document.write('<table width=160 border=0 cellspacing=0 cellpadding=0>');
document.write('<form name=form12 method=post action=http://www.fx120.net/func/wzdc.asp target="_blank">');
document.write('  <tr> ');
document.write('    <td>　　如果7月1日抗生素无处方在药店无法买到，你觉得：<br><input type=checkbox name=ck121 value=1>能接受<br><input type=checkbox name=ck122 value=2>不能接受<br><input name=dc_id  type=hidden value=12><input name=dc_number  type=hidden value=2><input name=dc_type  type=hidden value=2></td>');
document.write('  </tr>');
document.write('  <tr> ');
document.write('    <td> ');
document.write('      <table width=100% border=0 cellspacing=0 cellpadding=0 height=25><tr><td width=50% align=center><input name=imageField type=image src=http://www.fx120.net/func/images/dc_tj.gif width=40 height=18 border=0></td><td width=50% align=center><a href=http://www.fx120.net/func/ck_zldc.asp?dc_id=12 target="_blank"><img src=http://www.fx120.net/func/images/dc_ck.gif width=60 height=18 border=0></a></td></tr></table>');
document.write('    </td>');
document.write('  </tr>');
document.write('</form>');
document.write('</table>');