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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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<div class="header_frm_page">
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<label class="title1">Screening</label>
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<label class="title2">ECOG Performance Status</label>
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</div>
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<span><label>Date of Report:</label><input type="text" id="txt_date" name="txt_date" /></span>
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<table>
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<thead>
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<tr><th style="width:120px">Grade</th>
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<th style="width:120px">Descriptions</th>
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<th style="width:100px">Flag<br/>(Normal/<br/>Abnormal)</th>
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<th style="width:80px">Clinically<br/>Significant<br/>(Y/N)?</th>
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<th style="width:80px">Repeated?<br/>(Y/N)</th>
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<th style="width:120px">If No,<br/><small>Comment</small></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_test" style="width:120px" /></td>
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<td><input type="text" name="txt_description" style="width:120px" /></td>
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<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td>
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<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><input type="text" name="txt_comment" style="width:120px" /></td>
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</tr>
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<tr>
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<td><input type="text" name="txt_test" style="width:120px" /></td>
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<td><input type="text" name="txt_description" style="width:120px" /></td>
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<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td>
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<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><input type="text" name="txt_comment" style="width:120px" /></td>
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</tr>
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<tr>
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<td><input type="text" name="txt_test" style="width:120px" /></td>
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<td><input type="text" name="txt_description" style="width:120px" /></td>
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<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td>
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<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><input type="text" name="txt_comment" style="width:120px" /></td>
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</tr>
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<tr>
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<td><input type="text" name="txt_test" style="width:120px" /></td>
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<td><input type="text" name="txt_description" style="width:120px" /></td>
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<td><select name="flag" class="form_select" style="width: 80px"><option>Normal</option><option>Abnormal</option></select></td>
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<td><select name="clinical" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><select name="repeat" class="form_select" style="width: 60px"><option>Yes</option><option>No</option></select></td>
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<td><input type="text" name="txt_comment" style="width:120px" /></td>
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</tr>
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</tbody>
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</table>
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