highBloodPressureTable.html 16 KB

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  1. <html>
  2. <head>
  3. <meta charset="UTF-8" />
  4. <title>高血压患者随访服务记录表</title>
  5. <style type="text/css" media="all">
  6. * {
  7. margin: 0;
  8. padding: 0;
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  33. .textAlign,
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  37. h3 {
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  76. </style>
  77. </head>
  78. <body style="margin: 32px 10px">
  79. <div id="content">
  80. <!-- <div class="header">
  81. <span>档案号:</span>
  82. <div class="line"></div>
  83. <button type="button" class="btn hid">打印</button>
  84. <div>
  85. <button type="button" class="btn">导出</button>
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  89. </div> -->
  90. <div class="main">
  91. <h3 class="textAlign" style="font-weight: bold">
  92. 高血压患者随访服务记录表
  93. </h3>
  94. <p>
  95. <span style="font-weight: bold"
  96. >姓名:<span id="patientName" style="font-weight: bold"
  97. ></span
  98. ></span
  99. >
  100. </p>
  101. <table style="width: 100%">
  102. <tbody>
  103. <tr>
  104. <td colspan="2" class="boldTd require">随访日期</td>
  105. <td colspan="2" class="boldTd">
  106. <span id="Follow_Time1"></span>
  107. </td>
  108. <td colspan="2" class="boldTd">
  109. <span id="Follow_Time2"></span>
  110. </td>
  111. <td colspan="2" class="boldTd">
  112. <span id="Follow_Time3"></span>
  113. </td>
  114. <td colspan="2" class="boldTd">
  115. <span id="Follow_Time4"></span>
  116. </td>
  117. </tr>
  118. <tr>
  119. <td colspan="2" class="boldTd require">随访方式</td>
  120. <td colspan="2">
  121. <span>1 门诊 2 家庭 3 电话</span>
  122. <div class="boxPosition">
  123. <span id="Follow_Type1" class="box"></span>
  124. </div>
  125. </td>
  126. <td colspan="2">
  127. <span>1 门诊 2 家庭 3 电话</span>
  128. <div class="boxPosition">
  129. <span id="Follow_Type2" class="box"></span>
  130. </div>
  131. </td>
  132. <td colspan="2">
  133. <span>1 门诊 2 家庭 3 电话</span>
  134. <div class="boxPosition">
  135. <span id="Follow_Type3" class="box"></span>
  136. </div>
  137. </td>
  138. <td colspan="2">
  139. <span>1 门诊 2 家庭 3 电话</span>
  140. <div class="boxPosition">
  141. <span id="Follow_Type4" class="box"></span>
  142. </div>
  143. </td>
  144. </tr>
  145. <tr>
  146. <td rowspan="2" class="boldTd2 require">症 状</td>
  147. <td rowspan="2" class="boldTd require">
  148. 1 无症状 <br />2 头痛头晕<br />3 恶心呕吐<br />4
  149. 眼花耳鸣<br />5 呼吸困难<br />6 心悸胸闷<br />7
  150. 鼻衄出血不止<br />8 四肢发麻<br />9 下肢水肿<br />10
  151. 其他
  152. </td>
  153. <td colspan="2" >
  154. <div class="textRight">
  155. <div id="Symptom1" class="checkBox" data-param="4">
  156. <!-- 使用JavaScript生成10个方框 -->
  157. </div>
  158. </div>
  159. </td>
  160. <td colspan="2" >
  161. <div class="textRight">
  162. <div id="Symptom2" class="checkBox" data-param="4">
  163. <!-- 使用JavaScript生成10个方框 -->
  164. </div>
  165. </td>
  166. <td colspan="2">
  167. <div class="textRight">
  168. <div id="Symptom3" class="checkBox" data-param="4">
  169. <!-- 使用JavaScript生成10个方框 -->
  170. </div>
  171. </td>
  172. <td colspan="2">
  173. <div class="textRight">
