frm_21.php
46 lines
| 2.1 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"> | ||||
<label class="title1">Baseline (30 days prior to initial treatment) Tumor Assessment</label> | ||||
<label class="title2">by Standard Method(MRI, CT, etc)</label> | ||||
<label class="title3">(use if need to be transcribed)</label> | ||||
</div> | ||||
<span><label>Date of Report:</label><input type="text" name="txt_date" id="txt_date" /></span> | ||||
<table class="tbl_general"> | ||||
<thead> | ||||
<tr> | ||||
<th style="width:120px">Test</th> | ||||
<th style="width:120px">Result</th> | ||||
<th style="width:120px">Flag<br/>(Normal/<br/>Abnormal)</th> | ||||
<th style="width:120px">Clinically<br/>Significant<br/>(Y/N)?</th> | ||||
<th style="width:120px">Repeated?<br/>(Y/N)</th> | ||||
<th style="width:120px">If No,<br/>Comment</th> | ||||
</tr> | ||||
</thead> | ||||
<tbody> | ||||
<tr> | ||||
<td><input type="text" name="txt_test" style="width:120px" /></td> | ||||
<td><input type="text" name="txt_result" style="width:120px" /></td> | ||||
<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td> | ||||
<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td> | ||||
<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td> | ||||
<td><input type="text" name="txt_comment" style="width:120px" /></td> | ||||
</tr> | ||||
<tr> | ||||
<td><input type="text" name="txt_test" style="width:120px" /></td> | ||||
<td><input type="text" name="txt_result" style="width:120px" /></td> | ||||
<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td> | ||||
<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td> | ||||
<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td> | ||||
<td><input type="text" name="txt_comment" style="width:120px" /></td> | ||||
</tr> | ||||
</tbody> | ||||
</table> | ||||