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ostyleo
Mar 4th, 2018
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  1. <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"
  2. "http://www.w3.org/TR/html4/loose.dtd">
  3.  
  4. <head>
  5. <meta http-equiv="Content-Type" content="text/html;charset=utf-8">
  6. <title>Bilet externare</title>
  7. </head>
  8. <body>
  9. <center> <form action="/bilet.php" method="post">
  10. <table style="width: 780px" border="1px solid black">
  11. <tr align="center" bgcolor="yellow">
  12. <td colspan="4">BILET DE EXTERNARE</td>
  13. </tr>
  14. <tr align="center">
  15. <td colspan="2">Nume <input type="text" name="Nume" size="50"></td>
  16. <td colspan="2">Data nasterii <input type="text" name="DataNasterii"></td>
  17. </tr>
  18. <tr align="center" >
  19. <td>
  20. Sex <input type="radio" name="Sex" value="M">M
  21. <input type="radio" name="Sex" value="F">F
  22. </td>
  23. <td>Varsta <input type="text" name="Varsta" size="10"></td>
  24. <td colspan="2" >Nr foaie internare <input type="text" name="NrFoaieInternare"></td>
  25. </tr>
  26. <tr align="center">
  27. <td>Cod pacient <input type="text" name="CodPacient"></td>
  28. <td>Data internarii <input type="text" name="DataInternarii"></td>
  29. <td colspan="2">Data externarii <input type="text" name="DataExternarii"></td>
  30. </tr>
  31. <tr align="center">
  32. <td colspan="4" bgcolor="#7fffd4"> DATE MEDICALE </td>
  33. </tr>
  34. <tr>
  35. <td colspan="4">
  36. <table style="width: 778px" border="1px solid black">
  37. <tr>
  38. <td align="center">
  39. Grupa sanguina
  40. <select name="GrupeSanguine" size="1">
  41. <option value="0">O I</option>
  42. <option value="1">A II</option>
  43. <option value="2">B III</option>
  44. <option value="3">AB IV</option>
  45. </select>
  46. </td>
  47. <td>Rh <input type="text" name="Rh" size="10"></td>
  48. <td colspan="2">Diagnostic <input type="text" name="Diagnostic" size="50"></td>
  49. </tr>
  50. <tr>
  51. <td colspan="1" align="center">Interventii</td>
  52. <td colspan="3" align="center">
  53. <select name="GrupeSanguine" size="3" >
  54. <option value="0">Interventia 1 22/06/2018 Mihai Vasile</option>
  55. <option value="1">Operatie 1 23/01/2018 Mihai Vasile</option>
  56. <option value="2">Ecografie 05/03/2018 Mihai Vasile</option>
  57. <option value="3">i4 22/06/2018 Mihai Vasile</option>
  58. <option value="4">i5 22/06/2018 Mihai Vasile</option>
  59. </select>
  60. </td>
  61. </tr>
  62. <tr>
  63. <td colspan="4" align="center">Medic curant <input type="text" name="MedicCurant" size="100%"></td>
  64. </tr>
  65. <tr>
  66. <td colspan="1">Tratament recomandat</td>
  67. <td colspan="3">
  68. <textarea rows="4" cols="71"></textarea>
  69. </td>
  70. </tr>
  71. </table>
  72. </td>
  73. </tr>
  74. <tr align="center">
  75. <td colspan="4" bgcolor="#ff8c00"> MEDICAMENTE PRESCRISE </td>
  76. </tr>
  77. <tr>
  78. <td colspan="4">
  79. <table style="width: 778px" border="1px solid black">
  80. <tr>
  81. <td align="center"> Nr </td>
  82. <td align="center"> Cod </td>
  83. <td align="center"> Medicament </td>
  84. <td align="center"> Mod administrare </td>
  85. </tr>
  86. <tr>
  87. <td align="center"> 1 </td>
  88. <td align="center" > <input type="text" name="Cod1" size="10%"> </td>
  89. <td align="center"> <input type="text" name="Medicament1" size="30%"> </td>
  90. <td align="center"> <input type="text" name="Administrare1" size="50%"> </td>
  91. </tr>
  92. <tr>
  93. <td align="center"> 2 </td>
  94. <td align="center" > <input type="text" name="Cod2" size="10%"> </td>
  95. <td align="center"> <input type="text" name="Medicament2" size="30%"> </td>
  96. <td align="center"> <input type="text" name="Administrare2" size="50%"> </td>
  97. </tr>
  98. <tr>
  99. <td align="center"> 3 </td>
  100. <td align="center" > <input type="text" name="Cod3" size="10%"> </td>
  101. <td align="center"> <input type="text" name="Medicament3" size="30%"> </td>
  102. <td align="center"> <input type="text" name="Administrare3" size="50%"> </td>
  103. </tr>
  104. <tr>
  105. <td align="center"> 4 </td>
  106. <td align="center" > <input type="text" name="Cod4" size="10%"> </td>
  107. <td align="center"> <input type="text" name="Medicament4" size="30%"> </td>
  108. <td align="center"> <input type="text" name="Administrare4" size="50%"> </td>
  109. </tr>
  110. <tr>
  111. <td align="center"> 5 </td>
  112. <td align="center" > <input type="text" name="Cod5" size="10%"> </td>
  113. <td align="center"> <input type="text" name="Medicament5" size="30%"> </td>
  114. <td align="center"> <input type="text" name="Administrare5" size="50%"> </td>
  115. </tr>
  116. </table>
  117. </td>
  118. </tr>
  119. <tr>
  120. <td colspan="4" bgcolor="aqua" align="center">OBSERVATII</td>
  121. </tr>
  122. <tr>
  123. <td colspan="4" rowspan="1">
  124. <textarea rows="4" cols="94"></textarea>
  125. </td>
  126. </tr>
  127. <tr>
  128. <td colspan="4" align="left">
  129. Frecventa consult perioadic
  130. <select name="GrupeSanguine" size="1">
  131. <option value="0">1</option>
  132. <option value="1">2</option>
  133. <option value="2">3</option>
  134. <option value="3">4</option>
  135. <option value="4">5</option>
  136. <option value="5">6</option>
  137. <option value="6">7</option>
  138. </select>
  139. pe saptamana
  140. </td>
  141. </tr>
  142. <tr>
  143. <td colspan="4" align="right"><input type="submit" value="Salveaza si Printeaza"></td>
  144. </tr>
  145. </table>
  146. </form></center>
  147. </body>
  148. </html>
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