中轉檔案
患兒資訊：
<!DOCTYPE html>
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<head>
<title>中國兒童呼吸運用現狀調查</title>
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<body>
<nav class="navbar navbar-inverse navbar-fixed-top" role="navigation">
<div class="container-fluid">
<div class="navbar-header">
<h3>
<p class="text-muted">中國兒童呼吸運用現狀調查</p>
</h3>
</div>
</div>
</nav>
</br>
</br>
</br>
<div class="container">
<div class="row clearfix">
<div class="col-md-12 column">
<div class="page-header">
<h1>
患兒資訊
</h1>
</div>
</div>
</div>
</div>
<div class="container">
</br>
<form class="form-horizontal" role="form">
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
一、 基本資料
</div>
</legend>
<div class="form-group">
<label class="col-sm-1 control-label" for="zhuyuan_hao">住院號</label>
<div class="col-sm-4">
<input class="form-control" id="zhuyuan_hao" type="text" placeholder="請輸入住院號" />
</div>
</div>
<div class="form-group">
<label for="age" class="col-sm-1 control-label">年齡：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="age" placeholder="請輸入年齡">
<span class="input-group-btn">
<button class="btn btn-default" type="button">月</span>
</span>
</div>
</div>
<label for="height" class="col-sm-1 control-label">體重：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="height" placeholder="請輸入體重">
<span class="input-group-btn">
<button class="btn btn-default" type="button">公斤</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="ruyuanshijian" class="col-sm-1 control-label">入院時間：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="ruyuanshijian" placeholder="請輸入入院時間">
<span class="input-group-btn">
<button class="btn btn-default" type="button">例:2017-01-01-00:00</span>
</span>
</div>
</div>
<label for="picu_time" class="col-sm-1 control-label">入院PICU時間：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="picu_time" placeholder="請輸入入院PICU時間">
<span class="input-group-btn">
<button class="btn btn-default" type="button">例:2017-01-01-00:00</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="jiqitongqi_time" class="col-sm-1 control-label">開始機械通氣時間：</label>
<div class="col-sm-4">
<input class="form-control" id="jiqitongqi_time" type="text" placeholder="請輸入開始機械通氣時間" />
</div>
<label for="opt_zhuangtai" class="col-sm-1 control-label">目前狀態：</label>
<label class="checkbox-inline">
<input type="radio" name="zhuangtai" id="opt_zhuangtai" value="tongqi_opt1" checked> 機器通氣
</label>
<label class="checkbox-inline">
<input type="radio" name="zhuangtai" id="opt_zhuangtai" value="cheli_opt2"> 已經撤離
</label>
</div>
<div class="form-group">
<label for="chelitongqi_time" class="col-sm-1 control-label">撤離有創通氣時間：</label>
<div class="col-sm-4">
<input class="form-control" id="chelitongqi_time" type="text" placeholder="請輸入撤離有創通氣時間" />
</div>
<label for="opt_cheliyuanyin" class="col-sm-1 control-label">撤離原因：</label>
<label class="checkbox-inline">
<input type="radio" name="cheliyuanyin" id="opt_cheliyuanyin" value="haozhuan" checked> 好轉
</label>
<label class="checkbox-inline">
<input type="radio" name="cheliyuanyin" id="opt_cheliyuanyin" value="siwang"> 死亡
</label>
<label class="checkbox-inline">
<input type="radio" name="cheliyuanyin" id="opt_cheliyuanyin" value="fangqi"> 放棄治療
</label>
</div>
<div class="form-group">
<label class="col-sm-1 control-label" for="zhuyuan_hao">填表日是開始機械通氣：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="ruyuanshijian" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">天</span>
</span>
</div>
</div>
</div>
</fieldset>
</br>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
二、 疾病資料
</div>
</legend>
<div class="form-group">
<label for="chelitongqi_time">a) 導致機械通氣之主要疾病</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_1"> 急性呼吸衰竭
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_2"> 嚴重膿毒症
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_3"> 心功能不全(急性肺水腫／充血性心力衰竭)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_4"> 複合外傷後(不包括顱腦損傷)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_5"> 心肺復甦後
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_6"> 外科手術後生命支援(非顱腦手術，手術前無機械通氣)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_7"> 中樞性呼吸衰竭(顱腦外傷後／顱腦手術後／顱腦病變至顱內壓增高，腦病)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2a" id="2a_id" value="2a_8"> 外周神經肌肉疾病
</label>
</div>
</br>
<div class="form-group">
<label for="chelitongqi_time">b) 合併慢性疾病</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="checkbox" name="2b" id="2b_id" value="2b_1"> 先天性畸形(心血管／消化系統／神經系統／代謝性)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2b" id="2b_id" value="2b_2"> 腫瘤
</label>
<label class="checkbox-inline">
<input type="checkbox" name="2b" id="2b_id" value="2b_3"> 免疫缺陷或免疫紊亂
</label>
</div>
</br>
<div class="form-group">
<label for="ards_id">c) 合併ARDS</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="radio" name="ards[]" id="ards_id" value="ards_yes" checked> 是
</label>
<label class="checkbox-inline">(</label>
