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<script>
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$(function() {
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$( ".date_picker" ).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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$('.time_picker').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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<div class="header_frm_page">
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<label class="title1">28 Day Cycle 1 MTD Only: Day 1 and Day 26 Urine Collection for PK Analysis</label>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label>Date of Collection 1:</label>
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<input type="text" class="date_picker" id="date_exam_day01" name="datos[date_exam_day01]" 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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</div>
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<br/>
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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: 150px; height: 35px">To be collected<br>Hrs after dosing</th>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 120px">Collection Time</th>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 120px">Collected<br/>(Y/N)</th>
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<th style="border-bottom: 1px solid #ccc; width: 200px">Comment</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; text-align: left; padding-left: 20px; height: 25px" colspan="4">On Day 1</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; text-align: center; height: 40px">6</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="time_picker" id="day01_coll_day_6" name="datos[day01_coll_day_6]" value="" style="width:55px;" />
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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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<select id="day01_colleted_6" name="datos[day01_colleted_6]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day01_comment_6]" id="day01_comment_6" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">12</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="time_picker" id="day01_coll_day_12" name="datos[day01_coll_day_12]" value="" style="width:55px;" />
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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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<select id="day01_colleted_12" name="datos[day01_colleted_12]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day01_comment_12]" id="day01_comment_12" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">18</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="time_picker" id="day01_coll_day_18" name="datos[day01_coll_day_18]" value="" style="width:55px;" />
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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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<select id="day01_colleted_18" name="datos[day01_colleted_18]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day01_comment_18]" id="day01_comment_18" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">24</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="time_picker" id="day01_coll_day_24" name="datos[day01_coll_day_24_1]" value="" style="width:55px;" />
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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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<select id="day01_colleted_24" name="datos[day01_colleted_24]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day01_comment_24]" id="day01_comment_24" style="width:210px; height:35px;"></textarea>
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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; text-align: left; padding-left: 20px; height: 25px" colspan="4">On Day 26</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; text-align: center; height: 40px">6</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="time_picker" id="day05_coll_day_6" name="datos[day05_coll_day_6]" value="" style="width:55px;" />
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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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<select id="day05_colleted_6" name="datos[day05_colleted_6]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day05_comment_6]" id="day05_comment_6" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">12</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="time_picker" id="day05_coll_day_12" name="datos[day05_coll_day_12]" value="" style="width:55px;" />
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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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<select id="day05_colleted_12" name="datos[day05_colleted_12]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day05_comment_12]" id="day05_comment_12" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">18</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="time_picker" id="day05_coll_day_18" name="datos[day05_coll_day_18]" value="" style="width:55px;" />
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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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<select id="day05_colleted_18" name="datos[day05_colleted_18]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<textarea name="datos[day05_comment_18]" id="day05_comment_18" style="width:210px; height:35px;"></textarea>
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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; text-align: center; height: 40px">24</td>
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<td style="border-right: 1px solid #ccc; text-align: center">
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<input type="text" class="time_picker" id="day05_coll_day_24" name="datos[day05_coll_day_24]" value="" style="width:55px;" />
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</td>
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<td style="border-right: 1px solid #ccc; text-align: center">
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<select id="day05_colleted_24" name="datos[day05_colleted_24]" class="form_select">
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<option value="Y">Yes</option>
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<option value="N">No</option>
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</select>
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</td>
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<td style="text-align:center;">
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<textarea name="datos[day05_comment_24]" id="day05_comment_24" style="width:210px; height:35px;"></textarea>
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</td>
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</tr>
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</tbody>
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</table>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label>Date of Collection 26:</label>
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<input type="text" class="date_picker" id="date_exam_day05" name="datos[date_exam_day05]" 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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</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: 150px; height: 30px">Comments</th>
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|
<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 120px"></th>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 120px"></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-right: 1px solid #ccc; text-align: center; height: 20px"></td>
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<td style="border-right: 1px solid #ccc; text-align: center">
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</td>
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<td style="border-right: 1px solid #ccc; text-align: center">
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</td>
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</tr>
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</tbody>
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</table>
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<div class="tool_buttons" style="padding: 15px">
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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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