|
|
<?php
|
|
|
|
|
|
?>
|
|
|
<script>
|
|
|
$(function() {
|
|
|
//alert('hola');
|
|
|
$( "#date_exam" ).datepicker({
|
|
|
showWeek: true,
|
|
|
dateFormat: 'dd/M/yy',
|
|
|
firstDay: 1
|
|
|
});
|
|
|
|
|
|
});
|
|
|
</script>
|
|
|
<div style="width:650px; margin:0 auto;">
|
|
|
|
|
|
<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>
|
|
|
|
|
|
<h1>Screening Laboratory Measures</h1>
|
|
|
<h2>(within 21 Days prior to Dose 1)</h2>
|
|
|
|
|
|
|
|
|
<table width="100%" id="" class="" style="" >
|
|
|
<tbody>
|
|
|
<tr>
|
|
|
<td style="text-align:center;"></td>
|
|
|
<td style="text-align:center;">Date Obtained<br/>DD/MMM/YYYY</td>
|
|
|
<td style="text-align:center;">If repeat, List date<br/>DD/MMM/YYYY</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Chemistry obtained :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="che_obt" name="datos[che_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="che_obt_repeat" name="datos[che_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Hematology obtained :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="hema_obt" name="datos[hema_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="hema_obt_repeat" name="datos[hema_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">HIV, Hep B & C obtained :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="hiv_hep_obt" name="datos[hiv_hep_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="hiv_hep_obt_repeat" name="datos[hiv_hep_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Serum pregnancy obtained :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="sepo_obt" name="datos[sepo_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="sepo_obt_repeat" name="datos[sepo_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Urinalysis obtained :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="uo_obt" name="datos[uo_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="uo_obt_repeat" name="datos[uo_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Urine Droug screen (indicate if whith or whitout ETOH):</td>
|
|
|
<td style="text-align:center;"><input type="text" id="uds_obt" name="datos[uds_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="uds_obt_repeat" name="datos[uds_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Liber functions tests :</td>
|
|
|
<td style="text-align:center;"><input type="text" id="lf_obt" name="datos[lf_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="lf_obt_repeat" name="datos[lf_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">PT/PTT/INR:</td>
|
|
|
<td style="text-align:center;"><input type="text" id="pt_ptt_inr_obt" name="datos[pt_ptt_inr_obt]" value="" /></td>
|
|
|
<td style="text-align:center;"><input type="text" id="pt_ptt_inr_obt_repeat" name="datos[pt_ptt_inr_obt_repeat]" value="" /></td>
|
|
|
</tr>
|
|
|
|
|
|
</tbody>
|
|
|
<tfoot>
|
|
|
<tr>
|
|
|
<td colspan="4" style="text-align:right;"><input type="submit" value="save" id="btn_save" name="btn_save"><input type="reset" value="clear" id="btn_clear" name="btn_clear"></td>
|
|
|
</tr>
|
|
|
</tfoot>
|
|
|
</table>
|
|
|
|
|
|
|
|
|
</div>
|
|
|
|