<label class="checkbox-inline">
<input type="radio" name="ards_qz[]" id="ards_qz_id" value="ards_small"> 輕
</label>
<label class="checkbox-inline">
<input type="radio" name="ards_qz[]" id="ards_qz_id" value="ards_medium"> 中
</label>
<label class="checkbox-inline">
<input type="radio" name="ards_qz[]" id="ards_qz_id" value="ards_high"> 重
</label>
<label class="checkbox-inline">)</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="radio" name="ards[]" id="ards_id" value="ards_no"> 否
</label>
</div>
</fieldset>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
三、 生理資訊 (記錄時間：調查當天8:00，PRISMIII除外)
</div>
</legend>
<div class="form-group">
<label class="control-label" for="3a">a) 生命體徵</label>
</div>
<div class="form-group">
<label for="3a_xinlu" class="col-sm-1 control-label">心率：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_xinlu" placeholder="請輸入心率">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(次／分)</span>
</span>
</div>
</div>
<label for="3a_huxi" class="col-sm-1 control-label">呼吸：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_huxi" placeholder="請輸入呼吸">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(次／分)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3a_xueya" class="col-sm-1 control-label">血壓：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_xueya" placeholder="請輸入血壓">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(mmHg)</span>
</span>
</div>
</div>
<label for="3a_tongkong" class="col-sm-1 control-label">瞳孔：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_tongkong" placeholder="請輸入瞳孔">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(mm)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3a_tiwen" class="col-sm-1 control-label">體溫：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_tiwen" placeholder="請輸入體溫">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(攝氏度)</span>
</span>
</div>
</div>
<label for="3a_sao2" class="col-sm-1 control-label">SaO2：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3a_sao2" placeholder="請輸入SaO2">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(%)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label" for="3b">b) 入PICU時PRISM III</label>
</div>
<div class="form-group">
<label for="3b_PRISM_III" class="col-sm-1 control-label">PRISM III：</label>
<div class="col-sm-9">
<input class="form-control" id="3b_PRISM_III" type="text" placeholder="請輸入入PICU時PRISM III" />
</div>
</div>
<div class="form-group">
<label class="control-label" for="3c">c) 填表日血氣分析</label>
</div>
<div class="form-group">
<label for="3c_pH" class="col-sm-1 control-label">pH：</label>
<div class="col-sm-4">
<input class="form-control" id="3c_pH" type="text" placeholder="請輸入pH" />
</div>
<label for="3c_PaCO2" class="col-sm-1 control-label">PaCO2：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3c_PaCO2" placeholder="請輸入PaCO2">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(mmHg / kPa)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3c_PaO2" class="col-sm-1 control-label">PaO2：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3c_PaO2" placeholder="請輸入PaO2">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(mmHg / kPa)</span>
</span>
</div>
</div>
<label for="3c_BE" class="col-sm-1 control-label">BE：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="3c_BE" placeholder="請輸入PaO2">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(mmol／L)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label" for="3d">d) 入院後抗生素使用</label>
</div>
<div class="form-group">
<label for="3d_1_id" class="col-sm-1 control-label">二代頭孢：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_1" id="3d_1_id" value="3d_1_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_1" id="3d_1_id" value="3d_1_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_1_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
<label for="3d_2_id" class="col-sm-1 control-label">三代頭孢：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_2" id="3d_2_id" value="3d_2_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_2" id="3d_2_id" value="3d_2_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_2_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3d_3_id" class="col-sm-1 control-label">四代頭孢：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_3" id="3d_3_id" value="3d_3_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_3" id="3d_3_id" value="3d_3_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_3_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
<label for="3d_4_id" class="col-sm-1 control-label">碳青黴烯：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_4" id="3d_4_id" value="3d_4_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_4" id="3d_4_id" value="3d_4_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_4_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3d_5_id" class="col-sm-1 control-label">青黴素＋酶抑制劑：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_5" id="3d_5_id" value="3d_5_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_5" id="3d_5_id" value="3d_5_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_5_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
