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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>28 Day Cycle, Cycle 1, Day 1</h1>
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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>Blood Pressure <br>before Dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blood Pressure 30<br>min post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blod Pressure 60<br>min post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_60" name="datos[blod_presure_v1_60]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_60" name="datos[blod_presure_v2_60]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_60" name="datos[pulse_rate_60]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_60" name="datos[respirations_60]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_60" name="datos[oral_temperatutre_60]" value="" style="width:55px;" /> C</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>Blod Pressure 120<br>min post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_120" name="datos[blod_presure_v1_120]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_120" name="datos[blod_presure_v2_120]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_120" name="datos[pulse_rate_120]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_120" name="datos[respirations_120]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_120" name="datos[oral_temperatutre_120]" value="" style="width:55px;" /> C</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>Blood Pressure 3.75<br>hrs post Dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blood Pressure 4.083<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blood Pressure 4.5<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blod Pressure 6<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_180" name="datos[blod_presure_v1_180]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_180" name="datos[blod_presure_v2_180]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_180" name="datos[pulse_rate_180]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_180" name="datos[respirations_180]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_180" name="datos[oral_temperatutre_180]" value="" style="width:55px;" /> C</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>Blood Pressure 8<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blood Pressure 10<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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>Blood Pressure 24<br>hrs post dose</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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<tr>
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<td><input type="text" id="blod_presure_v1_30" name="datos[blod_presure_v1_30]" value="" style="width:35px;" />/<input type="text" id="blod_presure_v2_30" name="datos[blod_presure_v2_30]" value="" style="width:35px;" /> mmHg</td>
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<td><input type="text" id="pulse_rate_30" name="datos[pulse_rate_30]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="respirations_30" name="datos[respirations_30]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="oral_temperatutre_30" name="datos[oral_temperatutre_30]" value="" style="width:55px;" /> C</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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<input type="submit" value="save" id="btn_save" name="btn_save"><input type="reset" value="clear" id="btn_clear" name="btn_clear">
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</div>
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</div>
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