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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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<style>
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.box-table-a
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{
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font-family: "Lucida Sans Unicode", "Lucida Grande", Sans-Serif;
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font-size: 12px;
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margin: 0px 0 0px 0;
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width: 650px;
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text-align: left;
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border-collapse: collapse;
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}
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.box-table-a th
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{
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font-size: 12px;
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font-weight: normal;
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padding: 5px 0px 5px 0px;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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}
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.box-table-a td
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{
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padding: 8px 3px 8px 5px ;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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border-top: 1px solid transparent;
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}
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.box-table-a tr:hover td
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{
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background: #fff;
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color: #333 ;
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}
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</style>
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<div class="header_frm_page">
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<span>
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<label class="title4">28 Days Cycle #</label><input type="text" name="txt_cycle" style="width: 15px" />
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<label class="title4">, Treatment Week Number#</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 targeted 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">
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<thead>
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<tr><th style="width:60px">Pulse Rate</th>
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<th>Respirations</th>
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<th>Oral Temperature</th>
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<th>Blood Pressure</th>
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<th>Weight</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" /> bpm</td>
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<td><input type="text" name="txt_result" /> rpm</td>
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<td><input type="text" name="txt_flag" /> °C</td>
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<td><input type="text" name="txt_flag" /> mmHg</td>
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<td><input type="text" name="txt_flag" /> Kg</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">
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<thead>
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<tr>
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<th>Site or Organ System</th>
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<th><label>Any change since <br> previous visit?</label><br>No | Yes</th>
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<th>*If Yes, 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><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Skin</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></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><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></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><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Heart</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Abdomen</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Extremities</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Neurologic</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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<tr>
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<td>Other</td>
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<td><input type="radio" name="rdo_yes" /> | <input type="radio" name="rdo_yes" /></td>
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<td><input type="text" name="txt_flag" /></td>
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</tr>
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</tbody>
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</table>
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<a href="#">Add</a>
|
