frm_60.php
286 lines
| 13.6 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"> | |||
<span> | |||
<label class="title4">Study Exit, Study Day</label><input type="text" name="txt_cycle" style="width: 15px" /> | |||
</span> | |||
<label class="title1">Laboratory Measures</label> | |||
<label class="title3">(use only if electronically transfered)</label> | |||
</div> | |||
<table width="100%" class="tbl_general" style="border: 1px solid #ccc"> | |||
<thead> | |||
<tr> | |||
<th class="tbl_th_border"></th> | |||
<th class="tbl_th_border">Date Obtained<br/>DD/MM/YYYY</th> | |||
<th class="tbl_th_border_sup_last">If Repeated, List Date<br/>DD/MM/YYYY</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr> | |||
<td class="tbl_td_border" style="text-align: left"> | |||
<label style="padding-left: 10px; display: block">LTFs and Chemistry</label> | |||
<label style="padding-left: 10px">Obtained:</label> | |||
</td> | |||
<td class="tbl_td_border"> | |||
<input type="text" name="txt_dateobt_ltf" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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" /> | |||
</td> | |||
<td class="tbl_td_border_right"> | |||
<input type="text" name="txt_datertd_ltf" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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" /> | |||
</td> | |||
</tr> | |||
<tr> | |||
<td class="tbl_td_border_last" style="text-align: left"> | |||
<label style="padding-left: 10px">Hematology Obtained:</label> | |||
</td> | |||
<td class="tbl_td_border_last"> | |||
<input type="text" name="txt_dateobt_hema" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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" /> | |||
</td> | |||
<td class="tbl_td_border_last_right"> | |||
<input type="text" name="txt_datertd_hema" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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" /> | |||
</td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
<div class="header_frm_page" style="margin-top: 15px"> | |||
<span> | |||
<label class="title4">Study Exit, Study Day</label><input type="text" name="txt_cycle" style="width: 15px" /> | |||
</span> | |||
<label class="title1">Hematology</label> | |||
<label class="title3">(use below if labs need to be transcribed)</label> | |||
</div> | |||
<div style="margin-top: 15px; margin-bottom: 15px"> | |||
<label>Date: </label> | |||
<input type="text" name="txt_date" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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> | |||
<div style="margin-top: 20px; margin-bottom: 15px"> | |||
<table border="0" class="tbl_general" width="100%" style="border:1px solid #ccc"> | |||
<thead> | |||
<tr> | |||
<th class="tbl_th_border">Test</th> | |||
<th class="tbl_th_border">Result</th> | |||
<th class="tbl_th_border">Clinically<br/>Significant?<br/>(Y/N)</th> | |||
<th class="tbl_th_border">Repeated?<br/>(Y/N)</th> | |||
<th class="tbl_th_border_sup_last">If No, Comment</th> | |||
</tr> | |||
</thead> | |||
<tbody> | |||
<tr><td class="tbl_td_border">WBC Count</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">RBC Count</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Hemoglobin</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Hematocrit</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">MCV</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">MCH</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">MCHC</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">RDW</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Platelets</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Polys</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Lymphs</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Monocytes</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border">Eos</td> | |||
<td class="tbl_td_border"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
<tr><td class="tbl_td_border_last">Basos</td> | |||
<td class="tbl_td_border_last"><input type="text" name="txt_result" /></td> | |||
<td class="tbl_td_border_last"> | |||
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_last"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select"> | |||
<option value="Y">Yes</option> | |||
<option value="N">No</option> | |||
</select> | |||
</td> | |||
<td class="tbl_td_border_last_right"><input type="text" name="txt_comment" /></td> | |||
</tr> | |||
</tbody> | |||
</table> | |||
</div> |