<label for="3d_6_id" class="col-sm-1 control-label">頭孢菌素＋酶抑制劑：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_6" id="3d_6_id" value="3d_6_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_6" id="3d_6_id" value="3d_6_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_6_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3d_7_id" class="col-sm-1 control-label">大環內酯：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_7" id="3d_7_id" value="3d_7_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_7" id="3d_7_id" value="3d_7_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_7_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
<label for="3d_8_id" class="col-sm-1 control-label">糖肽類：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_8" id="3d_8_id" value="3d_8_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_8" id="3d_8_id" value="3d_8_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_8_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3d_9_id" class="col-sm-1 control-label">唑烷酮：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_9" id="3d_9_id" value="3d_9_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_9" id="3d_9_id" value="3d_9_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_9_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
<label for="3d_10_id" class="col-sm-1 control-label">磺胺類：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_10" id="3d_10_id" value="3d_10_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_10" id="3d_10_id" value="3d_10_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_10_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="3d_11_id" class="col-sm-1 control-label">氨基糖甙：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_11" id="3d_11_id" value="3d_11_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="3d_11" id="3d_11_id" value="3d_11_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="3d_11_days" placeholder="請輸入天數">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
</fieldset>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
四、 機械通氣治療相關(記錄時間：調查當天8:00，PRISMIII除外
</div>
</legend>
<div class="form-group">
<label class="control-label" for="4a">a) 通氣模式</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_1"> Assist-control ventilation
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_2"> SIMV
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_3"> VCV
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="2b_id" value="4a_4"> PCV
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_5"> Pressure Regulated Volume Control
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_6"> Pressure support
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4a" id="4a_id" value="4a_7"> High-frequency
</label>
</div>
<div class="form-group">
<label class="control-label" for="4b">b) 呼吸機引數(設定及測得實際引數)</label>
</div>
<div class="form-group">
<label class="col-sm-1 control-label" for="4b_1_id">呼吸頻率：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_1_id" placeholder="請輸入呼吸頻率">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(次／分)|(格式：測得次數／設定次數)</span>
</span>
</div>
</div>
<label class="col-sm-1 control-label" for="4b_2_id">潮氣量：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_2_id" placeholder="請輸入潮氣量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(ml)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="col-sm-1 control-label" for="4b_3_id">吸氣峰壓：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_3_id" placeholder="請輸入吸氣峰壓">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(cmH2O)</span>
</span>
</div>
</div>
<label class="col-sm-1 control-label" for="4b_4_id">氣道平均壓：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_4_id" placeholder="請輸入氣道平均壓">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(cmH2O)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="col-sm-1 control-label" for="4b_5_id">PEEP：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_5_id" placeholder="請輸入PEEP">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(cmH2O)</span>
</span>
</div>
</div>
<label class="col-sm-1 control-label" for="4b_6_id">吸入氧濃度：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_6_id" placeholder="請輸入吸入氧濃度">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(％)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="col-sm-1 control-label" for="4b_7_id">PS：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="4b_7_id" placeholder="請輸入PS">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(cmH2O)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label" for="4c">c) 呼吸機相關疾病</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="checkbox" name="4c" id="4c_id" value="4c_1"> 氣壓傷(考慮與機械通氣相關)