  174. <div id="Symptom4" class="checkBox" data-param="4">
  175. <!-- 使用JavaScript生成10个方框 -->
  176. </div>
  177. </td>
  178. </tr>
  179. <tr>
  180. <td colspan="2" class="boldTd3">
  181. 其他:<span></span>
  182. </td>
  183. <td colspan="2" class="boldTd3">
  184. 其他:<span></span>
  185. </td>
  186. <td colspan="2" class="boldTd3">
  187. 其他:<span></span>
  188. </td>
  189. <td colspan="2" class="boldTd3">
  190. 其他:<span></span>
  191. </td>
  192. </tr>
  193. <tr>
  194. <td rowspan="8" class="boldTd2 require">体征</td>
  195. <td class="boldTd">血压(mmHg)</td>
  196. <td colspan="2" id="Right1"><span></span></td>
  197. <td colspan="2" id="Right2"><span></span></td>
  198. <td colspan="2" id="Right3"><span></span></td>
  199. <td colspan="2" id="Right4"><span></span></td>
  200. </tr>
  201. <tr>
  202. <td class="boldTd require">体重(kg)</td>
  203. <td colspan="2" id="Weight1"></td>
  204. <td colspan="2" id="Weight2"></td>
  205. <td colspan="2" id="Weight3"></td>
  206. <td colspan="2" id="Weight4"></td>
  207. </tr>
  208. <tr>
  209. <td class="boldTd require">下次随访目标(kg)</td>
  210. <td colspan="2" id="Weight_Next1"></td>
  211. <td colspan="2" id="Weight_Next2"></td>
  212. <td colspan="2" id="Weight_Next3"></td>
  213. <td colspan="2" id="Weight_Next4"></td>
  214. </tr>
  215. <tr>
  216. <td class="boldTd require">身高(cm)</td>
  217. <td colspan="2" id="Height1"></td>
  218. <td colspan="2" id="Height2"></td>
  219. <td colspan="2" id="Height3"></td>
  220. <td colspan="2" id="Height4"></td>
  221. </tr>
  222. <tr>
  223. <td class="boldTd">体质指数(BMI)kg/m²</td>
  224. <td colspan="2" id="Bmi1"></td>
  225. <td colspan="2" id="Bmi2"></td>
  226. <td colspan="2" id="Bmi3"></td>
  227. <td colspan="2" id="Bmi4"></td>
  228. </tr>
  229. <tr>
  230. <td class="boldTd">下次随访目标(kg/m²)</td>
  231. <td colspan="2" id="Bmi_Next1"></td>
  232. <td colspan="2" id="Bmi_Next2"></td>
  233. <td colspan="2" id="Bmi_Next3"></td>
  234. <td colspan="2" id="Bmi_Next4"></td>
  235. </tr>
  236. <tr>
  237. <td class="boldTd require">
  238. 心率<br />
  239. (次/分钟)
  240. </td>
  241. <td colspan="2" id="Heart_Rate1"></td>
  242. <td colspan="2" id="Heart_Rate2"></td>
  243. <td colspan="2" id="Heart_Rate3"></td>
  244. <td colspan="2" id="Heart_Rate4"></td>
  245. </tr>
  246. <tr>
  247. <td class="boldTd require">其他</td>
  248. <td colspan="2" id="Sign_Other1"></td>
  249. <td colspan="2" id="Sign_Other2"></td>
  250. <td colspan="2" id="Sign_Other3"></td>
  251. <td colspan="2" id="Sign_Other4"></td>
  252. </tr>
  253. <tr>
  254. <td rowspan="10" class="boldTd2 require">
  255. 生活方式指导
  256. </td>
  257. <td class="boldTd">日吸烟量(支)</td>
  258. <td colspan="2" id="Smoking_Daily1"></td>
  259. <td colspan="2" id="Smoking_Daily2"></td>
  260. <td colspan="2" id="Smoking_Daily3"></td>
  261. <td colspan="2" id="Smoking_Daily4"></td>
  262. </tr>
  263. <tr>
  264. <td class="boldTd">下次随访目标(支)</td>
  265. <td colspan="2">
  266. <span id="Goal_Smoking1"></span>
  267. </td>
  268. <td colspan="2">
  269. <span id="Goal_Smoking2"></span>
  270. </td>
  271. <td colspan="2">
  272. <span id="Goal_Smoking3"></span>
  273. </td>
