<link href="//netdna.bootstrapcdn.com/bootstrap/3.2.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.2.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <form class="form-horizontal"> <fieldset> <!-- Form Name --> <legend>Insertion Form</legend> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_lot_num">Lot #</label> <div class="col-md-4"> <input id="insertion_lot_num" name="insertion_lot_num" type="text" placeholder="0000000" class="form-control input-md"> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_venous_access_device">Venous Access Device</label> <div class="col-md-4"> <select id="insertion_venous_access_device" name="insertion_venous_access_device" class="form-control"> <option value="PICC">PICC</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_catheter">Catheter</label> <div class="col-md-4"> <select id="insertion_catheter" name="insertion_catheter" class="form-control"> <option value="5fr">5fr</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_lumen">Lumen</label> <div class="col-md-4"> <select id="insertion_lumen" name="insertion_lumen" class="form-control"> <option value="Double">Double</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_extremity">Extremity</label> <div class="col-md-4"> <select id="insertion_extremity" name="insertion_extremity" class="form-control"> <option value="Right">Right</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_attempts">Attempts</label> <div class="col-md-4"> <select id="insertion_attempts" name="insertion_attempts" class="form-control"> <option value="0">0</option> <option value="1">1</option> <option value="2">2</option> <option value="3">3</option> <option value="4">4</option> <option value="5">5</option> <option value="6">6</option> <option value="7">7</option> <option value="8">8</option> <option value="9">9</option> <option value="10">10</option> </select> </div> </div> <!-- Select Basic --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_vein">Vein</label> <div class="col-md-4"> <select id="insertion_vein" name="insertion_vein" class="form-control"> <option value="Basilic">Basilic</option> </select> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_catheter_length">Catheter Length</label> <div class="col-md-2"> <input id="insertion_catheter_length" name="insertion_catheter_length" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_external_length">External Length</label> <div class="col-md-2"> <input id="insertion_external_length" name="insertion_external_length" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_arm_circumference">Arm Circumference</label> <div class="col-md-2"> <input id="insertion_arm_circumference" name="insertion_arm_circumference" type="text" placeholder="" class="form-control input-md"> </div> </div> <!-- Multiple Checkboxes --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_site_assessment">Site Assessment</label> <div class="col-md-4"> <div class="checkbox"> <label for="insertion_site_assessment-0"> <input type="checkbox" name="insertion_site_assessment" id="insertion_site_assessment-0" value="Clean, Dry and Intact"> Clean, Dry and Intact </label> </div> <div class="checkbox"> <label for="insertion_site_assessment-1"> <input type="checkbox" name="insertion_site_assessment" id="insertion_site_assessment-1" value="No Evidence of Bleeding or Hematoma"> No Evidence of Bleeding or Hematoma </label> </div> <div class="checkbox"> <label for="insertion_site_assessment-2"> <input type="checkbox" name="insertion_site_assessment" id="insertion_site_assessment-2" value="Check All"> Check All </label> </div> <div class="checkbox"> <label for="insertion_site_assessment-3"> <input type="checkbox" name="insertion_site_assessment" id="insertion_site_assessment-3" value="Other Site Assessment"> Other Site Assessment </label> </div> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_other_site_assessment"></label> <div class="col-md-5"> <input id="insertion_other_site_assessment" name="insertion_other_site_assessment" type="text" placeholder="Specify other here..." class="form-control input-md"> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_flushes_easily">Flushes Easily</label> <div class="col-md-4"> <label class="radio-inline" for="insertion_flushes_easily-0"> <input type="radio" name="insertion_flushes_easily" id="insertion_flushes_easily-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="insertion_flushes_easily-1"> <input type="radio" name="insertion_flushes_easily" id="insertion_flushes_easily-1" value="No"> No </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_flushes_easily_solution"></label> <div class="col-md-4"> <label class="checkbox-inline" for="insertion_flushes_easily_solution-0"> <input type="checkbox" name="insertion_flushes_easily_solution" id="insertion_flushes_easily_solution-0" value="Saline"> Saline </label> <label class="checkbox-inline" for="insertion_flushes_easily_solution-1"> <input type="checkbox" name="insertion_flushes_easily_solution" id="insertion_flushes_easily_solution-1" value="Heparin (100 units/ml)"> Heparin (100 units/ml) </label> </div> </div> <!