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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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<style>
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.box-table-a
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{
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font-family: "Lucida Sans Unicode", "Lucida Grande", Sans-Serif;
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font-size: 12px;
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margin: 0px 0 0px 0;
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width: 650px;
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text-align: left;
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border-collapse: collapse;
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}
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.box-table-a th
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{
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font-size: 12px;
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font-weight: normal;
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padding: 5px 0px 5px 0px;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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}
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.box-table-a td
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{
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padding: 8px 3px 8px 5px ;
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background: #fff;
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border: 1px solid #000;
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color: #333;
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border-top: 1px solid transparent;
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}
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.box-table-a tr:hover td
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{
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background: #fff;
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color: #333 ;
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}
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</style>
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<div class="header_frm_page">
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<span>
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<label class="title4">28 Day Cycle #</label><input type="text" name="txt_cycle" style="width: 15px" />
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<label class="title4">, Treatment Week Number#</label><input type="text" name="txt_numWeek" style="width: 15px" />
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<label class="title4">, Study Day</label><input type="text" name="txt_styDay" style="width: 15px" />
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</span>
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<label class="title2">vital signs and targeted Physical Exam</label>
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</div>
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<div style="display: block; width: 100%; text-align: left; padding-top: 25px; margin-bottom: 45px">
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<label for="txt_date" style="float: left; width: 50px;">Date:</label>
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<input type="text" name="txt_date" id="txt_date" style="float:left; color: #666" 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 class="box-table-a" width="100%">
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<thead>
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<tr>
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<th scope="col" align="center" width="23%">Blood Pressure</th>
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<th scope="col" align="center" width="25%">Pulse Rate</th>
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<th scope="col" align="center" width="20%">Respirations</th>
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<th scope="col" align="center">Oral Temperature</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>
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<div style="width: 35px; 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: 35px; 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_bpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> bpm</td>
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<td><input type="text" name="txt_rpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> rpm</td>
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<td style="padding-left: 120px">
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<div style="width: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c1" id="temp_c1" style="width: 90%; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000; "/>
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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: 25px; float: left; border: 0px solid #f00">
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<input type="text" name="temp_c2" id="temp_c2" style="width: 90%; border-left:0; border-right: 0; border-bottom: 1px solid #000; border-top: 0"/>
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</div>
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<div style="font-size: 9px;float: left; border: 0px solid #f00; padding-left: 5px; padding-top: 3px"> °C </div>
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</td>
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</tr>
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</tbody>
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</table>
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<table class="box-table-a" width="100%" >
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<thead>
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<tr>
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<th scope="col" align="center" width="23%">Height</th>
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<th scope="col" align="center" width="25%">Weight</th>
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<th scope="col" align="center" style="background-color:#A6A6A6; color: #000; border-bottom: 1px solid #A6A6A6 !important "> </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_bpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> bpm</td>
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<td><input type="text" name="txt_rpm" style="width:70%; margin-right: 5px; float: left; border-left:0; border-right: 0; border-top: 0; border-bottom: 1px solid #000;"/> rpm</td>
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<td style="background-color:#A6A6A6; color: #000 "> </td>
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</tr>
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</tbody>
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</table>
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<div style="width: 100%; height: 30px;"></div>
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<table width="100%" class="box-table-a">
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<thead>
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<tr>
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<th scope="col" align="center" width="25%">Site or Organ System</th>
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<th scope="col" align="center" style="padding: 0 !important">
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<div style="clear:both; width: 100%; border-bottom: 1px solid #000;">
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Any changes since<br />previous visit? (<img src="images/check2.png">)
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</div>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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No
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</div>
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<div style="float:left; width: 49%; text-align: center">
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Yes*
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</div>
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</th>
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<th scope="col" align="center">*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 align="center" style="background-color:#A6A6A6; color: #000 ">General <br />Appearance</td>
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<td>
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<div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div>
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</td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center" style="background-color:#A6A6A6; color: #000 ">Skin</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center" style="background-color:#A6A6A6; color: #000 ">Head, Ears, Eyes, Nose, Throat</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Chest and Lungs</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center">Heart</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Abdomen</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center">Extremities</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%"/></td>
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</tr>
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<tr>
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<td align="center" style="background-color:#A6A6A6; color: #000 ">Neurologic</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag" style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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<tr>
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<td align="center" style="background-color:#A6A6A6; color: #000 ">Other</td>
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<td><div style="float:left; width: 50%; text-align: center; border-right: 1px solid #000">
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<input type="radio" name="rdo_yes" />
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</div>
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<div style="float:left; width: 49%; text-align: center">
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<input type="radio" name="rdo_yes" />
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</div></td>
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<td><input type="text" name="txt_flag"style="border:0px solid #f00; width: 98%" /></td>
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</tr>
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</tbody>
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</table>
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<a href="#" style="display:none">Add</a>
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