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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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$(function() {
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//alert('hola');
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$( "#che_obt" ).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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$( "#che_obt_repeat" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<script>
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$(function() {
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//alert('hola');
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$( "#hema_obt" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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$( "#hema_obt_repeat" ).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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$(function() {
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//alert('hola');
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$( "#hiv_hep_obt" ).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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$( "#hiv_hep_obt_repeat" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<script>
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$(function() {
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//alert('hola');
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$( "#sepo_obt" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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$( "#sepo_obt_repeat" ).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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$(function() {
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//alert('hola');
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$( "#uo_obt" ).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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$( "#uo_obt_repeat" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<script>
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$(function() {
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//alert('hola');
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$( "#uds_obt" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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$( "#uds_obt_repeat" ).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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$(function() {
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//alert('hola');
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$( "#lf_obt" ).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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$( "#lf_obt_repeat" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<script>
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$(function() {
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//alert('hola');
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$( "#pt_ptt_inr_obt" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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$( "#pt_ptt_inr_obt_repeat" ).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>Baseline Laboratory Measures</h1>
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<h2>(within 72 Hours prior to Dose 1)</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;"></td>
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<td style="text-align:center;">Date Obtained<br/>DD/MMM/YYYY</td>
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<td style="text-align:center;">If repeat, List date<br/>DD/MMM/YYYY</td>
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</tr>
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<tr>
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<td style="text-align:left;">Chemistry obtained :</td>
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<td style="text-align:center;"><input type="text" id="che_obt" name="datos[che_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="che_obt_repeat" name="datos[che_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">Hematology obtained :</td>
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<td style="text-align:center;"><input type="text" id="hema_obt" name="datos[hema_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="hema_obt_repeat" name="datos[hema_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">HIV, Hep B & C obtained :</td>
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<td style="text-align:center;"><input type="text" id="hiv_hep_obt" name="datos[hiv_hep_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="hiv_hep_obt_repeat" name="datos[hiv_hep_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">Serum pregnancy obtained :</td>
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<td style="text-align:center;"><input type="text" id="sepo_obt" name="datos[sepo_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="sepo_obt_repeat" name="datos[sepo_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">Urinalysis obtained :</td>
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<td style="text-align:center;"><input type="text" id="uo_obt" name="datos[uo_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="uo_obt_repeat" name="datos[uo_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">Urine Droug screen (indicate if whith or whitout ETOH):</td>
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<td style="text-align:center;"><input type="text" id="uds_obt" name="datos[uds_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="uds_obt_repeat" name="datos[uds_obt_repeat]" value="" /></td>
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</tr>
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<tr>
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<td style="text-align:left;">Liber functions tests :</td>
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<td style="text-align:center;"><input type="text" id="lf_obt" name="datos[lf_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="lf_obt_repeat" name="datos[lf_obt_repeat]" value="" /></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="pt_ptt_inr_obt" name="datos[pt_ptt_inr_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" id="pt_ptt_inr_obt_repeat" name="datos[pt_ptt_inr_obt_repeat]" value="" /></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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