frm_10.php
91 lines
| 2.8 KiB
| text/x-php
|
XmlPhpLexer
|
r0 | <?php | |
?> | |||
<script> | |||
$(function() { | |||
//alert('hola'); | |||
$( "#date_exam" ).datepicker({ | |||
showWeek: true, | |||
dateFormat: 'dd/M/yy', | |||
firstDay: 1 | |||
}); | |||
}); | |||
</script> | |||
<div style="width:650px; margin:0 auto;"> | |||
<h1>Screening Histologically Confirmed Solid Tumor</h1> | |||
<h2>(use if labs need to be transcribed)</h2> | |||
<table id="" class="" style="" > | |||
<tbody> | |||
<tr> | |||
<td>Date of Report:</td> | |||
<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam_day01]" value="" /></td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<table id="" class="" style="" width="100%" > | |||
<thead> | |||
<tr> | |||
<th style="text-align:center;">Test</th> | |||
<th style="text-align:center;">Result</th> | |||
<th style="text-align:center;">Flag<br/>(Normal/<br/>Abnormal)</th> | |||
<th style="text-align:center;">Clinically<br> Significant?<br/>(Y/N)</th> | |||
<th style="text-align:center;">Repeated<br/>(Y/N)</th> | |||
<th style="text-align:center;">If no, comment</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
<td> | |||
<select name="datos[flag]" class="form_select"> | |||
<option value="1">Normal</option> | |||
<option value="2">Abnormal</option> | |||
</select> | |||
</td> | |||
<td> | |||
<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select"> | |||
<option value="1">Yes</option> | |||
<option value="0">No</option> | |||
</select> | |||
</td> | |||
<td> | |||
<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select"> | |||
<option value="1">Yes</option> | |||
<option value="0">No</option> | |||
</select> | |||
</td> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
</tr> | |||
<tr> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
<td> | |||
<select name="datos[flag]" class="form_select"> | |||
<option value="1">Normal</option> | |||
<option value="2">Abnormal</option> | |||
</select> | |||
</td> | |||
<td> | |||
<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select"> | |||
<option value="1">Yes</option> | |||
<option value="0">No</option> | |||
</select> | |||
</td> | |||
<td> | |||
<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select"> | |||
<option value="1">Yes</option> | |||
<option value="0">No</option> | |||
</select> | |||
</td> | |||
<td><input type="text" class="txt_result" name="datos[]" value="" /></td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
</div> |