diabetesTable.html 23 KB

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  1. <html>
  2. <head>
  3. <meta charset="UTF-8" />
  4. <title>2型糖尿病患者随访服务记录表</title>
  5. <style type="text/css" media="all">
  6. * {
  7. margin: 0;
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  11. table {
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  15. th,
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  23. h3 {
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  82. </style>
  83. </head>
  84. <body>
  85. <div id="content">
  86. <!-- <div class="header">
  87. <span>档案号:</span>
  88. <div class="line"></div>
  89. <button type="button" class="btn hid">打印</button>
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  96. <div class="main">
  97. <h3 class="textAlign" style="font-weight: bold">
  98. 2型糖尿病患者随访服务记录表
  99. </h3>
  100. <div class="tableHeader">
  101. <span class="require">姓名:<span></span></span><span></span>
  102. </div>
  103. <table>
  104. <tbody>
  105. <tr>
  106. <td colspan="2" class="boldTd require">随访日期</td>
  107. <td colspan="2" class="boldTd">
  108. <span id="Follow_Time1"></span>
  109. </td>
  110. <td colspan="2" class="boldTd">
  111. <span id="Follow_Time2"></span>
  112. </td>
  113. <td colspan="2" class="boldTd">
  114. <span id="Follow_Time3"></span>
  115. </td>
  116. <td colspan="2" class="boldTd">
  117. <span id="Follow_Time4"></span>
  118. </td>
  119. </tr>
  120. <tr>
  121. <td colspan="2" class="boldTd require">随访方式</td>
  122. <td colspan="2">
  123. <span>1 门诊 2 家庭 3 电话</span>
  124. <div class="boxPosition">
  125. <span id="Follow_Type1" class="box"></span>
  126. </div>
  127. </td>
  128. <td colspan="2">
  129. <span>1 门诊 2 家庭 3 电话</span>
  130. <div class="boxPosition">
  131. <span id="Follow_Type2" class="box"></span>
  132. </div>
  133. </td>
  134. <td colspan="2">
  135. <span>1 门诊 2 家庭 3 电话</span>
  136. <div class="boxPosition">
  137. <span id="Follow_Type3" class="box"></span>
  138. </div>
  139. </td>
  140. <td colspan="2">
  141. <span>1 门诊 2 家庭 3 电话</span>
  142. <div class="boxPosition">
  143. <span id="Follow_Type4" class="box"></span>
  144. </div>
  145. </td>
  146. </tr>
  147. <tr>
  148. <td rowspan="2" class="boldTd2 require">症 状</td>
  149. <td rowspan="2" class="boldTd require">
  150. 1 无症状 <br />2 多饮<br />3 多食<br />4
  151. 多尿<br />5 视力模糊<br />6 感染<br />7
  152. 手脚麻木<br />8 下肢浮肿<br />9 体重明显下降<br />10
  153. 其他
  154. </td>
  155. <td colspan="2">
  156. <div class="textRight">
  157. <div id="Symptom1" class="checkBox" data-param="4">
  158. <!-- 使用JavaScript生成10个方框 -->
  159. </div>
  160. </div>
  161. </td>
  162. <td colspan="2">
  163. <div class="textRight">
  164. <div id="Symptom2" class="checkBox" data-param="4">
  165. <!-- 使用JavaScript生成10个方框 -->
  166. </div>
  167. </td>
  168. <td colspan="2">
  169. <div class="textRight">
  170. <div id="Symptom3" class="checkBox" data-param="4">
  171. <!-- 使用JavaScript生成10个方框 -->
  172. </div>
  173. </td>
  174. <td colspan="2">
  175. <div class="textRight">
  176. <div id="Symptom4" class="checkBox" data-param="4">
  177. <!-- 使用JavaScript生成10个方框 -->
  178. </div>
  179. </td>
  180. </tr>
  181. <tr>
  182. <td colspan="2" class="boldTd3">
  183. 其他:<span></span>
  184. </td>
  185. <td colspan="2" class="boldTd3">
  186. 其他:<span></span>
  187. </td>
  188. <td colspan="2" class="boldTd3">
  189. 其他:<span></span>
  190. </td>
  191. <td colspan="2" class="boldTd3">
  192. 其他:<span></span>
  193. </td>
  194. </tr>
  195. <tr>
  196. <td rowspan="8" class="boldTd2 require">体征</td>
  197. <td class="boldTd">血压(mmHg)</td>
  198. <td colspan="2" id="Right1"><span></span></td>
