<option value="2005">2005</option>
				<option value="2006">2006</option>
				<option value="2007">2007</option>
				<option value="2008">2008</option>
				<option value="2009">2009</option>
				<option value="2010">2010</option>
				<option value="2011">2011</option>
				<option value="2012">2012</option>
				<option value="2013">2013</option>
				<option value="2014">2014</option>
				<option value="2015">2015</option>
				<option value="2016">2016</option>
				<option value="2017">2017</option>
				<option value="2018">2018</option>
				<option value="2019">2019</option>
				<option value="2020">2020</option>	
		</p>
	</td></tr>
  	<tr><td>
		<p><? echo $vraag_land; ?></b></td><td>
			<select name="land">
			<option value="-1"><? echo $antw_land; ?></option>
			<option value="Afganistan">Afghanistan</option>
			<option value="Albania">Albania</option>
			<option value="Algeria">Algeria</option>
			<option value="American Samoa">American Samoa</option>
			<option value="Andorra">Andorra</option>
			<option value="Angola">Angola</option>
			<option value="Anguilla">Anguilla</option>
			<option value="Antigua &amp; Barbuda">Antigua &amp; Barbuda</option>
			<option value="Argentina">Argentina</option>
			<option value="Armenia">Armenia</option>
			<option value="Aruba">Aruba</option>
			<option value="Australia">Australia</option>
			<option value="Austria">Austria</option>
			<option value="Azerbaijan">Azerbaijan</option>
			<option value="Bahamas">Bahamas</option>
			<option value="Bahrain">Bahrain</option>
			<option value="Bangladesh">Bangladesh</option>
			<option value="Barbados">Barbados</option>
			<option value="Belarus">Belarus</option>
			<option value="Belgium">Belgium</option>
			<option value="Belize">Belize</option>
			<option value="Benin">Benin</option>
			<option value="Bermuda">Bermuda</option>
			<option value="Bhutan">Bhutan</option>
			<option value="Bolivia">Bolivia</option>
			<option value="Bonaire">Bonaire</option>
			<option value="Bosnia &amp; Herzegovina">Bosnia &amp; Herzegovina</option>
			<option value="Botswana">Botswana</option>
			<option value="Brazil">Brazil</option>
			<option value="British Indian Ocean Ter">British Indian Ocean Ter</option>
			<option value="Brunei">Brunei</option>
			<option value="Bulgaria">Bulgaria</option>
			<option value="Burkina Faso">Burkina Faso</option>
			<option value="Burundi">Burundi</option>
			<option value="Cambodia">Cambodia</option>
			<option value="Cameroon">Cameroon</option>
			<option value="Canada">Canada</option>
			<option value="Canary Islands">Canary Islands</option>
			<option value="Cape Verde">Cape Verde</option>
			<option value="Cayman Islands">Cayman Islands</option>
			<option value="Central African Republic">Central African Republic</option>
			<option value="Chad">Chad</option>
			<option value="Channel Islands">Channel Islands</option>
			<option value="Chile">Chile</option>
			<option value="China">China</option>
			<option value="Christmas Island">Christmas Island</option>
			<option value="Cocos Island">Cocos Island</option>
			<option value="Colombia">Colombia</option>
			<option value="Comoros">Comoros</option>
			<option value="Congo Democratic Replubic">Congo Democratic Replubic</option>
			<option value="Congo Brazzaville">Congo Brazzaville</option>
			<option value="Cook Islands">Cook Islands</option>
			<option value="Costa Rica">Costa Rica</option>
			<option value="Cote DIvoire">Cote D'Ivoire</option>
			<option value="Croatia">Croatia</option>
			<option value="Cuba">Cuba</option>
			<option value="Curaco">Curacao</option>
			<option value="Cyprus">Cyprus</option>
			<option value="Czech Republic">Czech Republic</option>
			<option value="Denmark">Denmark</option>
			<option value="Djibouti">Djibouti</option>
			<option value="Dominica">Dominica</option>
			<option value="Dominican Republic">Dominican Republic</option>
			<option value="East Timor">East Timor</option>
			<option value="Ecuador">Ecuador</option>
			<option value="Egypt">Egypt</option>
			<option value="El Salvador">El Salvador</option>
