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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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<br/>
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<label>Date:</label>
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<input type="text" class="txt_date" name="datos[date_exam]" style="border-top: 0; border-right: 0; border-left: 0; text-align: center" 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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<br/><br/>
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<div class="header_frm_page">
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<label class="title1">Discharge Laboratory Measures</label>
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</div>
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<table width="100%" id="" class="tbl_general" style="border: 1px solid #ccc">
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<thead>
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<tr>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 400px; height: 25px; text-align:center"></th>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 150px; text-align:center">
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Date Obtained<br/>DD/MMM/YYYY
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</th>
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<th style="border-bottom: 1px solid #ccc; width: 150px; text-align:center">If repeat, List date<br/>DD/MMM/YYYY</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="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 400px; height: 30px; text-align:center">
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Chemistry obtained:
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</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align:center">
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<input type="text" class="txt_date" name="datos[che_obt]" value="" />
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align:center">
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<input type="text" class="txt_date" name="datos[che_obt_repeat]" value="" />
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</td>
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</tr>
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<tr>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 400px; height: 30px; text-align:center">
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Hematology obtained:
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</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align:center">
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<input type="text" class="txt_date" name="datos[hema_obt]" value="" />
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align:center">
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<input type="text" class="txt_date" name="datos[hema_obt_repeat]" value="" />
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</td>
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</tr>
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<tr>
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|
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 400px; height: 30px; text-align:center">
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|
Urinalysis obtained:
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|
</td>
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|
<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align:center">
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<input type="text" class="txt_date" name="datos[uo_obt]" value="" />
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|
</td>
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|
|
<td style="border-bottom: 1px solid #ccc; text-align:center">
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|
|
<input type="text" class="txt_date" name="datos[uo_obt_repeat]" value="" />
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|
</td>
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|
</tr>
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|
<tr>
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|
<td style="border-right: 1px solid #ccc; width: 400px; height: 30px; text-align:center">
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|
|
Liver Function Tests:
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|
|
</td>
|
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|
<td style="border-right: 1px solid #ccc; text-align:center"><input type="text" class="txt_date" name="datos[uds_obt]" value="" /></td>
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|
<td style="text-align:center;"><input type="text" class="txt_date" name="datos[uds_obt_repeat]" value="" /></td>
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|
</tr>
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|
</tbody>
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|
</table>
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|
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|
<div class="tool_buttons" style="padding-top: 10px">
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<input type="submit" value="save" id="btn_save" name="btn_save">
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<input type="reset" value="clear" id="btn_clear" name="btn_clear">
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</div>
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