  199. <td colspan="2" id="Right2"><span></span></td>
  200. <td colspan="2" id="Right3"><span></span></td>
  201. <td colspan="2" id="Right4"><span></span></td>
  202. </tr>
  203. <tr>
  204. <td class="boldTd require">体重(kg)</td>
  205. <td colspan="2" id="Weight1"></td>
  206. <td colspan="2" id="Weight2"></td>
  207. <td colspan="2" id="Weight3"></td>
  208. <td colspan="2" id="Weight4"></td>
  209. </tr>
  210. <tr>
  211. <td class="boldTd require">下次随访目标(kg)</td>
  212. <td colspan="2" id="Weight_Next1"></td>
  213. <td colspan="2" id="Weight_Next2"></td>
  214. <td colspan="2" id="Weight_Next3"></td>
  215. <td colspan="2" id="Weight_Next4"></td>
  216. </tr>
  217. <tr>
  218. <td class="boldTd require">身高(cm)</td>
  219. <td colspan="2" id="Height1"></td>
  220. <td colspan="2" id="Height2"></td>
  221. <td colspan="2" id="Height3"></td>
  222. <td colspan="2" id="Height4"></td>
  223. </tr>
  224. <tr>
  225. <td class="boldTd">体质指数(BMI)kg/m²</td>
  226. <td colspan="2" id="Bmi1"></td>
  227. <td colspan="2" id="Bmi2"></td>
  228. <td colspan="2" id="Bmi3"></td>
  229. <td colspan="2" id="Bmi4"></td>
  230. </tr>
  231. <tr>
  232. <td class="boldTd">下次随访目标(kg/m²)</td>
  233. <td colspan="2" id="Bmi_Next1"></td>
  234. <td colspan="2" id="Bmi_Next2"></td>
  235. <td colspan="2" id="Bmi_Next3"></td>
  236. <td colspan="2" id="Bmi_Next4"></td>
  237. </tr>
  238. <tr>
  239. <td class="boldTd require">足背动脉搏动</td>
  240. <td colspan="2">
  241. <span>不正常(左侧:减弱,右侧:消失)</span>
  242. </td>
  243. <td colspan="2">
  244. <span>不正常(左侧:减弱,右侧:消失)</span>
  245. </td>
  246. <td colspan="2">
  247. <span>不正常(左侧:减弱,右侧:消失)</span>
  248. </td>
  249. <td colspan="2">
  250. <span>不正常(左侧:减弱,右侧:消失)</span>
  251. </td>
  252. </tr>
  253. <tr>
  254. <td class="boldTd require">其他</td>
  255. <td colspan="2" id="Sign_Other1"></td>
  256. <td colspan="2" id="Sign_Other2"></td>
  257. <td colspan="2" id="Sign_Other3"></td>
  258. <td colspan="2" id="Sign_Other4"></td>
  259. </tr>
  260. <tr>
  261. <td rowspan="10" class="boldTd2 require">
  262. 生活方式指导
  263. </td>
  264. <td class="boldTd">日吸烟量(支)</td>
  265. <td colspan="2" id="Smoking_Daily1"></td>
  266. <td colspan="2" id="Smoking_Daily2"></td>
  267. <td colspan="2" id="Smoking_Daily3"></td>
  268. <td colspan="2" id="Smoking_Daily4"></td>
  269. </tr>
  270. <tr>
  271. <td class="boldTd">下次随访目标(支)</td>
  272. <td colspan="2">
  273. <span id="Goal_Smoking1"></span>
  274. </td>
  275. <td colspan="2">
  276. <span id="Goal_Smoking2"></span>
  277. </td>
  278. <td colspan="2">
  279. <span id="Goal_Smoking3"></span>
  280. </td>
  281. <td colspan="2">
  282. <span id="Goal_Smoking4"></span>
  283. </td>
  284. </tr>
  285. <tr>
  286. <td class="boldTd require">日饮酒量(两)</td>
  287. <td colspan="2" id="Drinking_Daily1"></td>
  288. <td colspan="2" id="Drinking_Daily2"></td>
  289. <td colspan="2" id="Drinking_Daily3"></td>
  290. <td colspan="2" id="Drinking_Daily4"></td>
  291. </tr>
  292. <tr>
  293. <td class="boldTd require">下次随访目标(两)</td>
  294. <td colspan="2">
  295. <span id="Goal_Drinking1"></span>
  296. </td>
  297. <td colspan="2">
  298. <span id="Goal_Drinking2"></span>
  299. </td>
  300. <td colspan="2">
  301. <span id="Goal_Drinking3"></span>
  302. </td>
  303. <td colspan="2">
  304. <span id="Goal_Drinking4"></span>
  305. </td>
  306. </tr>
  307. <tr>
  308. <td class="boldTd require">运动</td>
  309. <td colspan="2">
  310. <span><span id="">1</span>次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span><span
  311. id="">1</span>分钟/次</span>
  312. </td>
  313. <td colspan="2">
  314. <span> <span id="">1</span>次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span><span
