frm_59.php
134 lines
| 8.0 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">Study Exit, Study Day <input type="text" name="txt_styday" value="" style="width: 18px"/></label> | |||
<label class="title1">Vital Signs and Physical Examination</label> | |||
</div> | |||
<div style="margin-top: 15px; margin-bottom: 15px"> | |||
<label>Date:</label> | |||
<input type="text" name="txt_date" id="txt_date" style="border-top: 0; border-right: 0; border-left: 0; text-align: center" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY" /> | |||
</div> | |||
<br/><br/> | |||
<label><font color="red">Delete these VS if the final VS of the Period are the same as the study exit VS</font></label> | |||
<table border="0" class="tbl_general" width="100%"> | |||
<thead> | |||
<tr> | |||
<th width="20%" style="text-align: center">Pulse Rate</th> | |||
<th width="20%" style="text-align: center">Respirations</th> | |||
<th width="20%" style="text-align: center">Oral Temperature</th> | |||
<th width="25%" style="text-align: center">Blood Pressure</th> | |||
<th width="15%" style="text-align: center">Weight</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td><input type="text" name="txt_test" style="width: 60px" /> bpm</td> | |||
<td><input type="text" name="txt_result" style="width: 60px" /> rpm</td> | |||
<td><input type="text" name="txt_flag" style="width: 80px" /> °C</td> | |||
<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_flag" style="width: 60px" /> Kg</td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<br/><br/> | |||
<table border="0" class="tbl_general" width="100%" style="border: 1px solid #ccc"> | |||
<thead> | |||
<tr> | |||
<th width="40%" style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; height: 60px">Site or Organ System</th> | |||
<th colspan="2" width="30%" style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc"> | |||
<table width="100%" cellpadding="0"> | |||
<thead> | |||
<tr> | |||
<th colspan="2" style="border-bottom: 1px solid #ccc; text-align: center"> | |||
Change from<br/>previous exam? | |||
</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr><td style="border-right: 1px solid #ccc; text-align: center">No</td> | |||
<td style="text-align: center">Yes</td></tr> | |||
</tbody> | |||
</table> | |||
</th> | |||
<th width="30%" style="border-bottom: 1px solid #ccc">*If Yes, Specify findings</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">General Appearance</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Skin</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Head, Ears, Eyes, Nose, Throat</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Chest and Lungs</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Heart</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Abdomen</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Extremities</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center; height: 30px">Neurologic</td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
<tr> | |||
<td style="border-right: 1px solid #ccc; text-align: center; height: 30px">Other</td> | |||
<td style="border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td> | |||
<td style="text-align: center"><input type="text" name="txt_flag" /></td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<br/> |