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<script>
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$(function() {
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$( ".css_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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$('.schedule_time').timepicker({
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timeOnlyTitle: 'Choose Time',
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timeText:'Time',
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hourText:'Hour',
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minuteText:'Minute',
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secondText:'Second',
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currentText:'Now',
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closeText:'Done'
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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: "Verdana";
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font-size: 9px;
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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: 8px;
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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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.inputxt_20{
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width: 20px;
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border: 0px !important;
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border-bottom:1px solid #000 !important;
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padding: 0 !important;
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font-size: 8px !important;
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text-align: center !important;
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}
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.inputxt_75{
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width: 75px;
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border: 0px !important;
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border-bottom:1px dashed #000 !important;
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padding: 0 !important;
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|
font-size: 8px !important;
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|
text-align: center !important;
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|
}
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.inputxt_40{
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|
|
width: 40px;
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|
border: 0px !important;
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border-bottom:1px solid #000 !important;
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padding: 0 !important;
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font-size: 8px !important;
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text-align: center !important;
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}
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.cbx_css{
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|
width: 50px;
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|
border: 1px solid #000;
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|
font-size: 8px;
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font-family:Verdana;
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|
}
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|
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</style>
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<div style="width: 650px; margin: 0pt auto;">
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<div style="display: block; width: 100%; text-align: center; font-family: Arial; font-size: 14px; font-weight: bold; padding-top: 10px; padding-bottom: 5px;">
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28 Day Cycle #<input type="text" name="arr_cycle" style="width: 15px" />, Day <input type="text" name="arr_day" style="width: 15px" /><br />
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Vital Signs and AE Query
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</div>
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<div style="clear: both; height: 20px; width: 100%"></div>
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<table class="box-table-a" width="100%">
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<thead>
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<tr>
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<th align="center" scope="col" width="5%">Study Day</th>
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<th align="center" scope="col" width="13%">Date<br />DD/MMM/YYYY</th>
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<th align="center" scope="col" width="7%">Interval <br />Hr pre<br /> or post<br /> dose</th>
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<th align="center" scope="col" width="14%">Initial Reading and Repeat Readings (check boc if needed)</th>
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<th align="center" scope="col" width="10%">Time <br /> Hr: Min</th>
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<th align="center" scope="col" width="20%">Blood Pressure<br />mmHg</th>
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<th align="center" scope="col" width="8%">Pulse Rate <br />bmp</th>
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<th align="center" scope="col" width="8%">Respirations<br />rpm</th>
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<th align="center" scope="col" width="8%">Temperature<br />ºC</th>
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<th align="center" scope="col" >AE <br />(Y/N)</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 align="center">
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<input type="text" name="arr_studyday[]" class="inputxt_20"/>
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</td>
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<td align="center">
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<input type="text" name="arr_date[]" class="inputxt_75 css_date" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY"/>
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</td>
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<td align="center">
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<input type="text" name="arr_interval[]" class="inputxt_20"/>
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</td>
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|
<td align="center">
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Initial
|
|
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</td>
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<td align="center">
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<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='00:00') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
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</td>
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<td align="center">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="arr_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: 8px; text-align: center; width: 100%; ">Supine</div>
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|
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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="arr_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: 8px; text-align: center; width: 100%; ">Standing</div>
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</div>
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<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
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|
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</td>
|
|
|
<td align="center">
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|
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<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
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|
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</td>
|
|
|
<td align="center">
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|
|
<select name="cbx_ae[]" class="cbx_css">
|
|
|
<option value="0">Select</option>
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|
|
<option value="1">Yes</option>
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|
|
<option value="2">No</option>
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|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 1st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 2st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6; ">
|
|
|
<input type="text" name="arr_date[]" style="background-color: #A6A6A6; color:#fff" class="inputxt_75 css_date" onfocus="if(this.value=='') this.value='';" onblur="if(this.value=='') this.value='';" value=""/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
Initial
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='00:00') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]"style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<select name="cbx_ae[]" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 1st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 2st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='DD/MMM/YYYY';" value="DD/MMM/YYYY"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
Initial
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]"style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<select name="cbx_ae[]" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 1st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 2st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6; ">
|
|
|
<input type="text" name="arr_date[]" style="background-color: #A6A6A6; color:#fff" class="inputxt_75 css_date" onfocus="if(this.value=='') this.value='';" onblur="if(this.value=='') this.value='';" value=""/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
Initial
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]"style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae[]" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 1st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
<tr>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_studyday[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_date[]" class="inputxt_75 css_date" />
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_interval[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="checkbox" name="arr_initial[]" style="float:left" /> 2st repeat
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_time[]" class="schedule_time inputxt_40" onfocus="if(this.value=='DD/MMM/YYYY') this.value='';" onblur="if(this.value=='') this.value='00:00';" value="00:00"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood1[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Supine</div>
|
|
|
</div>
|
|
|
<div style="width: 3px; float: left; border: 0px solid #f00; padding-left: 5px; padding-right: 5px;padding-top: 5px"> / </div>
|
|
|
<div style="width: 25px; float: left; border: 0px solid #f00">
|
|
|
<input type="text" name="arr_blood2[]" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000"/>
|
|
|
<div style="display: block; font-size: 8px; text-align: center; width: 100%; ">Standing</div>
|
|
|
</div>
|
|
|
<div style="font-size: 8px;float: right; border: 0px solid #f00; padding-right: 5px; padding-top: 5px"> <strong>mmHg</strong> </div>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_pulse[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_respirations[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center">
|
|
|
<input type="text" name="arr_temperature[]" class="inputxt_20"/>
|
|
|
</td>
|
|
|
<td align="center" style="background-color: #A6A6A6">
|
|
|
<select name="cbx_ae" class="cbx_css">
|
|
|
<option value="0">Select</option>
|
|
|
<option value="1">Yes</option>
|
|
|
<option value="2">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
|
|
</div>
|
