711 lines
26 KiB
PHP
711 lines
26 KiB
PHP
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<script>
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function validate()
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{/*
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var sbp = $('#sbp').val();
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if(sbp == ''){
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BootstrapDialog.alert('Please Enter SBP.!!!');
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return false;
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}
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var dbp = $('#dbp').val();
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if(dbp == ''){
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BootstrapDialog.alert('Please Enter DBP.!!!');
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return false;
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}
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var dvrt = $('#dvrt').val();
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if(dvrt == ''){
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BootstrapDialog.alert('Please Enter DVRT.!!!');
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return false;
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}
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var nvrt = $('#nvrt').val();
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if(nvrt == ''){
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BootstrapDialog.alert('Please Enter NVRT.!!!');
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return false;
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}
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var nvlt = $('#nvlt').val();
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if(nvlt == ''){
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BootstrapDialog.alert('Please Enter NVLT.!!!');
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return false;
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}
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var cv = $('#cv').val();
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if(cv == ''){
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BootstrapDialog.alert('Please Enter CV.!!!');
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return false;
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}
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var fundoscopy = $('#fundoscopy').val();
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if(fundoscopy == ''){
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BootstrapDialog.alert('Please Enter Fundoscopy.!!!');
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return false;
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}
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var urine_albumin = $('#urine_albumin').val();
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if(urine_albumin == ''){
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BootstrapDialog.alert('Please Enter Urine Albumin.!!!');
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return false;
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}
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var urine_sugar = $('#urine_sugar').val();
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if(urine_sugar == ''){
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BootstrapDialog.alert('Please Enter Urine Sugar.!!!');
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return false;
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}
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var urine_bile_pigments = $('#urine_bile_pigments').val();
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if(urine_bile_pigments == ''){
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BootstrapDialog.alert('Please Enter Urine Bile Pigment.!!!');
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return false;
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}
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var urine_ketones = $('#urine_ketones').val();
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if(urine_ketones == ''){
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BootstrapDialog.alert('Please Enter Urine ketones.!!!');
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return false;
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}
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var urine_epithelial_cells = $('#urine_epithelial_cells').val();
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if(urine_epithelial_cells == ''){
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BootstrapDialog.alert('Please Enter Urine Epithelial Cells .!!!');
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return false;
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}
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var hb = $('#hb').val();
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if(hb == ''){
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BootstrapDialog.alert('Please Enter HB%.!!!');
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return false;
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}
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*/
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var emp_id=$("#emp_id").val();
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if(emp_id=="" || emp_id==null){
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BootstrapDialog.alert('Please Select Employee');
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return false;
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}
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save_checkup();
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}
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</script>
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<style>
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.modal-dialog {
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padding: 15px;
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width:55%;
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height:100%;
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}
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</style>
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<div class="modal fade" id="modal-add-checkup" name="modal-add-checkup" role="dialog" aria-hidden="true" >
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<form role="form" id="checkup_form" name="checkup_form" action="#" method="post">
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<div class="modal-dialog modal-lg">
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<div class="modal-content">
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<div class="widget-header">
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<h5 class="widget-title">Checkup Form</h5>
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<div class="widget-toolbar">
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<div class="widget-menu">
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<a href="#" class="close" data-action="close" data-dismiss="modal">
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<i class="ace-icon fa fa-times"></i>
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</a>
