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<?php
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?>
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<script>
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$(function() {
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//alert('hola');
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$( "#date_exam" ).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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<script>
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$(function() {
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//alert('hola');
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$( "#date_test" ).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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<div style="width:650px; margin:0 auto;">
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<table id="" class="" style="" >
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<tbody>
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<tr>
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<td>Date</td>
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<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam]" value="" /></td>
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</tr>
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</tbody>
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</table>
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<h1>Screening(withing 21 days prior to dose 1)<!-- --> <br> Hematology and Pregnancy Test</h1>
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<h2>(use if labs need to be transcribed)</h2>
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<table width="100%" id="" class="" style="" >
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<tbody>
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<tr>
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<td style="text-align:center;">Test</td>
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<td style="text-align:center;">Result<br>(include units)</td>
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<td style="text-align:center;">Clinically<br> Significant?<br/>(Y/N)</td>
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<td style="text-align:center;">Repeated<br/>(Y/N)</td>
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<td style="text-align:center;">If no, comment</td>
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</tr>
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<tr>
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<td style="text-align:left;">WBC Count</td>
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<td style="text-align:center;"><input type="text" id="wbc_result" name="datos[wbc_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="wbc_clinically_sig" name="datos[wbc_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="wbc_repeat" name="datos[wbc_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[wbc_comment]" id="wbc_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">RBC Count</td>
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<td style="text-align:center;"><input type="text" id="rbc_result" name="datos[rbc_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="rbc_clinically_sig" name="datos[rbc_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="rbc_repeat" name="datos[rbc_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[rbc_comment]" id="rbc_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Hemoglobin</td>
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<td style="text-align:center;"><input type="text" id="hemo_result" name="datos[hemo_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="hemo_clinically_sig" name="datos[hemo_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="hemo_repeat" name="datos[hemo_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[hemo_comment]" id="hemo_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Hematocrit</td>
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<td style="text-align:center;"><input type="text" id="hema_result" name="datos[hema_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="hema_clinically_sig" name="datos[hema_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="hema_repeat" name="datos[hema_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[hema_comment]" id="hema_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Hematocrit</td>
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<td style="text-align:center;"><input type="text" id="hema_result" name="datos[hema_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="hema_clinically_sig" name="datos[hema_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="hema_repeat" name="datos[hema_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[hema_comment]" id="hema_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">MCV</td>
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<td style="text-align:center;"><input type="text" id="mcv_result" name="datos[mcv_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="mcv_clinically_sig" name="datos[mcv_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="mcv_repeat" name="datos[mcv_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[mcv_comment]" id="mcv_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">MCH</td>
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<td style="text-align:center;"><input type="text" id="mch_result" name="datos[mch_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="mch_clinically_sig" name="datos[mch_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="mch_repeat" name="datos[mch_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[mch_comment]" id="mch_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">MCHC</td>
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<td style="text-align:center;"><input type="text" id="mchc_result" name="datos[mchc_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="mchc_clinically_sig" name="datos[mchc_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="mchc_repeat" name="datos[mchc_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[mchc_comment]" id="mchc_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">RDW</td>
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<td style="text-align:center;"><input type="text" id="rdw_result" name="datos[rdw_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="rdw_clinically_sig" name="datos[rdw_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="rdw_repeat" name="datos[rdw_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[rdw_comment]" id="rdw_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Platelets</td>
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<td style="text-align:center;"><input type="text" id="plate_result" name="datos[plate_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="plate_clinically_sig" name="datos[plate_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="plate_repeat" name="datos[plate_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[plate_comment]" id="plate_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Polys</td>
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<td style="text-align:center;"><input type="text" id="polys_result" name="datos[polys_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="polys_clinically_sig" name="datos[polys_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="polys_repeat" name="datos[polys_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[polys_comment]" id="polys_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Lymphs</td>
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<td style="text-align:center;"><input type="text" id="lymphs_result" name="datos[lymphs_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="lymphs_clinically_sig" name="datos[lymphs_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="lymphs_repeat" name="datos[lymphs_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[lymphs_comment]" id="lymphs_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Monocytes</td>
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<td style="text-align:center;"><input type="text" id="monocytes_result" name="datos[monocytes_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="monocytes_clinically_sig" name="datos[monocytes_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="monocytes_repeat" name="datos[monocytes_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[monocytes_comment]" id="monocytes_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Eos</td>
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<td style="text-align:center;"><input type="text" id="eos_result" name="datos[eos_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="eos_clinically_sig" name="datos[eos_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="eos_repeat" name="datos[eos_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[eos_comment]" id="eos_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Basos</td>
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<td style="text-align:center;"><input type="text" id="basos_result" name="datos[basos_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="basos_clinically_sig" name="datos[basos_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="basos_repeat" name="datos[basos_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[basos_comment]" id="basos_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">PT/PTT/INR</td>
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<td style="text-align:center;"><input type="text" id="ppi_result" name="datos[ppi_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ppi_clinically_sig" name="datos[ppi_clinically_sig]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="ppi_repeat" name="datos[ppi_repeat]" value="" >
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;"><textarea name="datos[ppi_comment]" id="ppi_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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</tbody>
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</table>
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<table id="" class="" style="" >
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<tbody>
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<tr>
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<td>Date of Serum<br>Pregnancy test</td>
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<td style="text-align:right;"><input type="text" id="date_test" name="datos[date_test]" value="" /></td>
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</tr>
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</tbody>
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</table>
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<table width="100%" id="" class="" style="" >
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<tbody>
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<tr>
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<td style="text-align:right; width:150px;"><input type="radio" name="datos[result_test]" id="result_test_negative" value="negative"></td>
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<td style="text-align:left;">Negative</td>
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</tr>
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<tr>
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<td style="text-align:right;"><input type="radio" name="datos[result_test]" id="result_test_positive" value="positive"></td>
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<td style="text-align:left;">Positive (not eligible)</td>
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</tr>
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<tr>
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<td style="text-align:right;"><input type="radio" name="datos[result_test]" id="result_test_na" value="na"></td>
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<td style="text-align:left;">N/A</td>
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</tr>
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</tbody>
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<tfoot>
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<tr>
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<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>
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</tr>
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</tfoot>
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</table>
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</div>
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