			<option value="Equatorial Guinea">Equatorial Guinea</option>
			<option value="Eritrea">Eritrea</option>
			<option value="Estonia">Estonia</option>
			<option value="Ethiopia">Ethiopia</option>
			<option value="Falkland Islands">Falkland Islands</option>
			<option value="Faroe Islands">Faroe Islands</option>
			<option value="Fiji">Fiji</option>
			<option value="Finland">Finland</option>
			<option value="France">France</option>
			<option value="French Guiana">French Guiana</option>
			<option value="French Polynesia">French Polynesia</option>
			<option value="French Southern Ter">French Southern Ter</option>
			<option value="Gabon">Gabon</option>
			<option value="Gambia">Gambia</option>
			<option value="Georgia">Georgia</option>
			<option value="Germany">Germany</option>
			<option value="Ghana">Ghana</option>
			<option value="Gibraltar">Gibraltar</option>
			<option value="Great Britain">Great Britain</option>
			<option value="Greece">Greece</option>
			<option value="Greenland">Greenland</option>
			<option value="Grenada">Grenada</option>
			<option value="Guadeloupe">Guadeloupe</option>
			<option value="Guam">Guam</option>
			<option value="Guatemala">Guatemala</option>
			<option value="Guinea">Guinea</option>
			<option value="Guyana">Guyana</option>
			<option value="Haiti">Haiti</option>
			<option value="Hawaii">Hawaii</option>
			<option value="Honduras">Honduras</option>
			<option value="Hong Kong">Hong Kong</option>
			<option value="Hungary">Hungary</option>
			<option value="Iceland">Iceland</option>
			<option value="India">India</option>
			<option value="Indonesia">Indonesia</option>
			<option value="Iran">Iran</option>
			<option value="Iraq">Iraq</option>
			<option value="Ireland">Ireland</option>
			<option value="Isle of Man">Isle of Man</option>
			<option value="Israel">Israel</option>
			<option value="Italy">Italy</option>
			<option value="Jamaica">Jamaica</option>
			<option value="Japan">Japan</option>
			<option value="Jordan">Jordan</option>
			<option value="Kazakhstan">Kazakhstan</option>
			<option value="Kenya">Kenya</option>
			<option value="Kiribati">Kiribati</option>
			<option value="Korea North">Korea North</option>
			<option value="Korea Sout">Korea South</option>
			<option value="Kuwait">Kuwait</option>
			<option value="Kyrgyzstan">Kyrgyzstan</option>
			<option value="Laos">Laos</option>
			<option value="Latvia">Latvia</option>
			<option value="Lebanon">Lebanon</option>
			<option value="Lesotho">Lesotho</option>
			<option value="Liberia">Liberia</option>
			<option value="Libya">Libya</option>
			<option value="Liechtenstein">Liechtenstein</option>
			<option value="Lithuania">Lithuania</option>
			<option value="Luxembourg">Luxembourg</option>
			<option value="Macau">Macau</option>
			<option value="Macedonia">Macedonia</option>
			<option value="Madagascar">Madagascar</option>
			<option value="Malaysia">Malaysia</option>
			<option value="Malawi">Malawi</option>
			<option value="Maldives">Maldives</option>
			<option value="Mali">Mali</option>
			<option value="Malta">Malta</option>
			<option value="Marshall Islands">Marshall Islands</option>
			<option value="Martinique">Martinique</option>
			<option value="Mauritania">Mauritania</option>
			<option value="Mauritius">Mauritius</option>
			<option value="Mayotte">Mayotte</option>
			<option value="Mexico">Mexico</option>
			<option value="Midway Islands">Midway Islands</option>
			<option value="Moldova">Moldova</option>
			<option value="Monaco">Monaco</option>
			<option value="Mongolia">Mongolia</option>
			<option value="Montserrat">Montserrat</option>
			<option value="Morocco">Morocco</option>
			<option value="Mozambique">Mozambique</option>
			<option value="Myanmar">Myanmar</option>
			<option value="Nambia">Nambia</option>
			<option value="Nauru">Nauru</option>
			<option value="Nepal">Nepal</option>
			<option value="Netherland Antilles">Netherland Antilles</option>
			<option value="Netherlands">Netherlands (Holland, Europe)</option>
