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<script>
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$(function() {
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$( "#txt_date" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<style>
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.box-table-a
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{
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font-family: "Verdana";
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font-size: 12px;
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margin: 0px 0 0px 0;
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width: 650px;
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text-align: left;
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border-collapse: collapse;
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}
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.box-table-a th
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{
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font-size: 12px;
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font-weight: normal;
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padding: 5px 0px 5px 0px;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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}
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.box-table-a td
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{
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padding: 8px 3px 8px 5px ;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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border-top: 1px solid transparent;
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}
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.box-table-a tr:hover td
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{
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background: #fff;
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color: #333 ;
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}
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</style>
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<div style="width: 650px; margin: 0pt auto;">
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<div style="display: block; width: 100%; text-align: center; font-family: Arial; font-size: 14px; font-weight: bold; padding-top: 10px; padding-bottom: 5px;">Screening Vital Signs and Physical Exam (within 21 Days of Dose 1)</div>
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<div style="display: block; width: 100%; text-align: left; padding-top: 25px; margin-bottom: 45px">
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<label for="txt_date" style="float: left; width: 50px;">Date:</label>
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<input type="text" name="txt_date" id="txt_date" style="float:left; color: #666" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY"/>
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</div>
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<table class="box-table-a" width="100%">
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<thead>
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<tr>
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<th scope="col" align="center" width="23%">Blood Pressure</th>
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<th scope="col" align="center" width="25%">Pulse Rate</th>
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<th scope="col" align="center" width="20%">Respirations</th>
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<th scope="col" align="center">Oral Temperature</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td>
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<div style="width: 35px; float: left; border: 0px solid #f00">
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<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"/>
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<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Supine</div>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
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<div style="width: 35px; float: left; border: 0px solid #f00">
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<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"/>
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<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Standing</div>
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</div>
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<div style="font-size: 9px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
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</td>
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<td><input type="text" name="txt_bpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> bpm</td>
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<td><input type="text" name="txt_rpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> rpm</td>
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<td style="padding-left: 120px">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c1" id="temp_c1" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000; "/>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div>
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c2" id="temp_c2" style="width: 90%; border-left:0; border-right: 0; border-bottom: 1px solid #000; border-top: 0"/>
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</div>
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<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> °C </div>
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</td>
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</tr>
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</tbody>
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</table>
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<table class="box-table-a" width="100%">
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<thead>
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<tr>
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<th scope="col" align="center" width="23%">Height</th>
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<th scope="col" align="center" width="25%">Weight</th>
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<th scope="col" align="center" colspan="2">Frame Size by Elbow Breath (choose) </th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td><input type="text" name="txt_bpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> bpm</td>
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<td><input type="text" name="txt_rpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> rpm</td>
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<td>
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<div style="width: 100px; border:0px solid #f00; float:left; text-align: center">
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<input type="radio" name="rbt_size" value="1">Small
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</div>
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<div style="width: 100px; border:0px solid #f00; float:left; text-align: center">
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<input type="radio" name="rbt_size" value="2">Medium
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</div>
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<div style="width: 100px; border:0px solid #f00; float:left; text-align: center">
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<input type="radio" name="rbt_size" value="3">Large
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</div>
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</td>
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</tr>
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</tbody>
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</table>
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<div style="width: 100%; height: 30px;"></div>
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<table width="100%" class="box-table-a">
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<thead>
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<tr>
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<th scope="col" align="center" width="20%">Site or Organ System</th>
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<th scope="col" align="center">
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<div style="clear:both; width: 100%; border-bottom: 1px solid #000;">
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Status (<img src="images/check2.png">)
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</div>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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Normal
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</div>
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<div style="float:left; width: 49%; text-align: center">
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Abnormal*
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</div>
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</th>
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<th scope="col" align="center">*If Abnormal, Specify Findings</th>
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</tr>
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</thead>
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<tbody>
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<tr>
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<td align="center">General Appearance</td>
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<td>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div>
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</td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center">Skin</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center">Head, Ears, Eyes, Nose, Throat</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Chest and Lungs</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center">Heart</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Abdomen</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Extremities</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Neurologic</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center">Other</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag"style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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</tbody>
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</table>
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</div>
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