  274. <td colspan="2">
  275. <span id="Goal_Smoking4"></span>
  276. </td>
  277. </tr>
  278. <tr>
  279. <td class="boldTd require">日饮酒量(两)</td>
  280. <td colspan="2" id="Drinking_Daily1"></td>
  281. <td colspan="2" id="Drinking_Daily2"></td>
  282. <td colspan="2" id="Drinking_Daily3"></td>
  283. <td colspan="2" id="Drinking_Daily4"></td>
  284. </tr>
  285. <tr>
  286. <td class="boldTd require">下次随访目标(两)</td>
  287. <td colspan="2">
  288. <span id="Goal_Drinking1"></span>
  289. </td>
  290. <td colspan="2">
  291. <span id="Goal_Drinking2"></span>
  292. </td>
  293. <td colspan="2">
  294. <span id="Goal_Drinking3"></span>
  295. </td>
  296. <td colspan="2">
  297. <span id="Goal_Drinking4"></span>
  298. </td>
  299. </tr>
  300. <tr>
  301. <td class="boldTd require">运动</td>
  302. <td colspan="2">
  303. <span><span id="">1</span>次/周</span
  304. >&nbsp;&nbsp;&nbsp;&nbsp;<span
  305. ><span id="">1</span>分钟/次</span
  306. >
  307. </td>
  308. <td colspan="2">
  309. <span> <span id="">1</span>次/周</span
  310. >&nbsp;&nbsp;&nbsp;&nbsp;<span
  311. ><span id="">1</span>分钟/次</span
  312. >
  313. </td>
  314. <td colspan="2">
  315. <span><span id="">1</span>次/周</span
  316. >&nbsp;&nbsp;&nbsp;&nbsp;<span
  317. ><span id="">1</span>分钟/次</span
  318. >
  319. </td>
  320. <td colspan="2">
  321. <span><span id="">1</span>次/周</span
  322. >&nbsp;&nbsp;&nbsp;&nbsp;<span
  323. ><span id="">1</span>分钟/次</span
  324. >
  325. </td>
  326. </tr>
  327. <tr>
  328. <td class="boldTd require">下次随访目标</td>
  329. <td colspan="2">
  330. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span
  331. >60分钟/次</span
  332. >
  333. </td>
  334. <td colspan="2">
  335. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span
  336. >60分钟/次</span
  337. >
  338. </td>
  339. <td colspan="2">
  340. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span
  341. >60分钟/次</span
  342. >
  343. </td>
  344. <td colspan="2">
  345. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span
  346. >60分钟/次</span
  347. >
  348. </td>
  349. </tr>
  350. <tr>
  351. <td class="boldTd require">
  352. 摄盐情况<br />(咸淡)
  353. </td>
  354. <td colspan="2" id="Salt_Intake1"></td>
  355. <td colspan="2" id="Salt_Intake2"></td>
  356. <td colspan="2" id="Salt_Intake3"></td>
  357. <td colspan="2" id="Salt_Intake4"></td>
  358. </tr>
  359. <tr>
  360. <td class="boldTd require">下次随访目标(咸淡)</td>
  361. <td colspan="2" id="Goal_Salt_Intake1"></td>
  362. <td colspan="2" id="Goal_Salt_Intake2"></td>
  363. <td colspan="2" id="Goal_Salt_Intake3"></td>
  364. <td colspan="2" id="Goal_Salt_Intake4"></td>
  365. </tr>
  366. <tr>
  367. <td class="boldTd require">心理调整</td>
  368. <td colspan="2" id="Psychol_Adjust1"></td>
  369. <td colspan="2" id="Psychol_Adjust2"></td>
  370. <td colspan="2" id="Psychol_Adjust3"></td>
  371. <td colspan="2" id="Psychol_Adjust4"></td>
  372. </tr>
  373. <tr>
  374. <td class="boldTd require">遵医行为</td>
  375. <td colspan="2" id="Compliance1"></td>
  376. <td colspan="2" id="Compliance2"></td>
  377. <td colspan="2" id="Compliance3"></td>
  378. <td colspan="2" id="Compliance4"></td>
  379. </tr>
  380. <tr>
  381. <td colspan="2" class="boldTd require">