			<option value="Nevis">Nevis</option>
			<option value="New Caledonia">New Caledonia</option>
			<option value="New Zealand">New Zealand</option>
			<option value="Nicaragua">Nicaragua</option>
			<option value="Niger">Niger</option>
			<option value="Nigeria">Nigeria</option>
			<option value="Niue">Niue</option>
			<option value="Norfolk Island">Norfolk Island</option>
			<option value="Norway">Norway</option>
			<option value="Oman">Oman</option>
			<option value="Pakistan">Pakistan</option>
			<option value="Palau Island">Palau Island</option>
			<option value="Palestine">Palestine</option>
			<option value="Panama">Panama</option>
			<option value="Papua New Guinea">Papua New Guinea</option>
			<option value="Paraguay">Paraguay</option>
			<option value="Peru">Peru</option>
			<option value="Phillipines">Philippines</option>
			<option value="Pitcairn Island">Pitcairn Island</option>
			<option value="Poland">Poland</option>
			<option value="Portugal">Portugal</option>
			<option value="Puerto Rico">Puerto Rico</option>
			<option value="Qatar">Qatar</option>
			<option value="Republic of Montenegro">Republic of Montenegro</option>
			<option value="Republic of Serbia">Republic of Serbia</option>
			<option value="Reunion">Reunion</option>
			<option value="Romania">Romania</option>
			<option value="Russia">Russia</option>
			<option value="Rwanda">Rwanda</option>
			<option value="St Barthelemy">St Barthelemy</option>
			<option value="St Eustatius">St Eustatius</option>
			<option value="St Helena">St Helena</option>
			<option value="St Kitts-Nevis">St Kitts-Nevis</option>
			<option value="St Lucia">St Lucia</option>
			<option value="St Maarten">St Maarten</option>
			<option value="St Pierre &amp; Miquelon">St Pierre &amp; Miquelon</option>
			<option value="St Vincent &amp; Grenadines">St Vincent &amp; Grenadines</option>
			<option value="Saipan">Saipan</option>
			<option value="Samoa">Samoa</option>
			<option value="Samoa American">Samoa American</option>
			<option value="San Marino">San Marino</option>
			<option value="Sao Tome &amp; Principe">Sao Tome &amp; Principe</option>
			<option value="Saudi Arabia">Saudi Arabia</option>
			<option value="Senegal">Senegal</option>
			<option value="Serbia">Serbia</option>
			<option value="Seychelles">Seychelles</option>
			<option value="Sierra Leone">Sierra Leone</option>
			<option value="Singapore">Singapore</option>
			<option value="Slovakia">Slovakia</option>
			<option value="Slovenia">Slovenia</option>
			<option value="Solomon Islands">Solomon Islands</option>
			<option value="Somalia">Somalia</option>
			<option value="South Africa">South Africa</option>
			<option value="Spain">Spain</option>
			<option value="Sri Lanka">Sri Lanka</option>
			<option value="Sudan">Sudan</option>
			<option value="Suriname">Suriname</option>
			<option value="Swaziland">Swaziland</option>
			<option value="Sweden">Sweden</option>
			<option value="Switzerland">Switzerland</option>
			<option value="Syria">Syria</option>
			<option value="Tahiti">Tahiti</option>
			<option value="Taiwan">Taiwan</option>
			<option value="Tajikistan">Tajikistan</option>
			<option value="Tanzania">Tanzania</option>
			<option value="Thailand">Thailand</option>
			<option value="Togo">Togo</option>
			<option value="Tokelau">Tokelau</option>
			<option value="Tonga">Tonga</option>
			<option value="Trinidad &amp; Tobago">Trinidad &amp; Tobago</option>
			<option value="Tunisia">Tunisia</option>
			<option value="Turkey">Turkey</option>
			<option value="Turkmenistan">Turkmenistan</option>
			<option value="Turks &amp; Caicos Is">Turks &amp; Caicos Is</option>
			<option value="Tuvalu">Tuvalu</option>
			<option value="Uganda">Uganda</option>
			<option value="Ukraine">Ukraine</option>
			<option value="United Arab Erimates">United Arab Emirates</option>
			<option value="United Kingdom">United Kingdom</option>
			<option value="United States of America">United States of America</option>
			<option value="Uraguay">Uruguay</option>
			<option value="Uzbekistan">Uzbekistan</option>