</label>
<label class="checkbox-inline">
<input type="checkbox" name="4c" id="4c_id" value="4c_2"> 呼吸機相關性肺炎
</label>
</div>
</fieldset>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
五、 鎮痛、鎮靜的運用
</div>
</legend>
<div class="form-group">
<label class="control-label" for="5a">a) 鎮靜</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="radio" name="5a" id="5a_id" value="5a_yes"> 是
</label>
<label class="checkbox-inline">
<input type="radio" name="5a" id="5a_id" value="5a_no"> 否(下面不需要填寫)
</label>
</div>
<div class="form-group">
<label for="5a_1_id" class="col-sm-1 control-label">咪達唑侖：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_1" id="5a_1_id" value="5a_1_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_1" id="5a_1_id" value="5a_1_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5a_1_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/min)</span>
</span>
</div>
</div>
<label for="5a_2_id" class="col-sm-1 control-label">丙泊酚：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_2" id="5a_2_id" value="5a_2_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_2" id="5a_2_id" value="5a_2_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5a_2_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/min)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="5a_3_id" class="col-sm-1 control-label">右美托米定：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_3" id="5a_3_id" value="5a_3_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_3" id="5a_3_id" value="5a_3_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5a_3_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/hr)</span>
</span>
</div>
</div>
<label for="5a_4_id" class="col-sm-1 control-label">苯巴比妥：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_4_id" id="5a_4_id_id" value="5a_4_id_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5a_4_id" id="5a_4_id_id" value="5a_4_id_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5a_4_id_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/day)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label" for="5b">b) 鎮痛</label>
</div>
<div class="form-group">
<label class="checkbox-inline">
<input type="radio" name="5b" id="5b_id" value="5b_yes"> 是
</label>
<label class="checkbox-inline">
<input type="radio" name="5b" id="5b_id" value="5b_no"> 否(下面不需要填寫)
</label>
</div>
<div class="form-group">
<label for="5b_1_id" class="col-sm-1 control-label">嗎啡：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_1" id="5b_1_id" value="5b_1_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_1" id="5b_1_id" value="5b_1_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5b_1_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/hr)</span>
</span>
</div>
</div>
<label for="5b_2_id" class="col-sm-1 control-label">芬太尼：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_2" id="5b_2_id" value="5b_2_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_2" id="5b_2_id" value="5b_2_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5b_2_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/hr)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label for="5b_3_id" class="col-sm-1 control-label">舒芬太尼：</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_3" id="5b_3_id" value="5b_3_yes"> 是
</label>
<label class="checkbox-inline col-sm-1">
<input type="radio" name="5b_3" id="5b_3_id" value="5b_3_no" checked> 否
</label>
<div class="col-sm-2">
<div class="input-group">
<input type="text" class="form-control" id="5b_3_jiliang" placeholder="劑量">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(μg/kg/hr)</span>
</span>
</div>
</div>
</div>
</fieldset>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
六、 醫護人員調查
</div>
</legend>
</fieldset>
</br>
<fieldset>
<legend>
<div class="form-group" style="background-color:grey">
七、 呼吸機維護
</div>
</legend>
<div class="form-group">
<label class="control-label" for="7a_1_id">a) 一次性呼吸機管路</label>
</div>
<div class="form-group">
<label class="col-sm-1 checkbox-inline">
<input type="radio" name="7a" id="7a_1_id" value="7a_1_yes"> 是
</label>
<label class="col-sm-1 checkbox-inline">
<input type="radio" name="7a" id="7a_1_id" value="7a_1_no"> 否
</label>
<label class="col-sm-2 control-label" for="7a_2_id">管路更換時間：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="7a_2_id" placeholder="請輸入管路更換時間">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(天)</span>
</span>
</div>
</div>
</div>
<div class="form-group">
<label class="control-label" for="7b_1_id">b) 吸痰操作</label>
</div>
<div class="form-group">
<label class="col-sm-1 checkbox-inline">
<input type="radio" name="7b" id="7b_1_id" value="7b_1_yes"> 開放式
</label>
<label class="col-sm-1 checkbox-inline">
<input type="radio" name="7b" id="7b_1_id" value="7b_1_no"> 密閉式
</label>
<label class="col-sm-2 control-label" for="7b_2_id">間隔：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="7b_2_id" placeholder="請輸入間隔時間">
