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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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<span>
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<label class="title4">Study Exit, Study Day</label><input type="text" name="txt_cycle" style="width: 15px" />
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</span>
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<label class="title1">Laboratory Measures</label>
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<label class="title3">(use only if electronically transfered)</label>
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</div>
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<table width="100%" class="tbl_general" style="border: 1px solid #ccc">
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<thead>
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<tr>
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<th class="tbl_th_border"></th>
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<th class="tbl_th_border">Date Obtained<br/>DD/MM/YYYY</th>
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<th class="tbl_th_border_sup_last">If Repeated, List Date<br/>DD/MM/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 class="tbl_td_border" style="text-align: left">
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<label style="padding-left: 10px; display: block">LTFs and Chemistry</label>
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<label style="padding-left: 10px">Obtained:</label>
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</td>
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<td class="tbl_td_border">
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<input type="text" name="txt_dateobt_ltf" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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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</td>
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<td class="tbl_td_border_right">
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<input type="text" name="txt_datertd_ltf" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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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</td>
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</tr>
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<tr>
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<td class="tbl_td_border_last" style="text-align: left">
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<label style="padding-left: 10px">Hematology Obtained:</label>
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</td>
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<td class="tbl_td_border_last">
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<input type="text" name="txt_dateobt_hema" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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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</td>
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<td class="tbl_td_border_last_right">
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<input type="text" name="txt_datertd_hema" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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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</td>
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</tr>
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</tbody>
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</table>
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<div class="header_frm_page" style="margin-top: 15px">
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<span>
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<label class="title4">Study Exit, Study Day</label><input type="text" name="txt_cycle" style="width: 15px" />
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</span>
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<label class="title1">Hematology</label>
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<label class="title3">(use below if labs need to be transcribed)</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" class="txt_date" style="border-left: 0; border-top: 0; border-right: 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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<div style="margin-top: 20px; margin-bottom: 15px">
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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 class="tbl_th_border">Test</th>
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<th class="tbl_th_border">Result</th>
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<th class="tbl_th_border">Clinically<br/>Significant?<br/>(Y/N)</th>
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<th class="tbl_th_border">Repeated?<br/>(Y/N)</th>
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<th class="tbl_th_border_sup_last">If No, Comment</th>
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</tr>
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</thead>
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<tbody>
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<tr><td class="tbl_td_border">WBC Count</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">RBC Count</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">Hemoglobin</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">Hematocrit</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">MCV</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">MCH</td>
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|
<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">MCHC</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">RDW</td>
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|
<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
|
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|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">Platelets</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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>
|
|
|
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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|
</tr>
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<tr><td class="tbl_td_border">Polys</td>
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<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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|
|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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>
|
|
|
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
|
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|
</tr>
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<tr><td class="tbl_td_border">Lymphs</td>
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|
<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">Monocytes</td>
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|
<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
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|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td class="tbl_td_border">Eos</td>
|
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|
<td class="tbl_td_border"><input type="text" name="txt_result" /></td>
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<td class="tbl_td_border">
|
|
|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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>
|
|
|
<td class="tbl_td_border"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" 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 class="tbl_td_border_right"><input type="text" name="txt_comment" /></td>
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|
</tr>
|
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|
<tr><td class="tbl_td_border_last">Basos</td>
|
|
|
<td class="tbl_td_border_last"><input type="text" name="txt_result" /></td>
|
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|
<td class="tbl_td_border_last">
|
|
|
<select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select">
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td class="tbl_td_border_last"><select id="sg_clinically_sig" name="datos[sg_clinically_sig]" class="form_select">
|
|
|
<option value="Y">Yes</option>
|
|
|
<option value="N">No</option>
|
|
|
</select>
|
|
|
</td>
|
|
|
<td class="tbl_td_border_last_right"><input type="text" name="txt_comment" /></td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
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|
</div>
|
