##// END OF EJS Templates
jro_apps » pbase
RSS
modificada la instancia de la clase SessionModel
modificada la instancia de la clase SessionModel
arturo - - Load All Authors

File last commit:

r0:1
r11:12
Show More
frm_40.php
69 lines | 2.4 KiB | text/x-php | XmlPhpLexer
/ trunk / components / com_data / views / frm_40.php
History | Annotation | Raw |Copy content |Copy permalink
<label>Adverse Events (AEs)</label><br/><br/>
<label>Are there any adverse events to be recorded on this page?</label>&nbsp;
<input type="radio" name="rbn_opt"/>Yes&nbsp;&nbsp;<input type="radio" name="rbn_opt"/>No<br/>
<table border="1">
<thead>
<tr>
<th>AE#</th>
<th>Adverse Event<br/>Serious AE?<br/>(Check if yes)</th>
<th>Onset Date<br/>DD/MMM/YYYY</th>
<th>Date Resolved<br/>DD/MMM/YYYY</th>
<th>Ongoing</th>
<th>
<table border="1">
<thead><tr><th colspan="3">Record ONE number in<br/>each category blow</th></tr></thead>
<tbody>
<tr><td>Severity<br/>1. Mild<br/>2. Moderate<br/>3. Severe</td>
<td>Relationship<br/>1. Unlikely related<br/>2. Possibly related<br/>3. Probably related<br/>4. Definitely related</td>
<td>Outcome<br/>1. Recovered without sequelae<br/>2. Recovered with sequelae<br/>
<small>(record sequelae en box)</small><br/>3. Death
</td>
</tr>
</tbody>
</table>
</th>
<th>
<table border="1">
<thead><tr><th colspan="3">Record ALL that apply</th></tr></thead>
<tbody>
<tr>
<td>Action Taken<br/>1=No action taken
<br/>2=Study drug discontinued
<br/>3=Dose modified
<br/>4=Medication
<br/>5=Procedure<small>(Specify in box)</small>
<br/>6=Other<small>(Specify in box)</small>
</td>
</tr>
</tbody>
</table>
</th>
</tr>
</thead>
<tbody>
<tr>
<td></td>
<td><input type="text" name="txt_ae" value="" />&nbsp;<input type="radio" name="rbnAE" value="" /></td>
<td><input type="text" name="txt_dateOnset" value="" /></td>
<td><input type="text" name="txt_dateResolved" value="" /></td>
<td><input type="radio" name="rbnOngoing" value="" /></td>
<td>
<table>
<tbody>
<tr>
<td><input text="type" name="txt_severity" /></td>
<td><input text="type" name="txt_relation" /></td>
<td><input text="type" name="txt_outcome" /></td>
</tr>
</tbody>
</table>
</td>
<td>
<table>
<tbody>
<tr><td><input text="type" name="txt_action" /></td></tr>
</tbody>
</table>
</td>
</tr>
</tbody>
</table>