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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>Baseline (Within 72 hrs prior to dose 1 )Chemistry </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</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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<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</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;">Glucose</td>
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<td style="text-align:center;"><input type="text" id="glucose_result" name="datos[glucose_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="glucose_clinically_sig" name="datos[glucose_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="glucose_repeat" name="datos[glucose_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[glucose_comment]" id="glucose_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;">BUN</td>
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<td style="text-align:center;"><input type="text" id="bun_result" name="datos[bun_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="bun_clinically_sig" name="datos[bun_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="bun_repeat" name="datos[bun_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[bun_comment]" id="bun_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;">Calcium</td>
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<td style="text-align:center;"><input type="text" id="calcium_result" name="datos[calcium_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="calcium_clinically_sig" name="datos[calcium_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="calcium_repeat" name="datos[calcium_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[calcium_comment]" id="calcium_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;">Phosphorous (PO4)</td>
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<td style="text-align:center;"><input type="text" id="phos_result" name="datos[phos_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="phos_clinically_sig" name="datos[phos_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="phos_repeat" name="datos[phos_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[phos_comment]" id="phos_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;">Protein (total)</td>
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<td style="text-align:center;"><input type="text" id="protein_result" name="datos[protein_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="protein_clinically_sig" name="datos[protein_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="protein_repeat" name="datos[protein_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[protein_comment]" id="protein_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;">Bilirubin (total)</td>
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<td style="text-align:center;"><input type="text" id="bilirubin_result" name="datos[bilirubin_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="bilirubin_clinically_sig" name="datos[bilirubin_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="bilirubin_repeat" name="datos[bilirubin_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[bilirubin_comment]" id="bilirubin_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;">Bilirubin (Direct)</td>
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<td style="text-align:center;"><input type="text" id="bili_direct_result" name="datos[bili_direct_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="bili_direct_clinically_sig" name="datos[bili_direct_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="bili_direct_repeat" name="datos[bili_direct_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[bili_direct_comment]" id="bili_direct_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;">Albumin</td>
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<td style="text-align:center;"><input type="text" id="albumin_result" name="datos[albumin_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="albumin_clinically_sig" name="datos[albumin_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="albumin_repeat" name="datos[albumin_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[albumin_comment]" id="albumin_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;">Alkaline Phosphatase</td>
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<td style="text-align:center;"><input type="text" id="alk_phos_result" name="datos[alk_phos_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="alk_phos_clinically_sig" name="datos[alk_phos_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="alk_phos_repeat" name="datos[alk_phos_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[alk_phos_comment]" id="alk_phos_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;">LDH</td>
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<td style="text-align:center;"><input type="text" id="ldh_result" name="datos[ldh_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ldh_clinically_sig" name="datos[ldh_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="ldh_repeat" name="datos[ldh_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[ldh_comment]" id="ldh_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;">ALT</td>
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<td style="text-align:center;"><input type="text" id="alt_result" name="datos[alt_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="alt_clinically_sig" name="datos[alt_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="alt_repeat" name="datos[alt_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[alt_comment]" id="alt_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;">AST</td>
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<td style="text-align:center;"><input type="text" id="ast_result" name="datos[ast_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ast_clinically_sig" name="datos[ast_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="ast_repeat" name="datos[ast_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[ast_comment]" id="ast_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;">Choresterol (total)</td>
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<td style="text-align:center;"><input type="text" id="choles_result" name="datos[choles_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="choles_clinically_sig" name="datos[choles_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="choles_repeat" name="datos[choles_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[choles_comment]" id="choles_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;">Creatinine</td>
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<td style="text-align:center;"><input type="text" id="creatinine_result" name="datos[creatinine_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="creatinine_clinically_sig" name="datos[creatinine_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="creatinine_repeat" name="datos[creatinine_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[creatinine_comment]" id="creatinine_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;">Sodium</td>
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<td style="text-align:center;"><input type="text" id="sodium_result" name="datos[sodium_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="sodium_clinically_sig" name="datos[sodium_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="sodium_repeat" name="datos[sodium_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[sodium_comment]" id="sodium_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;">Potassium</td>
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<td style="text-align:center;"><input type="text" id="potassium_result" name="datos[potassium_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="potassium_clinically_sig" name="datos[potassium_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="potassium_repeat" name="datos[potassium_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[potassium_comment]" id="potassium_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;">Choride</td>
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<td style="text-align:center;"><input type="text" id="choride_result" name="datos[choride_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="choride_clinically_sig" name="datos[choride_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="choride_repeat" name="datos[choride_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[choride_comment]" id="choride_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;">CO2</td>
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<td style="text-align:center;"><input type="text" id="co2_result" name="datos[co2_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="co2_clinically_sig" name="datos[co2_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="co2_repeat" name="datos[co2_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[co2_comment]" id="co2_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;">GGT</td>
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<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ggt_clinically_sig" name="datos[ggt_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="ggt_repeat" name="datos[ggt_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[ggt_comment]" id="ggt_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;">Serum Mg</td>
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<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
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<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
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|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
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|
<option value="Y">Yes</option>
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|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Total Cholesterol</td>
|
|
|
<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Triglycerides</td>
|
|
|
<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">PT/PTT</td>
|
|
|
<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">INR</td>
|
|
|
<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td style="text-align:left;">Others</td>
|
|
|
<td style="text-align:center;"><input type="text" id="ggt_result" name="datos[ggt_result]" value="" /></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_clinically_sig" name="datos[ggt_clinically_sig]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select></td>
|
|
|
<td style="text-align:center;">
|
|
|
<select id="ggt_repeat" name="datos[ggt_repeat]" value="" >
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td style="text-align:center;"><textarea name="datos[ggt_comment]" id="ggt_comment" style="width:210px; height:35px;"></textarea></td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
<tfoot>
|
|
|
<tr>
|
|
|
<td colspan="5" 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>
|
|
|
</tr>
|
|
|
</tfoot>
|
|
|
|
|
|
</table>
|
|
|
|
|
|
|
|
|
</div>
|
|
|
|
