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<script>
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$(function() {
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$( ".txt_date" ).datepicker({
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showWeek: true,
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dateFormat: 'dd/M/yy',
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firstDay: 1
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});
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});
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</script>
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<div class="header_frm_page">
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<label class="title1">Unscheduled Laboratory Measures</label>
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</div>
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<div class="header_question" style="padding-left: 10px">
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<span style="float: left; width: 400px; border: 0px solid #1cc; line-height: 15px">
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<label>Are there any repeat or unscheduled labs to be<br/>recorded on this page?</label>
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</span>
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<span style="float: left; width: 60px; border: 0px solid #fcc; line-height: 30px">
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<input type="radio" name="rbn_opt" /><label>Yes</label>
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</span>
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<span style="float: left; line-height: 30px; width: 150px; border: 0px solid #f00">
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<input type="radio" name="rbn_opt"/><label>No, do not complete</label>
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</span>
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<div style="clear: both; overflow: hidden"></div>
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</div>
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<table border="0" class="tbl_general" style="margin-top: 20px; margin-bottom: 20px; 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">Date<br/>DD/MMM/YYYY</th>
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<th class="tbl_th_border">Result</th>
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<th class="tbl_th_border">Flag<br/>(if UA)<br/>H/L/abn</th>
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<th class="tbl_th_border">Clinically 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, Comments</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"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border">
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<input type="text" name="txt_date" style="width:80px" class="txt_date" value="" />
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</td>
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<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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<td class="tbl_td_border">
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<select name="datos[flag]" class="form_select">
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<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
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<td class="tbl_td_border"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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<td class="tbl_td_border">
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<select name="datos[flag]" class="form_select">
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<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
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<td class="tbl_td_border"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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<td class="tbl_td_border">
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<select name="datos[flag]" class="form_select">
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<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
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<td class="tbl_td_border"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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<td class="tbl_td_border">
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<select name="datos[flag]" class="form_select">
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<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
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<td class="tbl_td_border"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
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<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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|
<td class="tbl_td_border">
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|
<select name="datos[flag]" class="form_select">
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|
<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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|
<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
|
|
|
<td class="tbl_td_border"><input type="text" name="txt_test" value="" style="width:100px" /></td>
|
|
|
<td class="tbl_td_border"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
|
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|
<td class="tbl_td_border"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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|
<td class="tbl_td_border">
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|
<select name="datos[flag]" class="form_select">
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|
<option value="1">H</option>
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<option value="2">L</option>
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<option value="3">abn</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="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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<option value="1">Yes</option>
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<option value="0">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" value="" style="width:100px" /></td>
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</tr>
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<tr>
|
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<td class="tbl_td_border_last"><input type="text" name="txt_test" value="" style="width:100px" /></td>
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<td class="tbl_td_border_last"><input type="text" name="txt_date" value="" style="width:80px" class="txt_date" /></td>
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<td class="tbl_td_border_last"><input type="text" name="txt_rsult" value="" style="width:100px" /></td>
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<td class="tbl_td_border_last">
|
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|
<select name="datos[flag]" class="form_select">
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|
<option value="1">H</option>
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|
<option value="2">L</option>
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<option value="3">abn</option>
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|
</select>
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</td>
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|
<td class="tbl_td_border_last">
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|
<select id="lst_clinically_sig" name="datos[sign_<?php echo $value_data['iddm']; ?>]" class="form_select">
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|
<option value="1">Yes</option>
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|
<option value="0">No</option>
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|
</select>
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</td>
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<td class="tbl_td_border_last">
|
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|
<select id="lst_repeat" name="datos[repeat_<?php echo $value_data['iddm']; ?>]" class="form_select">
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|
<option value="1">Yes</option>
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|
<option value="0">No</option>
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</select>
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</td>
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<td><input type="text" name="txt_comment" value="" style="width:100px" /></td>
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</tr>
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</tbody>
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</table>
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