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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 class="header_frm_page">
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<label class="title1">Study Exit, Study Day <input type="text" name="txt_styday" value="" style="width: 18px"/></label>
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<label class="title1">Vital Signs and Physical Examination</label>
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</div>
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<div style="margin-top: 15px; margin-bottom: 15px">
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<label>Date:</label>
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<input type="text" name="txt_date" id="txt_date" 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/><br/>
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<label><font color="red">Delete these VS if the final VS of the Period are the same as the study exit VS</font></label>
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<table border="0" class="tbl_general" width="100%">
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<thead>
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<tr>
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<th width="20%" style="text-align: center">Pulse Rate</th>
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<th width="20%" style="text-align: center">Respirations</th>
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<th width="20%" style="text-align: center">Oral Temperature</th>
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<th width="25%" style="text-align: center">Blood Pressure</th>
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<th width="15%" style="text-align: center">Weight</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><input type="text" name="txt_test" style="width: 60px" /> bpm</td>
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<td><input type="text" name="txt_result" style="width: 60px" /> rpm</td>
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<td><input type="text" name="txt_flag" style="width: 80px" /> °C</td>
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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" name="txt_flag" style="width: 60px" /> Kg</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" width="100%" style="border: 1px solid #ccc">
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<thead>
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<tr>
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<th width="40%" style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; height: 60px">Site or Organ System</th>
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<th colspan="2" width="30%" style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc">
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<table width="100%" cellpadding="0">
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<thead>
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<tr>
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<th colspan="2" style="border-bottom: 1px solid #ccc; text-align: center">
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Change from<br/>previous exam?
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</th>
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</tr>
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</thead>
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<tbody>
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<tr><td style="border-right: 1px solid #ccc; text-align: center">No</td>
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<td style="text-align: center">Yes</td></tr>
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</tbody>
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</table>
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</th>
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<th width="30%" style="border-bottom: 1px solid #ccc">*If Yes, Specify findings</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; text-align: center; height: 30px">General Appearance</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Skin</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Head, Ears, Eyes, Nose, Throat</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Chest and Lungs</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Heart</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Abdomen</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Extremities</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Neurologic</td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-bottom: 1px solid #ccc; text-align: center"><input type="text" name="txt_flag" /></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: 30px">Other</td>
|
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|
<td style="border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
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<td style="border-right: 1px solid #ccc; text-align: center"><input type="radio" name="rdo_yes" /></td>
|
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<td style="text-align: center"><input type="text" name="txt_flag" /></td>
|
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</tr>
|
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</tbody>
|
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</table>
|
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|
<br/>
|
