{template member/header}
<link href="/views/admin/images/table_form.css" rel="stylesheet" type="text/css" />
	<link href="/views/admin/images/dialog.css" rel="stylesheet" type="text/css" />
	<script type="text/javascript" src="/views/admin/js/dialog.js"></script>
	<script type="text/javascript">var sitepath = "/index.php";</script>
    <script type="text/javascript" src="/extensions/language/zh-cn/lang.js"></script>
	<script type="text/javascript" src="/views/admin/js/core.js"></script>

<script type="text/javascript">
function checkuser() {
	$('#err_username').html("");
	$.get('{SITE_PATH}{ENTRY_SCRIPT_NAME}?s=member&c=pms&a=checkuser&id='+Math.random(), { username:$('#username').val()}, function(data){ 
	    $('#err_username').html(data);
	});
}
</script>


<div class="Mallbox">

			<div class="Mall">
            			
                       {template member/left}
                            
                            <div class="Mallright">
                            			<div class="Mallright1topbj"></div>
										
										
										<div class="Mallrightnr">
			<div class="Malldefault">
				<div class="mallOutboxtitel">健康档案</div>	
				<div class="mallService">
				<div class="item-list">
            <form action="/index.php?c=form&a=post&modelid=12&cid=0" method="post">
			<table width="100%" class="table_form ">
			<tbody><tr>
				<th width="100"></th>
				<td></td>
			</tr>
			<tr id="fine_jiuzhenyiyuan"><th>就诊医院：</th><td><input type="text" value="" class="input-text" name="data[jiuzhenyiyuan]" style="width:150px;"><span id="ck_jiuzhenyiyuan"></span></td></tr><tr id="fine_jiuzhenshijian"><th>就诊时间：</th><td>
		<link href="/extensions/calendar/jscal2.css" type="text/css" rel="stylesheet">
		<link href="/extensions/calendar/border-radius.css" type="text/css" rel="stylesheet">
		<link href="/extensions/calendar/win2k.css" type="text/css" rel="stylesheet">
		<script type="text/javascript" src="/extensions/calendar/calendar.js"></script>
		<script type="text/javascript" src="/extensions/language/zh-cn/calendar.js"></script>
		<script type="text/javascript" src="/views/admin/js/jquery-ui.min.js"></script>
	<input type="hidden" value="" name="data[jiuzhenshijian]" id="fc_jiuzhenshijian">
	<input type="text" readonly="" class="date input-text" style="width:150px;" value="" id="jiuzhenshijian">
	<script type="text/javascript">
		Calendar.setup({
		weekNumbers : true,
		inputField  : "jiuzhenshijian",
		trigger     : "jiuzhenshijian",
		dateFormat  : "%Y-%m-%d %H:%M:%S",
		showTime    : true,
		minuteStep  : 1,
		onSelect    : function() {
			this.hide();
			var time = $("#jiuzhenshijian").val();
			var date = (new Date(Date.parse(time.replace(/-/g,"/")))).getTime() / 1000;
			$("#fc_jiuzhenshijian").val(date);
		}
		});
    </script><span id="ck_jiuzhenshijian"></span></td></tr><tr id="fine_jiuzhenkeshi"><th>就诊科室：</th><td><input type="text" value="" class="input-text" name="data[jiuzhenkeshi]" style="width:150px;"><span id="ck_jiuzhenkeshi"></span></td></tr><tr id="fine_shangchuanwenjian"><th>上传文件：</th><td><input type="text" class="input-text" size="50" value="" name="data[shangchuanwenjian]" id="fc_shangchuanwenjian">
    <input type="button" style="width:66px;cursor:pointer;" class="button" onclick="file_info('fc_shangchuanwenjian')" value="文件信息">
    <input type="button" style="width:66px;cursor:pointer;" class="button" onclick="uploadFile('fc_shangchuanwenjian','anBnLHBuZyx3b3JkLHBwdCxnaWY=','2')" value="上传文件"><span id="ck_shangchuanwenjian"></span></td></tr><tr id="fine_liuyan"><th>留言：</th><td><textarea style="width:400px;height:90px;" name="data[liuyan]"></textarea><span id="ck_liuyan"></span></td></tr>			<tr>
				<th style="border:none">&nbsp;</th>
				<td style="border:none"><input type="submit" class="button" value="提 交" name="submit"></td>
			</tr>
			</tbody></table>
			</form>
        </div>
				</div>
		  </div>
					
					
		</div>
                                        
										
                                        
                                                       <div class="clear"></div>
 <div class="Mallright1botbj"></div>
                                        
                            </div>
                            
            
            				<div class="clear"></div>
            </div>




            {template hospitalphoto}
     
     
</div>     
     
{template member/footer}