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</div>
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</div>
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</div>
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<div class="modal-body">
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="role">Checkup Date</label>
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<div class="input-group">
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<input class="form-control date-picker" style="width:70px;font-size:10px;height:25px;" name="checkup_date" id="checkup_date" type="text" data-date-format="dd/mm/yyyy" />
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<span class="input-group-addon">
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<i class="fa fa-calendar bigger-110"></i>
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</span>
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</div>
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</div>
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<div class="form-group col-sm-2">
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<label for="role">SBP</label>
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<input type="hidden" class="form-control" name="checkup_id"
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id="checkup_id" value="" required/>
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<input type="text" class="form-control" name="sbp" style="font-size:10px;"
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id="sbp" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">DBP</label>
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<input type="text" class="form-control" name="dbp" style="font-size:10px;"
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id="dbp" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">DVRT</label>
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<input type="text" class="form-control" name="dvrt" style="font-size:10px;"
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id="dvrt" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">NVRT</label>
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<input type="text" class="form-control" name="nvrt" style="font-size:10px;"
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id="nvrt" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">NVLT</label>
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<input type="text" class="form-control" name="nvlt" style="font-size:10px;"
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id="nvlt" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">CV</label>
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<input type="text" class="form-control" name="cv" style="font-size:10px;"
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id="cv" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Fundoscopy</label>
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<input type="text" class="form-control" name="fundoscopy" style="font-size:10px;"
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id="fundoscopy" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Albumin</label>
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<input type="text" class="form-control" name="urine_albumin" style="font-size:10px;"
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id="urine_albumin" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Suagr</label>
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<input type="text" class="form-control" name="urine_sugar" style="font-size:10px;"
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id="urine_sugar" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Biles</label>
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<input type="text" class="form-control" name="urine_bile_pigments" style="font-size:10px;"
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id="urine_bile_pigments" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Kitones</label>
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<input type="text" class="form-control" name="urine_ketones" style="font-size:10px;"
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id="urine_ketones" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Pus Cells</label>
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<input type="text" class="form-control" name="urine_pus_cells" style="font-size:10px;"
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id="urine_pus_cells" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Urine Epithelial </label>
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<input type="text" class="form-control" name="urine_epithelial_cells" style="font-size:10px;"
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id="urine_epithelial_cells" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Hb%</label>
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<input type="text" class="form-control" name="Hb%" style="font-size:10px;"
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id="Hb%" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">WBC</label>
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<input type="text" class="form-control" name="wbc" style="font-size:10px;"
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id="wbc" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">R B C</label>
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<input type="text" class="form-control" name="rbc" style="font-size:10px;"
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id="rbc" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">P C V</label>
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<input type="text" class="form-control" name="pcv" style="font-size:10px;"
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id="pcv" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">M C V</label>
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<input type="text" class="form-control" name="mcv" style="font-size:10px;"
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id="mcv" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">M C H</label>
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<input type="text" class="form-control" name="mch" style="font-size:10px;"
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id="mch" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">M C H C</label>
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<input type="text" class="form-control" name="mchc" style="font-size:10px;"
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id="mchc" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Neutrophils</label>
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<input type="text" class="form-control" name="Neutrophils" style="font-size:10px;"
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id="Neutrophils" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Lymphocytes</label>
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<input type="text" class="form-control" name="lymphocytes" style="font-size:10px;"
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id="lymphocytes" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Eosinophils</label>
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<input type="text" class="form-control" name="eosinophils" style="font-size:10px;"
