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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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<div style="margin: 0 auto; text-align: center">
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<label>28 Day Cycle#<input type="text" name="txt_test" style="width:15px" /></label>
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<label>, Treatment Week Number#</label><input type="text" name="txt_test" style="width:15px" />
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<label>, Study Day </label><input type="text" name="txt_test" style="width:15px" />
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</div>
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<br/><br/>
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<table border="0" class="tbl_general">
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<thead>
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<tr>
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<th colspan="3">Interval History</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 colspan="2">Have there been any changes to the history since the last visit?</td>
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<td><input type="radio" name="txt_active" />Yes*</td>
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<td><input type="radio" name="txt_active" />No</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="0" class="tbl_general">
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<thead>
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<tr>
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<th colspan="2" style="text-align: center; width:250px">*If Yes, List findings below</th>
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<th>Active</th>
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<th>Not active</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 style="text-align: center; width:5px">1.</td>
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<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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</tr>
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<tr>
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<td style="text-align: center; width:5px">2.</td>
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<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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</tr>
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<tr>
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<td style="text-align: center; width:5px">3.</td>
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<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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</tr>
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<tr>
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|
<td style="text-align: center; width:5px">4.</td>
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<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
|
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|
<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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</tr>
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<tr>
|
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|
<td style="text-align: center; width:5px">5.</td>
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<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
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<td style="text-align: center"><input type="radio" name="txt_active" /></td>
|
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|
<td style="text-align: center"><input type="radio" name="txt_active" /></td>
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|
</tr>
|
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<tr>
|
|
|
<td style="text-align: center; width:5px">6.</td>
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|
|
<td style="text-align: center; width:400px"><input type="text" name="txt_test" style="width:300px" /></td>
|
|
|
<td style="text-align: center"><input type="radio" name="txt_active" /></td>
|
|
|
<td style="text-align: center"><input type="radio" name="txt_active" /></td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
|
|
<br/><br/>
|
|
|
<table border="0" class="tbl_general">
|
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<thead>
|
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|
<tr><th colspan="3">AE Query</th></tr>
|
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</thead>
|
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<tbody>
|
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<tr>
|
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<td>Has the subject been queried about AEs since the last visit?</td>
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<td><input type="radio" name="rdo_yes" />Yes**</td>
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<td><input type="radio" name="rdo_yes" />No</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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<label>**If any AEs reported, record on AE page.</label>
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