frm_29.php
352 lines
| 12.9 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>28 Days Cycle#<input type="text" id="cicle" name="datos[cicle]" value="" style="width: 15px;"/>, Treatment Week<input type="text" id="tratament_week" name="datos[tratament_week]" value="" style="width: 15px"/>, Dosing Day<input type="text" id="dosing_day" name="datos[dosing_day]" value="" style="width: 15px"/> Urinalysis</h1> | ||||
<h2>(use if labs need to be transcribed)</h2> | ||||
<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 style="text-align:center;">Test</td> | ||||
<td style="text-align:center;">Result</td> | ||||
<td style="text-align:center;">Flag<br>(H/L/Abn)</td> | ||||
<td style="text-align:center;">Clinically<br> Significant?<br/>(Y/N)</td> | ||||
<td style="text-align:center;">Repeated<br/>(Y/N)</td> | ||||
<td style="text-align:center;">If no, comment</td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Specific gravity</td> | ||||
<td style="text-align:center;"><input type="text" id="sg_result" name="datos[sg_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="sg_flag" name="datos[sg_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="sg_repeat" name="datos[sg_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[sg_comment]" id="sg_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">pH</td> | ||||
<td style="text-align:center;"><input type="text" id="ph_result" name="datos[ph_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="ph_flag" name="datos[ph_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="ph_clinically_sig" name="datos[ph_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="ph_repeat" name="datos[ph_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[ph_comment]" id="ph_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Color</td> | ||||
<td style="text-align:center;"><input type="text" id="color_result" name="datos[color_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="color_flag" name="datos[color_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="color_clinically_sig" name="datos[color_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="color_repeat" name="datos[color_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[color_comment]" id="color_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Appearance</td> | ||||
<td style="text-align:center;"><input type="text" id="appearance_result" name="datos[appearance_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="appearance_flag" name="datos[appearance_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="appearance_clinically_sig" name="datos[appearance_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="appearance_repeat" name="datos[appearance_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[appearance_comment]" id="appearance_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">WBC Esterase</td> | ||||
<td style="text-align:center;"><input type="text" id="WBC_esterase_result" name="datos[WBC_esterase_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="WBC_esterase_flag" name="datos[WBC_esterase_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="WBC_esterase_clinically_sig" name="datos[WBC_esterase_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="WBC_esterase_repeat" name="datos[WBC_esterase_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[WBC_esterase_comment]" id="WBC_esterase_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Protein</td> | ||||
<td style="text-align:center;"><input type="text" id="protein_result" name="datos[protein_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="appearance_flag" name="datos[appearance_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="protein_clinically_sig" name="datos[protein_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="protein_repeat" name="datos[protein_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[protein_comment]" id="protein_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Glucose</td> | ||||
<td style="text-align:center;"><input type="text" id="glucose_result" name="datos[glucose_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="glucose_rflag" name="datos[glucose_rflag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="glucose_clinically_sig" name="datos[glucose_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="glucose_repeat" name="datos[glucose_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[glucose_comment]" id="glucose_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Ketones</td> | ||||
<td style="text-align:center;"><input type="text" id="ketones_result" name="datos[ketones_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="ketones_flag" name="datos[ketones_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="ketones_clinically_sig" name="datos[ketones_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="ketones_repeat" name="datos[ketones_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[ketones_comment]" id="ketones_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Occult Blood</td> | ||||
<td style="text-align:center;"><input type="text" id="occult_blood_result" name="datos[occult_blood_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="occult_blood_flag" name="datos[occult_blood_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="occult_blood_clinically_sig" name="datos[occult_blood_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="occult_blood_repeat" name="datos[occult_blood_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[occult_blood_comment]" id="occult_blood_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Bilirubin</td> | ||||
<td style="text-align:center;"><input type="text" id="bilirubin_result" name="datos[bilirubin_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="bilirubin_flag" name="datos[bilirubin_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="bilirubin_clinically_sig" name="datos[bilirubin_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="bilirubin_repeat" name="datos[bilirubin_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[bilirubin_comment]" id="bilirubin_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Urobilinogen</td> | ||||
<td style="text-align:center;"><input type="text" id="urobilinogen_result" name="datos[urobilinogen_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="urobilinogen_flag" name="datos[urobilinogen_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="urobilinogen_clinically_sig" name="datos[urobilinogen_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="urobilinogen_repeat" name="datos[urobilinogen_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[urobilinogen_comment]" id="urobilinogen_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
<tr> | ||||
<td style="text-align:left;">Nitrite</td> | ||||
<td style="text-align:center;"><input type="text" id="nitrite_result" name="datos[nitrite_result]" value="" /></td> | ||||
<td style="text-align:center;"> | ||||
<select id="nitrite_flag" name="datos[nitrite_flag]" > | ||||
<option value="H">H</option> | ||||
<option value="L">L</option> | ||||
<option value="Abn">Abn</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"> | ||||
<select id="nitrite_clinically_sig" name="datos[nitrite_clinically_sig]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select></td> | ||||
<td style="text-align:center;"> | ||||
<select id="nitrite_repeat" name="datos[nitrite_repeat]" value="" > | ||||
<option value="Y">Yes</option> | ||||
<option value="N">No</option> | ||||
</select> | ||||
</td> | ||||
<td style="text-align:center;"><textarea name="datos[nitrite_comment]" id="nitrite_comment" style="width:210px; height:35px;"></textarea></td> | ||||
</tr> | ||||
</tbody> | ||||
</table> | ||||
</div> | ||||
<div class="tool_buttons"> | ||||
<input type="submit" value="save" id="btn_save" name="btn_save"> | ||||
<input type="reset" value="clear" id="btn_clear" name="btn_clear"> | ||||
</div> | ||||