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id="eosinophils" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">Monocytes</label>
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<input type="text" class="form-control" name="monocytes" style="font-size:10px;"
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id="monocytes" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Basophils</label>
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<input type="text" class="form-control" name="basophils" style="font-size:10px;"
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id="basophils" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Platelets</label>
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<input type="text" class="form-control" name="platelets" style="font-size:10px;"
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id="platelets" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">E S R</label>
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<input type="text" class="form-control" name="esr" style="font-size:10px;"
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id="esr" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">RBS</label>
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<input type="text" class="form-control" name="rbs" style="font-size:10px;"
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id="rbs" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Blood Urea</label>
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<input type="text" class="form-control" name="bloodurea" style="font-size:10px;"
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id="bloodurea" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">Sr. Creatinine</label>
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<input type="text" class="form-control" name="creatinine" style="font-size:10px;"
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id="creatinine" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Uric Acid</label>
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<input type="text" class="form-control" name="uric_acid" style="font-size:10px;"
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id="uric_acid" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Total Cholesterol</label>
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<input type="text" class="form-control" name="total_cholesterol" style="font-size:10px;"
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id="total_cholesterol" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">HDL</label>
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<input type="text" class="form-control" name="hdl" style="font-size:10px;"
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id="hdl" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">LDL</label>
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<input type="text" class="form-control" name="ldl" style="font-size:10px;"
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id="ldl" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Triglycerides</label>
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<input type="text" class="form-control" name="triglycerides" style="font-size:10px;"
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id="triglycerides" placeholder="" required/>
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</div>
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</div>
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<div class="row">
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<div class="form-group col-sm-2">
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<label for="checkup">Total Bilirubin</label>
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<input type="text" class="form-control" name="total_bilirubin" style="font-size:10px;"
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||
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id="total_bilirubin" placeholder="" required/>
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</div>
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<div class="form-group col-sm-2">
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<label for="checkup">Direct Bilirubin</label>
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||
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<input type="text" class="form-control" name="direct_bilirubin" style="font-size:10px;"
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||
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id="direct_bilirubin" placeholder="" required/>
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||
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</div>
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||
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<div class="form-group col-sm-2">
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<label for="checkup">Indirect Bilirubin</label>
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||
|
|
<input type="text" class="form-control" name="indirect_bilirubin" style="font-size:10px;"
|
||
|
|
id="indirect_bilirubin" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">SGOT</label>
|
||
|
|
<input type="text" class="form-control" name="sgot" style="font-size:10px;"
|
||
|
|
id="sgot" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">SGPT</label>
|
||
|
|
<input type="text" class="form-control" name="total_cholesterol" style="font-size:10px;"
|
||
|
|
id="total_cholesterol" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">ALP</label>
|
||
|
|
<input type="text" class="form-control" name="alp" style="font-size:10px;"
|
||
|
|
id="alp" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">FVC</label>
|
||
|
|
<input type="text" class="form-control" name="total_cholesterol" style="font-size:10px;"
|
||
|
|
id="total_cholesterol" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">FEV1</label>
|
||
|
|
<input type="text" class="form-control" name="fev1" style="font-size:10px;"
|
||
|
|
id="fev1" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">FEV1/FVC</label>
|
||
|
|
<input type="text" class="form-control" name="fev1_fvc" style="font-size:10px;"
|
||
|
|
id="fev1_fvc" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">FEF 25-75</label>
|
||
|
|
<input type="text" class="form-control" name="FEF_25_75" style="font-size:10px;"
|
||
|
|
id="FEF_25_75" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">PFT Result</label>
|
||
|
|
<input type="text" class="form-control" name="PFT_result" style="font-size:10px;"
|
||
|
|
id="PFT_result" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Chest X-ray</label>
|
||
|
|
<input type="text" class="form-control" name="Chest_X_ray" style="font-size:10px;"
|
||
|
|
id="Chest_X_ray" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">ECG</label>
|
||
|
|
<input type="text" class="form-control" name="ECG" style="font-size:10px;"
|
||
|
|
id="ECG" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">HBsAg</label>
|
||
|
|
<input type="text" class="form-control" name="HBsAg" style="font-size:10px;"
|
||
|
|
id="HBsAg" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Widal Test</label>
|
||
|
|
<input type="text" class="form-control" name="Widal_test" style="font-size:10px;"
|
||
|
|
id="Widal_test" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Mantoux Test</label>
|
||
|
|
<input type="text" class="form-control" name="Mantoux_test" style="font-size:10px;"