  315. id="">1</span>分钟/次</span>
  316. </td>
  317. <td colspan="2">
  318. <span><span id="">1</span>次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span><span
  319. id="">1</span>分钟/次</span>
  320. </td>
  321. <td colspan="2">
  322. <span><span id="">1</span>次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span><span
  323. id="">1</span>分钟/次</span>
  324. </td>
  325. </tr>
  326. <tr>
  327. <td class="boldTd require">下次随访目标</td>
  328. <td colspan="2">
  329. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span>60分钟/次</span>
  330. </td>
  331. <td colspan="2">
  332. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span>60分钟/次</span>
  333. </td>
  334. <td colspan="2">
  335. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span>60分钟/次</span>
  336. </td>
  337. <td colspan="2">
  338. <span>5次/周</span>&nbsp;&nbsp;&nbsp;&nbsp;<span>60分钟/次</span>
  339. </td>
  340. </tr>
  341. <tr>
  342. <td class="boldTd require">主食(克/天)</td>
  343. <td colspan="2">9</td>
  344. <td colspan="2">9</td>
  345. <td colspan="2">9</td>
  346. <td colspan="2">9</td>
  347. </tr>
  348. <tr>
  349. <td class="boldTd require">
  350. 下次随访<br />目标(克/天)
  351. </td>
  352. <td colspan="2">1</td>
  353. <td colspan="2">1</td>
  354. <td colspan="2">1</td>
  355. <td colspan="2">1</td>
  356. </tr>
  357. <tr>
  358. <td class="boldTd require">心理调整</td>
  359. <td colspan="2" id="Psychol_Adjust1"></td>
  360. <td colspan="2" id="Psychol_Adjust2"></td>
  361. <td colspan="2" id="Psychol_Adjust3"></td>
  362. <td colspan="2" id="Psychol_Adjust4"></td>
  363. </tr>
  364. <tr>
  365. <td class="boldTd require">遵医行为</td>
  366. <td colspan="2" id="Compliance1"></td>
  367. <td colspan="2" id="Compliance2"></td>
  368. <td colspan="2" id="Compliance3"></td>
  369. <td colspan="2" id="Compliance4"></td>
  370. </tr>
  371. <tr>
  372. <td colspan="2" class="boldTd require">
  373. 辅助检查*
  374. </td>
  375. <td colspan="2" id="Auxiliary_Other1"></td>
  376. <td colspan="2" id="Auxiliary_Other2"></td>
  377. <td colspan="2" id="Auxiliary_Other3"></td>
  378. <td colspan="2" id="Auxiliary_Other4"></td>
  379. </tr>
  380. <tr>
  381. <td colspan="2" class="boldTd require">
  382. 服药依从性
  383. </td>
  384. <td colspan="2" id="Compliance_Drug1"></td>
  385. <td colspan="2" id="Compliance_Drug2"></td>
  386. <td colspan="2" id="Compliance_Drug3"></td>
  387. <td colspan="2" id="Compliance_Drug4"></td>
  388. </tr>
  389. <tr>
  390. <td colspan="2" class="boldTd require">
  391. 药物不良反应
  392. </td>
  393. <td colspan="2" id="Adverse1"></td>
  394. <td colspan="2" id="Adverse2"></td>
  395. <td colspan="2" id="Adverse3"></td>
  396. <td colspan="2" id="Adverse4"></td>
  397. </tr>
  398. <tr>
  399. <td colspan="2" class="boldTd require">
  400. 低血糖反应
  401. </td>
  402. <td colspan="2"><span>偶尔</span></td>
  403. <td colspan="2"><span>偶尔</span></td>
  404. <td colspan="2"><span>偶尔</span></td>
  405. <td colspan="2"><span>偶尔</span></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" id="Next_Follow_Up_Time1"></td>
  441. <td colspan="2" class="require" id="Next_Follow_Up_Time2"></td>
  442. <td colspan="2" class="require" id="Next_Follow_Up_Time3"></td>
  443. <td colspan="2" class="require" id="Next_Follow_Up_Time4"></td>
  444. </tr>
  445. <!-- <tr>
  446. <td colspan="2" class="boldTd require">
  447. 随访医生签名
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  450. <img
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  454. />
  455. </td>
  456. </tr> -->
  457. </tbody>
  458. </table>
  459. <!-- <img
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  515. </script>
  516. </body>
  517. </html>