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<?php
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?>
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<script>
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$(function() {
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$( "#txt_date_urinalysis" ).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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$( "#txt_date_toxicology" ).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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<label>Study Exit, Study Day</label><input type="text" name="txt_styday" value="" /><br/>
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<label>Urinalysis and Toxicology<br/><font color="red">(use if labs need to be transcribed)</font></label><br/><br/>
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<label>Date of Urinalysis: </label><input type="text" name="txt_date_urinalysis" id="txt_date_urinalysis" />
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<br/><br/>
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<table width="100%" id="" class="" style="" >
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<thead>
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<tr>
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<th style="text-align:center;">Test</th>
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<th style="text-align:center;">Result</th>
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<th style="text-align:center;">Flag<br>(H/L/Abn)</th>
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<th style="text-align:center;">Clinically<br> Significant?<br/>(Y/N)</th>
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<th style="text-align:center;">Repeated<br/>(Y/N)</th>
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<th style="text-align:center;">If no, 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="text-align:left;">Specific gravity</td>
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<td style="text-align:center;"><input type="text" id="sg_result" name="datos[sg_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="sg_flag" name="datos[sg_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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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>
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<td style="text-align:center;">
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<select id="sg_repeat" name="datos[sg_repeat]" 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;"><textarea name="datos[sg_comment]" id="sg_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">pH</td>
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<td style="text-align:center;"><input type="text" id="ph_result" name="datos[ph_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ph_flag" name="datos[ph_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="ph_clinically_sig" name="datos[ph_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>
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<td style="text-align:center;">
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<select id="ph_repeat" name="datos[ph_repeat]" 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;"><textarea name="datos[ph_comment]" id="ph_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Color</td>
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<td style="text-align:center;"><input type="text" id="color_result" name="datos[color_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="color_flag" name="datos[color_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="color_clinically_sig" name="datos[color_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>
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<td style="text-align:center;">
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<select id="color_repeat" name="datos[color_repeat]" 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;"><textarea name="datos[color_comment]" id="color_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Appearance</td>
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<td style="text-align:center;"><input type="text" id="appearance_result" name="datos[appearance_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="appearance_flag" name="datos[appearance_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="appearance_clinically_sig" name="datos[appearance_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>
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<td style="text-align:center;">
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<select id="appearance_repeat" name="datos[appearance_repeat]" 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;"><textarea name="datos[appearance_comment]" id="appearance_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">WBC Esterase</td>
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<td style="text-align:center;"><input type="text" id="WBC_esterase_result" name="datos[WBC_esterase_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="WBC_esterase_flag" name="datos[WBC_esterase_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="WBC_esterase_clinically_sig" name="datos[WBC_esterase_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>
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<td style="text-align:center;">
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<select id="WBC_esterase_repeat" name="datos[WBC_esterase_repeat]" 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;"><textarea name="datos[WBC_esterase_comment]" id="WBC_esterase_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Protein</td>
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<td style="text-align:center;"><input type="text" id="protein_result" name="datos[protein_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="appearance_flag" name="datos[appearance_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="protein_clinically_sig" name="datos[protein_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>
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<td style="text-align:center;">
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<select id="protein_repeat" name="datos[protein_repeat]" 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;"><textarea name="datos[protein_comment]" id="protein_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Glucose</td>
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<td style="text-align:center;"><input type="text" id="glucose_result" name="datos[glucose_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="glucose_rflag" name="datos[glucose_rflag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="glucose_clinically_sig" name="datos[glucose_clinically_sig]" class="form_select">
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<option value="Y" selected>Yes</option>
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<option value="N">No</option>
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</select></td>
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<td style="text-align:center;">
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<select id="glucose_repeat" name="datos[glucose_repeat]" 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;"><textarea name="datos[glucose_comment]" id="glucose_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Ketones</td>
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<td style="text-align:center;"><input type="text" id="ketones_result" name="datos[ketones_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="ketones_flag" name="datos[ketones_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="ketones_clinically_sig" name="datos[ketones_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>
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<td style="text-align:center;">
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<select id="ketones_repeat" name="datos[ketones_repeat]" 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;"><textarea name="datos[ketones_comment]" id="ketones_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Occult Blood</td>
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<td style="text-align:center;"><input type="text" id="occult_blood_result" name="datos[occult_blood_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="occult_blood_flag" name="datos[occult_blood_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="occult_blood_clinically_sig" name="datos[occult_blood_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>
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<td style="text-align:center;">
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<select id="occult_blood_repeat" name="datos[occult_blood_repeat]" 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;"><textarea name="datos[occult_blood_comment]" id="occult_blood_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Bilirubin</td>
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<td style="text-align:center;"><input type="text" id="bilirubin_result" name="datos[bilirubin_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="bilirubin_flag" name="datos[bilirubin_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="bilirubin_clinically_sig" name="datos[bilirubin_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>
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<td style="text-align:center;">
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<select id="bilirubin_repeat" name="datos[bilirubin_repeat]" 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;"><textarea name="datos[bilirubin_comment]" id="bilirubin_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Urobilinogen</td>
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<td style="text-align:center;"><input type="text" id="urobilinogen_result" name="datos[urobilinogen_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="urobilinogen_flag" name="datos[urobilinogen_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="urobilinogen_clinically_sig" name="datos[urobilinogen_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>
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<td style="text-align:center;">
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<select id="urobilinogen_repeat" name="datos[urobilinogen_repeat]" 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;"><textarea name="datos[urobilinogen_comment]" id="urobilinogen_comment" style="width:210px; height:35px;"></textarea></td>
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</tr>
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<tr>
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<td style="text-align:left;">Nitrite</td>
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<td style="text-align:center;"><input type="text" id="nitrite_result" name="datos[nitrite_result]" value="" /></td>
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<td style="text-align:center;">
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<select id="nitrite_flag" name="datos[nitrite_flag]" class="form_select">
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<option value="H">H</option>
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<option value="L">L</option>
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<option value="Abn">Abn</option>
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</select>
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</td>
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<td style="text-align:center;">
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<select id="nitrite_clinically_sig" name="datos[nitrite_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>
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<td style="text-align:center;">
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<select id="nitrite_repeat" name="datos[nitrite_repeat]" 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;"><textarea name="datos[nitrite_comment]" id="nitrite_comment" style="width:210px; height:35px;"></textarea></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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<label>Date of Toxicology:</label><input type="text" name="txt_dateTaxicology" /><br/><br/>
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<table border="0" 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: 400px; height: 25px">Test</th>
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<th style="border-bottom: 1px solid #ccc; border-right: 1px solid #ccc; width: 100px">Negative</th>
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<th style="border-bottom: 1px solid #ccc; width: 100px">Positive</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; padding-right: 15px">
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Urine Toxicology screen
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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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<input type="radio" name="rdo_yes" />
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</td>
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<td style="border-bottom: 1px solid #ccc; text-align: center">
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<input type="radio" name="rdo_yes" />
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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; padding-right: 15px">
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Ethanol screen(may be part of<br/>urine toxicology screen above)
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</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>
|
|
|
<td style="border-bottom: 1px solid #ccc; text-align: center">
|
|
|
<input type="radio" name="rdo_yes" />
|
|
|
</td>
|
|
|
</tr>
|
|
|
</tbody>
|
|
|
</table>
|
