frm_24.php
209 lines
| 10.2 KiB
| text/x-php
|
XmlPhpLexer
|
r0 | <script> | |
$(function(){ | |||
$( "#txt_date" ).datepicker({ | |||
showWeek: true, | |||
dateFormat: 'dd/M/yy', | |||
firstDay: 1 | |||
}); | |||
}); | |||
</script> | |||
<div class="header_frm_page"> | |||
<span> | |||
<label class="title4">28 Day Cycle #</label><input type="text" name="txt_cycle" style="width: 15px" /> | |||
<label class="title4">, Week #</label><input type="text" name="txt_numWeek" style="width: 15px" /> | |||
<label class="title4">, Study Day</label><input type="text" name="txt_styDay" style="width: 15px" /> | |||
</span> | |||
<label class="title2">Vital Signs and Physical Exam</label> | |||
</div> | |||
<span><label>Date of Report: </label><input type="text" name="txt_date" id="txt_date" /></span> | |||
<table border="1" class="tbl_general" width="100%"> | |||
<thead> | |||
<tr> | |||
<th width="25%">Blood Pressure</th> | |||
<th width="25%">Pulse Rate</th> | |||
<th width="20%">Respirations</th> | |||
<th>Oral Temperature</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td> | |||
<div style="width: 45px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="txt_blood1" id="txt_blood1" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/> | |||
<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Supine</div> | |||
</div> | |||
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div> | |||
<div style="width: 45px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="txt_blood2" id="txt_blood2" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/> | |||
<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Standing</div> | |||
</div> | |||
<div style="font-size: 9px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmhg</strong> </div> | |||
</td> | |||
<td><input type="text" name="txt_result" style="width:75%; margin-right: 5px; float: left; border:0; border-bottom: 1px solid #000"/> bpm</td> | |||
<td><input type="text" name="txt_flag" style="width:70%; margin-right: 5px; float: left; border:0; border-bottom: 1px solid #000"/> rpm</td> | |||
<td style="padding-left: 48px"> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="temp_c1" id="temp_c1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="temp_c2" id="temp_c2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> °C </div> | |||
</td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<table border="1" width="100%" class="tbl_general"> | |||
<thead> | |||
<tr> | |||
<td align="center" width="21%">Heigth</td> | |||
<td align="center" width="21%">Weigth</td> | |||
<td> </td> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td style="padding-left: 48px"> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="heigth1" id="heigth1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="heigth2" id="heigth2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> cm </div> | |||
</td> | |||
<td style="padding-left: 48px"> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="weith1" id="weith1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div> | |||
<div style="width: 25px; float: left; border: 0px solid #f00"> | |||
<input type="text" name="weith2" id="weith2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/> | |||
</div> | |||
<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> Kg </div> | |||
</td> | |||
<td> </td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<br/><br/> | |||
<table border="1" width="100%" class="tbl_general"> | |||
<thead> | |||
<tr> | |||
<th width="20%">Site or Organ System</th> | |||
<th> | |||
<div style="clear:both; width: 100%; border-bottom: 1px solid #000;"> | |||
Status (<img src="">) | |||
</div> | |||
<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
Normal | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
Abnormal* | |||
</div> | |||
</th> | |||
<th>*If Abnormal, Specify Findings</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td>General Appearance</td> | |||
<td> | |||
<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
</td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td> | |||
</tr> | |||
<tr> | |||
<td>Skin</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td> | |||
</tr> | |||
<tr> | |||
<td>Head, Ears, Eyes, Nose, Throat</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td> | |||
</tr> | |||
<tr> | |||
<td>Chest and Lungs</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td> | |||
</tr> | |||
<tr> | |||
<td>Heart</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td> | |||
</tr> | |||
<tr> | |||
<td>Abdomen</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td> | |||
</tr> | |||
<tr> | |||
<td>Extremities</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td> | |||
</tr> | |||
<tr> | |||
<td>Neurologic</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td> | |||
</tr> | |||
<tr> | |||
<td>Other</td> | |||
<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div> | |||
<div style="float:left; width: 49%; text-align: center"> | |||
<input type="radio" name="rdo_yes" /> | |||
</div></td> | |||
<td><input type="text" name="txt_flag"style="border:0px solid #f00; width: 98%" /></td> | |||
</tr> | |||
</tbody> | |||
</table> |