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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_styday" value="" style="width: 15px"/>
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</span>
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<label class="title1">Chemistry</label>
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<label class="title3">(use 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" 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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<table border="1" class="tbl_general" width="100%">
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<thead>
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<tr>
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<th>Test</th>
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<th>Result</th>
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<th>Clinically<br/>Significant<br/>(Y/N)?</th>
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<th>Repeated?<br/>(Y/N)</th>
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<th>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>Glucose</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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><select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>BUN</td>
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<td><input type="text" name="txt_result" /></td>
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<td><select name="datos[value_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><select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Calcium</td>
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<td><input type="text" name="txt_result" /></td>
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<td><select name="datos[value_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><select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Phosphorus<br/>(PO)</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Bilirubin(total)</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Bilirubin(direct)</td>
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<td><input type="text" name="txt_result" /></td>
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<td><select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Albumin</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Alkaline<br/>phosphatase</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr>
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<td>LDH</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr>
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<td>ALT</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr>
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<td>AST</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Cholesterol<br/>(total)</td>
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<td><input type="text" name="txt_result" /></td>
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<td>
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<select name="datos[value_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>
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<select name="datos[value_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><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Creatinine</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Sodium</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Potassium</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Chloride</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>CO2</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>GGT</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Serum Mg</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Total Cholesterol</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Triglycerides</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>PT/PTT</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>INR</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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<tr><td>Others</td>
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<td><input type="text" name="txt_result" /></td>
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<td><input type="text" name="txt_cnsig" /></td>
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<td><input type="text" name="txt_repeated" /></td>
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<td><input type="text" name="txt_comment" /></td>
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</tr>
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</tbody>
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</table>
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