			<option value="Vanuatu">Vanuatu</option>
			<option value="Vatican City State">Vatican City State</option>
			<option value="Venezuela">Venezuela</option>
			<option value="Vietnam">Vietnam</option>
			<option value="Virgin Islands (Brit)">Virgin Islands (Brit)</option>
			<option value="Virgin Islands (USA)">Virgin Islands (USA)</option>
			<option value="Wake Island">Wake Island</option>
			<option value="Wallis &amp; Futana Is">Wallis &amp; Futana Is</option>
			<option value="Yemen">Yemen</option>
			<option value="Zaire">Zaire</option>
			<option value="Zambia">Zambia</option>
			<option value="Zimbabwe">Zimbabwe</option>
</select>

		</p>
	</td></tr>

  	<tr><td width="50%" >
		<p><? echo $vraag_hoesten; ?></b></td><td width="70%" >
		<input name="hoesten" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="hoesten" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_dyspnoe; ?></b></td><td width="70%" >
		<input name="dyspnoe" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="dyspnoe" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_pijn; ?></b></td><td width="70%" >
		<input name="pijn" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="pijn" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_geur; ?></b></td><td width="70%" >
		<input name="geur" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="geur" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_smaak; ?></b></td><td width="70%" >
		<input name="smaak" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="smaak" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>

  	<tr><td width="50%" >
		<p><? echo $vraag_koorts; ?></b></td><td width="70%" >
		<input name="koorts" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="koorts" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_spier; ?></b></td><td width="70%" >
		<input name="spier" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="spier" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_vermoeid; ?></b></td><td width="70%" >
		<input name="vermoeid" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="vermoeid" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_neus; ?></b></td><td width="70%" >
		<input name="neus" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="neus" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_keel; ?></b></td><td width="70%" >
		<input name="keel" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="keel" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_hoofdpijn; ?></b></td><td width="70%" >
		<input name="hoofdpijn" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="hoofdpijn" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_eetlust; ?></b></td><td width="70%" >
		<input name="eetlust" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="eetlust" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_diarree; ?></b></td><td width="70%" >
		<input name="diarree" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="diarree" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_verward; ?></b></td><td width="70%" >
		<input name="verward" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="verward" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>
  	<tr><td width="50%" >
		<p><? echo $vraag_vallen; ?></b></td><td width="70%" >
		<input name="vallen" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="vallen" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>

  	<tr><td width="50%" >
		<p><? echo $vraag_luchtweg; ?></b></td><td width="70%" >
		<input name="luchtweg" type="radio" value="1"">&nbsp;&nbsp;<? echo $antw_ja; ?>
		&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input name="luchtweg" type="radio" value="2"">&nbsp;&nbsp;<? echo $antw_neen; ?></p>
	</td></tr>

  	<tr><td width="50%" >
  		<p>&nbsp;&nbsp;</p>
	</td></tr>
	<tr><td><div align="center"><br /><input style="font-size:30px" type="Submit" name="Submit" value="<? echo str_replace(" ","&nbsp;",$knop); ?>" /></div></td></tr>
</table>
</form>           

</font></div>
</br>
<? include "Footer.php" ?>