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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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<div style="width:650px; margin:0 auto;">
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<h1>Screening Liver Functions Test</h1>
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<h2>(use if labs need to be transcribed)</h2>
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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 Report:</td>
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<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam_day01]" value="" /></td>
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</tr>
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</tbody>
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</table>
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<table id="" class="" style="" width="100%" >
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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</th>
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<th style="text-align:center;">Flag<br/>(Normal/<br/>Abnormal)</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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<tr>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td>
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<select name="datos[flag]" class="form_select">
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<option value="1">Normal</option>
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<option value="2">Abnormal</option>
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</select>
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</td>
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<td>
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<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td>
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<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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</tr>
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<tr>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td>
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<select name="datos[flag]" class="form_select">
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<option value="1">Normal</option>
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<option value="2">Abnormal</option>
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</select>
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</td>
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<td>
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<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td>
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<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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</tr>
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<tr>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td>
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<select name="datos[flag]" class="form_select">
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<option value="1">Normal</option>
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<option value="2">Abnormal</option>
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</select>
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</td>
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<td>
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<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td>
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<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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</tr>
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<tr>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></td>
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<td>
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<select name="datos[flag]" class="form_select">
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<option value="1">Normal</option>
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<option value="2">Abnormal</option>
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</select>
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</td>
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<td>
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<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td>
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<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">No</option>
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</select>
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</td>
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<td><input type="text" class="txt_result" name="datos[]" value="" /></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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