|
||
|
|
id="Mantoux_test" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Notes</label>
|
||
|
|
<input type="text" class="form-control" name="Notes" style="font-size:10px;"
|
||
|
|
id="Notes" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt500Hz" style="font-size:10px;"
|
||
|
|
id="ACRt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt1000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt2000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt500Hz" style="font-size:10px;"
|
||
|
|
id="ACRt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt1000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt2000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt500Hz" style="font-size:10px;"
|
||
|
|
id="ACRt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt1000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt2000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 4000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt4000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt4000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Rt 8000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACRt8000Hz" style="font-size:10px;"
|
||
|
|
id="ACRt8000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Lt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACLt500Hz" style="font-size:10px;"
|
||
|
|
id="ACLt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Lt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACLt1000Hz" style="font-size:10px;"
|
||
|
|
id="ACLt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Lt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACLt2000Hz" style="font-size:10px;"
|
||
|
|
id="ACLt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Lt 4000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACLt4000Hz" style="font-size:10px;"
|
||
|
|
id="ACLt4000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">AC Lt 8000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="ACLt8000Hz" style="font-size:10px;"
|
||
|
|
id="ACLt8000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Rt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCRt500Hz" style="font-size:10px;"
|
||
|
|
id="BCRt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Rt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCRt1000Hz" style="font-size:10px;"
|
||
|
|
id="BCRt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Rt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCRt2000Hz" style="font-size:10px;"
|
||
|
|
id="BCRt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Rt 4000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCRt4000Hz" style="font-size:10px;"
|
||
|
|
id="BCRt4000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Rt 8000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCRt8000Hz" style="font-size:10px;"
|
||
|
|
id="BCRt8000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Lt 500 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCLt500Hz" style="font-size:10px;"
|
||
|
|
id="BCLt500Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Lt 1000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCLt1000Hz" style="font-size:10px;"
|
||
|
|
id="BCLt1000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Lt 2000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCLt2000Hz" style="font-size:10px;"
|
||
|
|
id="BCLt2000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Lt 4000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCLt4000Hz" style="font-size:10px;"
|
||
|
|
id="BCLt4000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">BC Lt 8000 Hz</label>
|
||
|
|
<input type="text" class="form-control" name="BCLt8000Hz" style="font-size:10px;"
|
||
|
|
id="BCLt8000Hz" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Audiometry Result</label>
|
||
|
|
<input type="text" class="form-control" name="Audiometry_result" style="font-size:10px;"
|
||
|
|
id="Audiometry_result" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">ECHO</label>
|
||
|
|
<input type="text" class="form-control" name="ECHO" style="font-size:10px;"
|
||
|
|
id="ECHO" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Ultrasound</label>
|
||
|
|
<input type="text" class="form-control" name="Ultrasound" style="font-size:10px;"
|
||
|
|
id="Ultrasound" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">PAP Smear/PSA</label>
|
||
|
|
<input type="text" class="form-control" name="PAP_Smear" style="font-size:10px;"
|
||
|
|
id="PAP_Smear" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Mammogram</label>
|
||
|
|
<input type="text" class="form-control" name="Mammogram" style="font-size:10px;"
|
||
|
|
id="Mammogram" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="row">
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Vitamin B12</label>
|
||
|
|
<input type="text" class="form-control" name="Vitamin_B12" style="font-size:10px;"
|
||
|
|
id="Vitamin_B12" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Vitamin D</label>
|
||
|
|
<input type="text" class="form-control" name="Vitamin_D" style="font-size:10px;"
|
||
|
|
id="Vitamin_D" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">HbA1C</label>
|
||
|
|
<input type="text" class="form-control" name="HbA1C" style="font-size:10px;"
|
||
|
|
id="HbA1C" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Bone Density</label>
|
||
|
|
<input type="text" class="form-control" name="Bone_density" style="font-size:10px;"
|
||
|
|
id="Bone_density" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">CT Scan</label>
|
||
|
|
<input type="text" class="form-control" name="CT_Scan" style="font-size:10px;"
|
||
|
|
id="CT_Scan" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">MRI</label>
|
||
|
|
<input type="text" class="form-control" name="MRI" style="font-size:10px;"
|
||
|
|
id="MRI" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Other Tests</label>
|
||
|
|
<input type="text" class="form-control" name="Other_tests" style="font-size:10px;"
|
||
|
|
id="Other_tests" placeholder="" required/>
|
||
|
|
</div>
|
||
|
|
<div class="form-group col-sm-2">
|
||
|
|
<label for="checkup">Select Employee</label>
|
||
|
|
<select class="form-control" name="emp_id" style="font-size:10px;width:150px"
|
||
|
|
id="emp_id" placeholder="" required>
|
||
|
|
|
||
|
|
</select>
|
||
|
|
</div>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
|
||
|
|
</div>
|
||
|
|
<div class="widget-toolbox padding-8 clearfix" >
|
||
|
|
<button type="button" class="btn btn-info btn-sm save_button" onclick="validate();"><i class="ace-icon fa fa-floppy-o bigger-110"></i>Save </button>
|
||
|
|
<button type="button" class="btn btn-danger btn-sm" data-dismiss="modal"><i class="ace-icon fa fa-times bigger-110"></i>Cancel</button>
|
||
|
|
</div>
|
||
|
|
|
||
|
|
</div>
|
||
|
|
</div>
|
||
|
|
</form>
|
||
|
|
</div>
|
||
|
|
<script>
|
||
|
|
$('#checkup_date').datepicker({
|
||
|
|
autoclose:true,
|
||
|
|
format: 'dd/mm/yyyy',
|
||
|
|
startDate: '1d/1m/1970y',
|
||
|
|
|
||
|
|
}).next().on(ace.click_event, function(){
|
||
|
|
$(this).prev().focus();
|
||
|
|
|
||
|
|
});
|
||
|
|
|
||
|
|
</script>
|
||
|
|
<style>
|
||
|
|
.input-group-addon {
|
||
|
|
height:25px;
|
||
|
|
width:30px;
|
||
|
|
padding: 0px 0px;
|
||
|
|
}
|
||
|
|
label{
|
||
|
|
font-size: 10px;
|
||
|
|
|
||
|
|
}
|
||
|
|
.form-control{
|
||
|
|
width:80px;
|
||
|
|
|
||
|
|
height:25px;
|
||
|
|
}
|
||
|
|
|
||
|
|
</style>
|