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<?php
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?>
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<script>
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$(function() {
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//alert('hola');
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$( "#date_exam" ).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 style="width:650px; margin:0 auto;">
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<h1>Follow up Vital Signs And Phisical Exam </h1>
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<table id="" class="" style="" >
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<tbody>
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<tr>
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<td>Date</td>
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<td style="text-align:right;"><input type="text" id="date_exam" name="datos[date_exam]" value="" /></td>
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</tr>
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</tbody>
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</table>
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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 width="25%">Blod Pressure</td>
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<td>Pulse Rate</td>
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<td>Respirations</td>
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<td>Oral Temperature</td>
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</tr>
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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" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> bpm</td>
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<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> rpm</td>
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<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> C</td>
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</tr>
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<tr>
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<td>Height</td>
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<td>Weight</td>
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<td colspan="2">
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</tr>
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<tr>
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<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> cm.</td>
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<td><input type="text" id="date_exam" name="datos[date_exam]" value="" style="width:55px;" /> Kg.</td>
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<td colspan="2">
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</td>
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</tr>
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</tbody>
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</table>
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<br />
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<hr />
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<br />
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<div>
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<table id="" class="" style="" width="100%" >
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<thead>
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<tr>
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<td rowspan="2" > Site or Organ<BR> System</td>
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<td colspan="2"> Status </td>
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<td rowspan="2"> * If abnormal, Specify Findings </td>
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</tr>
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<tr>
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<td > Normal </td>
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<td > Abnormal </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 >General Appearance</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="ga_state_normal" name="datos[ga_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="ga_state_abnormal" name="datos[ga_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[ga_sf]" id="ga_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Skin</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="skin_state_normal" name="datos[skin_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="skin_state_abnormal" name="datos[skin_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[skin_sf]" id="skin_sf" style="width:280px; height:35px;"></textarea></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 style="text-align:center; vertical-align:middle;" ><input type="radio" id="heent_state_normal" name="datos[heent_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heent_state_abnormal" name="datos[heent_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[heent_sf]" id="heent_sf" style="width:280px; height:35px;"></textarea></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 style="text-align:center; vertical-align:middle;" ><input type="radio" id="chestlungs_state_normal" name="datos[chestlungs_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="chestlungs_state_abnormal" name="datos[chestlungs_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[chestlungs_sf]" id="chestlungs_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Heart</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heart_state_normal" name="datos[heart_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="heart_state_abnormal" name="datos[heart_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[heart_sf]" id="heart_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Abdomen</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="abdomen_state_normal" name="datos[abdomen_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="abdomen_state_abnormal" name="datos[abdomen_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[abdomen_sf]" id="abdomen_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Extremities</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="extremities_state_normal" name="datos[extremities_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="extremities_state_abnormal" name="datos[extremities_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[extremities_sf]" id="extremities_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Neurologic</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="neurologic_state_normal" name="datos[neurologic_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="neurologic_state_abnormal" name="datos[neurologic_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[neurologic_sf]" id="neurologic_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td >Other</td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="other_state_normal" name="datos[other_state]" value="normal"></td>
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<td style="text-align:center; vertical-align:middle;" ><input type="radio" id="other_state_abnormal" name="datos[other_state]" value="abnormal"></td>
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<td style="text-align:left; vertical-align:top;" ><textarea name="datos[other_sf]" id="other_sf" style="width:280px; height:35px;"></textarea></td>
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</tr>
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</tbody>
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<tfoot>
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<tr>
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<td colspan="4" style="text-align:right;"><input type="submit" value="save" id="btn_save" name="btn_save"><input type="reset" value="clear" id="btn_clear" name="btn_clear"></td>
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</tr>
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</tfoot>
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</table>
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</div>
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</div>
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