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<script>
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$(function() {
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$( "#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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$( "#date_exam_toxicology" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<?php if("flag_edit"){ ?>
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<form name="frm_09" method="post" action="index.php">
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<?php } ?>
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<div class="header_frm_page">
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<label class="title1">Screening Urinalysis and Toxicology</label>
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<label class="title2">(Within 21 Days prior to Dose 1)</label>
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<label class="title3">(use if labs need to be transcribed)</label>
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</div>
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<table id="" class="" style="" >
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<tbody>
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<tr>
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<td>Date</td>
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<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam]" value="" /></td>
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</tr>
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</tbody>
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</table>
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<?php
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$cont = 1;
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//var_dump($data_fields); die();
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foreach($data_fields as $data_field){
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if($cont == 1){
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?>
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<table id="" class="tbl_general" style="">
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<thead>
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<tr>
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<th style="text-align:center;">Test</th>
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<th style="text-align:center;">Result<br>(include units)</th>
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<th style="text-align:center;">Flag<br>(H/L/Abn)</th>
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<th style="text-align:center;">Clinically<br> Significant?<br/>(Y/N)</th>
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<th style="text-align:center;">Repeated<br/>(Y/N)</th>
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<th style="text-align:center;">If no, comment</th>
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</tr>
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</thead>
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<tbody>
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<?php
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}else{
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?>
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<hr>
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<span style="padding-top: 20px; margin-top: 10px">
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<label>Date of Toxicology:</label><input type="text" id="date_exam_toxicology" name="datos[date_exam_toxicology]" value="" />
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</span>
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<table width="100%" id="" class="tbl_general" style="padding-top: 10px;">
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<thead>
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<tr>
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<th style="text-align:center;">Test</th>
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<th style="text-align:center;">Positive</th>
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<th style="text-align:center;">Negative</th>
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</tr>
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</thead>
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<tbody>
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<?php
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}
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foreach ($data_field as $value_data){
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if($cont == 1){
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?>
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<tr>
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<td style="text-align:left;"><?php echo $value_data['name_field'] ?></td>
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<td style="text-align:center;"><input type="text" id="sg_result" name="datos[result_<?php echo $cont; ?>]" value="" /></td>
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<td style="text-align:center;">
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<select name="datos[flag_<?php echo $cont; ?>]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select name="datos[cs_<?php echo $cont; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="2">No</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select name="datos[repeat_<?php echo $cont; ?>]" class="form_select">
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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;">
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<textarea name="datos[comment_<?php echo $cont; ?>]" id="sg_comment" style="width:210px; height:35px;"></textarea>
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</td>
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</tr>
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<?php
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}else{
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?>
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<tr>
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<td><?php echo $value_data['name_field']; ?></td>
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<td style="text-align:center;"><input type="radio" name="datos[urine_toxico_screen]" value="1" /></td>
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<td style="text-align:center;"><input type="radio" name="datos[urine_toxico_screen]" value="2" /></td>
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</tr>
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<?php
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}
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}
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?>
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</tbody>
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</table>
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<?php
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$cont++;
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}
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?>
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<?php if($flag_edit){ ?>
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<div class="tool_buttons">
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<input type="submit" value="save" id="btn_save" name="btn_save" />
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</div>
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<input type="hidden" name="option" value="com_data" />
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<input type="hidden" name="controller" value="urinalysis" />
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<input type="hidden" name="action" value="save" />
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<input type="hidden" name="name_form" value="frm_09" />
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<input type="hidden" name="num_form" value="9" />
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<input type="hidden" name="datos[idtest]" value="<?php echo $idtest; ?>" />
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<input type="hidden" name="title_form" value="9" />
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</form>
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<?php } ?>
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