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<?php
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?>
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<script>
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$(function() {
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$( ".txt_LMdate" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 7
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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 Cicle#<input type="text" id="cicle" name="datos[cicle]" value="" style="width: 15px"/>, Treatment Week<input type="text" id="tratament_week" name="datos[tratament_week]" value="" style="width: 15px"/>, Dosing Day<input type="text" id="dosing_day" name="datos[dosing_day]" value="" style="width: 15px"/> Laboratory Measures</h1>
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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" class="txt_LMdate" name="datos[che_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[hema_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[hiv_hep_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[sepo_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[uo_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[uds_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[lf_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" 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" class="txt_LMdate" name="datos[pt_ptt_inr_obt]" value="" /></td>
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<td style="text-align:center;"><input type="text" class="txt_LMdate" name="datos[pt_ptt_inr_obt_repeat]" value="" /></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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<div class="tool_buttons">
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<input type="submit" value="save" id="btn_save" name="btn_save">
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<input type="reset" value="clear" id="btn_clear" name="btn_clear">
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</div>
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