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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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<span>
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<label class="title4">28 Day Cycle #</label><input type="text" name="txt_cycle" style="width: 15px" />
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<label class="title4">, Week #</label><input type="text" name="txt_numWeek" style="width: 15px" />
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<label class="title4">, Study Day</label><input type="text" name="txt_styDay" style="width: 15px" />
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</span>
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<label class="title2">Vital Signs and Physical Exam</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 border="1" class="tbl_general" width="100%">
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<thead>
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<tr>
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<th width="25%">Blood Pressure</th>
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<th width="25%">Pulse Rate</th>
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<th width="20%">Respirations</th>
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<th>Oral Temperature</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>
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<div style="width: 45px; float: left; border: 0px solid #f00">
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<input type="text" name="txt_blood1" id="txt_blood1" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
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<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Supine</div>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
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<div style="width: 45px; float: left; border: 0px solid #f00">
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<input type="text" name="txt_blood2" id="txt_blood2" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
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<div style="display: block; font-size: 9px; text-align: center; width: 100%; ">Standing</div>
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</div>
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<div style="font-size: 9px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmhg</strong> </div>
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</td>
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<td><input type="text" name="txt_result" style="width:75%; margin-right: 5px; float: left; border:0; border-bottom: 1px solid #000"/> bpm</td>
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<td><input type="text" name="txt_flag" style="width:70%; margin-right: 5px; float: left; border:0; border-bottom: 1px solid #000"/> rpm</td>
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<td style="padding-left: 48px">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c1" id="temp_c1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div>
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c2" id="temp_c2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> °C </div>
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</td>
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</tr>
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</tbody>
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</table>
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<table border="1" width="100%" class="tbl_general">
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<thead>
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<tr>
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<td align="center" width="21%">Heigth</td>
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<td align="center" width="21%">Weigth</td>
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<td> </td>
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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 style="padding-left: 48px">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="heigth1" id="heigth1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div>
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="heigth2" id="heigth2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> cm </div>
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</td>
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<td style="padding-left: 48px">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="weith1" id="weith1" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> . </div>
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="weith2" id="weith2" style="width: 90%; border-left:0; border-right: 0; border: 0; border-bottom: 1px solid #000"/>
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</div>
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<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> Kg </div>
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</td>
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<td> </td>
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</tr>
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</tbody>
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</table>
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<br/><br/>
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<table border="1" width="100%" class="tbl_general">
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<thead>
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<tr>
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<th width="20%">Site or Organ System</th>
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<th>
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<div style="clear:both; width: 100%; border-bottom: 1px solid #000;">
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Status (<img src="">)
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</div>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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Normal
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</div>
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<div style="float:left; width: 49%; text-align: center">
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Abnormal*
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</div>
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</th>
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<th>*If Abnormal, Specify Findings</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>General Appearance</td>
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<td>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div>
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</td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td>Skin</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td>Head, Ears, Eyes, Nose, Throat</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td>Chest and Lungs</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td>Heart</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td>Abdomen</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td>Extremities</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td>Neurologic</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td>Other</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag"style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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</tbody>
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</table>
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