frm_14.php
156 lines
| 7.9 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>Baseline Vital Signs And Physical Exam (whitin 72 Hours of Dose 1) </h1> | ||||
<table id="" class="" style="" > | ||||
<tbody> | ||||
<tr> | ||||
<td>Date</td> | ||||
<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam]" value="" /></td> | ||||
</tr> | ||||
</tbody> | ||||
</table> | ||||
<table width="100%" id="" class="" style="" > | ||||
<tbody> | ||||
<tr> | ||||
<td width="25%">Blood Pressure</td> | ||||
<td>Pulse Rate</td> | ||||
<td>Respirations</td> | ||||
<td>Oral Temperature</td> | ||||
</tr> | ||||
<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" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> bpm</td> | ||||
<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> rpm</td> | ||||
<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> °C</td> | ||||
</tr> | ||||
<tr> | ||||
<td>Height</td> | ||||
<td>Weight</td> | ||||
<td colspan="2">Frame Size Elbow Breadth (circle)</td> | ||||
</tr> | ||||
<tr> | ||||
<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> cm.</td> | ||||
<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> Kg.</td> | ||||
<td colspan="2"> | ||||
<label>Small</label><input type="radio" id="frame_size_small" name="datos[frame_size]" value="SMALL"> | ||||
<label>Medium</label><input type="radio" id="frame_size_medium" name="datos[frame_size]" value="MEDIUM"> | ||||
<label>Large</label><input type="radio" id="frame_size_large" name="datos[frame_size]" value="MEDIUM"> | ||||
</td> | ||||
</tr> | ||||
</tbody> | ||||
</table> | ||||
<br /> | ||||
<hr /> | ||||
<br /> | ||||
<div> | ||||
<table id="" class="" style="" width="100%" > | ||||
<thead> | ||||
<tr> | ||||
<td rowspan="2" > Site or Organ<BR> System</td> | ||||
<td colspan="2"> Status </td> | ||||
<td rowspan="2"> * If abnormal, Specify Findings </td> | ||||
</tr> | ||||
<tr> | ||||
<td > Normal </td> | ||||
<td > Abnormal </td> | ||||
</tr> | ||||
</thead> | ||||
<tbody> | ||||
<tr> | ||||
<td >General Appearance</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="ga_state_normal" name="datos[ga_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="ga_state_abnormal" name="datos[ga_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[ga_sf]" id="ga_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Skin</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="skin_state_normal" name="datos[skin_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="skin_state_abnormal" name="datos[skin_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[skin_sf]" id="skin_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Head, Ears, Eyes, Nose, throat</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heent_state_normal" name="datos[heent_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heent_state_abnormal" name="datos[heent_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[heent_sf]" id="heent_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Chest and Lungs</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="chestlungs_state_normal" name="datos[chestlungs_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="chestlungs_state_abnormal" name="datos[chestlungs_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[chestlungs_sf]" id="chestlungs_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Heart</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heart_state_normal" name="datos[heart_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heart_state_abnormal" name="datos[heart_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[heart_sf]" id="heart_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Abdomen</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="abdomen_state_normal" name="datos[abdomen_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="abdomen_state_abnormal" name="datos[abdomen_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[abdomen_sf]" id="abdomen_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Extremities</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="extremities_state_normal" name="datos[extremities_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="extremities_state_abnormal" name="datos[extremities_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[extremities_sf]" id="extremities_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Neurologic</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="neurologic_state_normal" name="datos[neurologic_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="neurologic_state_abnormal" name="datos[neurologic_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[neurologic_sf]" id="neurologic_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td >Other</td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="other_state_normal" name="datos[other_state]" value="normal"></td> | ||||
<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="other_state_abnormal" name="datos[other_state]" value="abnormal"></td> | ||||
<td style="text-align:left; vertical-align:top;" ><textarea name="datos[other_sf]" id="other_sf" style="width:280px; height:35px;"></textarea></td> | ||||
</tr> | ||||
</tbody> | ||||
<tfoot> | ||||
<tr> | ||||
<td colspan="4" style="text-align:right;"><input type="submit" value="save" id="btn_save" name="btn_save"><input type="reset" value="clear" id="btn_clear" name="btn_clear"></td> | ||||
</tr> | ||||
</tfoot> | ||||
</table> | ||||
</div> | ||||
</div> | ||||