  382. 辅助检查*
  383. </td>
  384. <td colspan="2" id="Auxiliary_Other1"></td>
  385. <td colspan="2" id="Auxiliary_Other2"></td>
  386. <td colspan="2" id="Auxiliary_Other3"></td>
  387. <td colspan="2" id="Auxiliary_Other4"></td>
  388. </tr>
  389. <tr>
  390. <td colspan="2" class="boldTd require">
  391. 服药依从性
  392. </td>
  393. <td colspan="2" id="Compliance_Drug1"></td>
  394. <td colspan="2" id="Compliance_Drug2"></td>
  395. <td colspan="2" id="Compliance_Drug3"></td>
  396. <td colspan="2" id="Compliance_Drug4"></td>
  397. </tr>
  398. <tr>
  399. <td colspan="2" class="boldTd require">
  400. 药物不良反应
  401. </td>
  402. <td colspan="2" id="Adverse1"></td>
  403. <td colspan="2" id="Adverse2"></td>
  404. <td colspan="2" id="Adverse3"></td>
  405. <td colspan="2" id="Adverse4"></td>
  406. </tr>
  407. <tr>
  408. <td colspan="2" class="boldTd require">
  409. 此次随访分类
  410. </td>
  411. <td colspan="2" id="Follow_Up_Classify1"></td>
  412. <td colspan="2" id="Follow_Up_Classify2"></td>
  413. <td colspan="2" id="Follow_Up_Classify3"></td>
  414. <td colspan="2" id="Follow_Up_Classify4"></td>
  415. </tr>
  416. <tr>
  417. <td colspan="2" class="boldTd">药物名称</td>
  418. <td colspan="2" class="boldTd" id="Appraisal1"></td>
  419. <td colspan="2" class="boldTd" id="Appraisal2"></td>
  420. <td colspan="2" class="boldTd" id="Appraisal3"></td>
  421. <td colspan="2" class="boldTd" id="Appraisal4"></td>
  422. </tr>
  423. <tr>
  424. <td rowspan="2" class="boldTd2">转诊</td>
  425. <td class="boldTd require">原因</td>
  426. <td colspan="2" id="Referral_Hospital1"></td>
  427. <td colspan="2" id="Referral_Hospital2"></td>
  428. <td colspan="2" id="Referral_Hospital3"></td>
  429. <td colspan="2" id="Referral_Hospital4"></td>
  430. </tr>
  431. <tr>
  432. <td class="boldTd require">机构及科别</td>
  433. <td colspan="2" id="Referral_Hospital1"></td>
  434. <td colspan="2" id="Referral_Hospital2"></td>
  435. <td colspan="2" id="Referral_Hospital3"></td>
  436. <td colspan="2" id="Referral_Hospital4"></td>
  437. </tr>
  438. <tr>
  439. <td colspan="2" class="boldTd">下次随访日期</td>
  440. <td colspan="2" class="require">2019-07-06</td>
  441. <td colspan="2" class="require">2019-07-06</td>
  442. <td colspan="2" class="require">2019-07-06</td>
  443. <td colspan="2" class="require">2019-07-06</td>
  444. </tr>
  445. <!-- <tr>
  446. <td colspan="2" class="boldTd require">
  447. 随访医生签名
  448. </td>
  449. <td colspan="2">
  450. <img
  451. alt=""
  452. class="sign-name"
  453. src="https://img.health.gagctv.com//open/file/download?data=yr2aRn1UUQ8kLh1v%2Fch92F3kevhJrvfSuUVW6DISwOO4WanynpnmOPyYIJYYSnfy"
  454. />
  455. </td>
  456. </tr> -->
  457. </tbody>
  458. </table>
  459. <!-- <img
  460. src="https://img.health.gagctv.com//open/file/download?data=yr2aRn1UUQ8kLh1v%2Fch92AZEp9NRmllwWh5I52wQ9dDxSEhkCc5d3%2Fs4HYHRorMa"
  461. />
  462. <img
  463. src="https://img.health.gagctv.com//open/file/download?data=yr2aRn1UUQ8kLh1v%2Fch92AZEp9NRmllw2iNBf94D%2FObVSj1lf6OtTpK0a7N8wta4"
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  510. // document.getElementById(key).innerHTML =
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