-- Multiple Radios (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_aspirate_blood">Aspirates Blood</label> <div class="col-md-4"> <label class="radio-inline" for="insertion_aspirate_blood-0"> <input type="radio" name="insertion_aspirate_blood" id="insertion_aspirate_blood-0" value="Yes" checked="checked"> Yes </label> <label class="radio-inline" for="insertion_aspirate_blood-1"> <input type="radio" name="insertion_aspirate_blood" id="insertion_aspirate_blood-1" value="No"> No </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_dressing_applied">Dressing Applied</label> <div class="col-md-4"> <label class="checkbox-inline" for="insertion_dressing_applied-0"> <input type="checkbox" name="insertion_dressing_applied" id="insertion_dressing_applied-0" value="Peripheral"> Peripheral </label> <label class="checkbox-inline" for="insertion_dressing_applied-1"> <input type="checkbox" name="insertion_dressing_applied" id="insertion_dressing_applied-1" value="Central"> Central </label> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_dressing_change">Dressing Change</label> <div class="col-md-4"> <label class="checkbox-inline" for="insertion_dressing_change-0"> <input type="checkbox" name="insertion_dressing_change" id="insertion_dressing_change-0" value="Peripheral"> Peripheral </label> <label class="checkbox-inline" for="insertion_dressing_change-1"> <input type="checkbox" name="insertion_dressing_change" id="insertion_dressing_change-1" value="Central"> Central </label> </div> </div> <!-- Multiple Checkboxes --> <div class="form-group"> <label class="col-md-4 control-label" for="inserition_dressing_type">Dressing Type</label> <div class="col-md-4"> <div class="checkbox"> <label for="inserition_dressing_type-0"> <input type="checkbox" name="inserition_dressing_type" id="inserition_dressing_type-0" value="Peripheral"> Peripheral </label> </div> <div class="checkbox"> <label for="inserition_dressing_type-1"> <input type="checkbox" name="inserition_dressing_type" id="inserition_dressing_type-1" value="Central"> Central </label> </div> <div class="checkbox"> <label for="inserition_dressing_type-2"> <input type="checkbox" name="inserition_dressing_type" id="inserition_dressing_type-2" value="Biooclusive"> Biooclusive </label> </div> <div class="checkbox"> <label for="inserition_dressing_type-3"> <input type="checkbox" name="inserition_dressing_type" id="inserition_dressing_type-3" value="Gauze"> Gauze </label> </div> <div class="checkbox"> <label for="inserition_dressing_type-4"> <input type="checkbox" name="inserition_dressing_type" id="inserition_dressing_type-4" value="Pressure"> Pressure </label> </div> </div> </div> <!-- Text input--> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_last_dressing_change">Last Dressing Change</label> <div class="col-md-5"> <input id="insertion_last_dressing_change" name="insertion_last_dressing_change" type="text" placeholder="00/00/0000 00:00:00" class="form-control input-md"> </div> </div> <!-- Multiple Checkboxes (inline) --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_dressing_change_nurse"></label> <div class="col-md-4"> <label class="checkbox-inline" for="insertion_dressing_change_nurse-0"> <input type="checkbox" name="insertion_dressing_change_nurse" id="insertion_dressing_change_nurse-0" value="Facility Nurse"> Facility Nurse </label> <label class="checkbox-inline" for="insertion_dressing_change_nurse-1"> <input type="checkbox" name="insertion_dressing_change_nurse" id="insertion_dressing_change_nurse-1" value="NPP Nurse"> NPP Nurse </label> </div> </div> <!-- Textarea --> <div class="form-group"> <label class="col-md-4 control-label" for="insertion_other">Insertion Other</label> <div class="col-md-4"> <textarea class="form-control" id="insertion_other" name="insertion_other"></textarea> </div> </div> </fieldset> </form>