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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">Baseline (30 days prior to initial treatment) Tumor Assessment</label>
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<label class="title2">by Standard Method(MRI, CT, etc)</label>
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<label class="title3">(use if need to be transcribed)</label>
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</div>
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<span><label>Date of Report:</label><input type="text" name="txt_date" id="txt_date" /></span>
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<table class="tbl_general">
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<thead>
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<tr>
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<th style="width:120px">Test</th>
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<th style="width:120px">Result</th>
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<th style="width:120px">Flag<br/>(Normal/<br/>Abnormal)</th>
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|
<th style="width:120px">Clinically<br/>Significant<br/>(Y/N)?</th>
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<th style="width:120px">Repeated?<br/>(Y/N)</th>
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<th style="width:120px">If No,<br/>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" name="txt_test" style="width:120px" /></td>
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|
<td><input type="text" name="txt_result" 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>
|
|
|
<tr>
|
|
|
<td><input type="text" name="txt_test" style="width:120px" /></td>
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|
|
<td><input type="text" name="txt_result" 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>
|
|
|
<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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