<span class="input-group-btn">
<button class="btn btn-default" type="button">(小時)</span>
</span>
</div>
</div>
</div>
</fieldset>
</form>
<legend>
</legend>
</br>
<ul class="pager">
<li class="previous disabled"><a href="#">← 上一步</a></li>
<li class="next"><a href="#">下一步 →</a></li>
</ul>
</div>
</body>
</html>醫院資訊：
<!DOCTYPE html>
<html lang="en">
<head>
<title>中國兒童呼吸運用現狀調查</title>
<style type='text/css'>
body {
background-color: #CCC;
}
</style>
<link rel="stylesheet" href="http://cdn.static.runoob.com/libs/bootstrap/3.3.7/css/bootstrap.min.css">
<script src="http://cdn.static.runoob.com/libs/jquery/2.1.1/jquery.min.js"></script>
<script src="http://cdn.static.runoob.com/libs/bootstrap/3.3.7/js/bootstrap.min.js"></script>
</head>
<body>
<nav class="navbar navbar-inverse navbar-fixed-top" role="navigation">
<div class="container-fluid">
<div class="navbar-header">
<h3>
<p class="text-muted">中國兒童呼吸運用現狀調查</p>
</h3>
</div>
</div>
</nav>
</br>
</br>
</br>
<div class="container">
<div class="row clearfix">
<div class="col-md-12 column">
<div class="page-header">
<h1>
醫院基本資訊
</h1>
</div>
</div>
</div>
</div>
<div class="container">
</br>
</br>
<form class="form-horizontal" role="form">
<div class="form-group">
<label for="yiyuanmingcheng_id" class="col-sm-2 control-label">醫院名稱：</label>
<div class="col-sm-9">
<input type="text" class="form-control" id="yiyuanmingcheng_id" placeholder="請輸入醫院名稱">
</div>
</div>
</br>
<div class="form-group">
<label for="yiyuanshengfen" class="col-sm-2 control-label">醫院地址：</label>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="yiyuanshengfen" placeholder="省份">
<span class="input-group-btn">
<button class="btn btn-default" type="button">省</span>
</span>
</div>
</div>
<div class="col-sm-1">
</div>
<div class="col-sm-4">
<div class="input-group">
<input type="text" class="form-control" id="yiyuanchengshi" placeholder="城市">
<span class="input-group-btn">
<button class="btn btn-default" type="button">市</span>
</span>
</div>
</div>
</div>
</br>
<div class="form-group">
<label for="address_id" class="col-sm-2 control-label">詳細地址：</label>
<div class="col-sm-6">
<input type="text" class="form-control" id="address_id" placeholder="請輸入醫院詳細地址">
</div>
<label for="youbian_id" class="col-sm-1 control-label">郵編：</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="youbian_id" placeholder="請輸入郵編">
</div>
</div>
</br>
<div class="form-group">
<label for="tel_id" class="col-sm-2 control-label">聯絡電話：</label>
<div class="col-sm-3">
<input type="text" class="form-control" id="tel_id" placeholder="請輸入聯絡電話">
</div>
<label for="email_id" class="col-sm-2 control-label">郵箱地址：</label>
<div class="col-sm-3">
<input type="text" class="form-control" id="email_id" placeholder="請輸入聯絡郵箱">
</div>
</div>
</br>
<div class="form-group">
<label for="opt_yiyuanjibie" class="col-sm-2 control-label">醫院級別：</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanjibie" id="jibie_opt1" value="option1" checked>二級甲等
</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanjibie" id="jibie_opt2" value="option2">二級乙等
</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanjibie" id="jibie_opt3" value="option2">三級甲等
</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanjibie" id="jibie_opt4" value="option2">三級乙等
</label>
</div>
</br>
<div class="form-group">
<label for="opt_yiyuanxingzhi" class="col-sm-2 control-label">醫院性質：</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanxingzhi" id="opt_zonghe" value="xingzhi_opt1" checked> 綜合性
</label>
<label class="checkbox-inline">
<input type="radio" name="opt_yiyuanxingzhi" id="opt_ertong" value="xingzhi_opt2"> 兒童醫院
</label>
</div>
</br>
<div class="form-group">
<label for="hushirenshu_chuji" class="col-sm-2 control-label">全科護士人數:</label>
<label for="hushirenshu_chuji" class="col-sm-1 control-label">初級:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="hushirenshu_chuji" placeholder="初級人數">
</div>
<label for="hushirenshu_zhongji" class="col-sm-1 control-label">中級:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="hushirenshu_zhongji" placeholder="中級人數">
</div>
<label for="hushirenshu_gaoji" class="col-sm-1 control-label">高階:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="hushirenshu_gaoji" placeholder="高階人數">
</div>
</div>
</br>
<div class="form-group">
<label for="yishengrenshu_chuji" class="col-sm-2 control-label">ICU專科醫生人數:</label>
<label for="yishengrenshu_chuji" class="col-sm-1 control-label">初級:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="yishengrenshu_chuji" placeholder="初級人數">
</div>
<label for="yishengrenshu_zhongji" class="col-sm-1 control-label">中級:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="yishengrenshu_zhongji" placeholder="中級人數">
</div>
<label for="yishengrenshu_gaoji" class="col-sm-1 control-label">高階:</label>
<div class="col-sm-2">
<input type="text" class="form-control" id="yishengrenshu_gaoji" placeholder="高階人數">
</div>
</div>
</br>
<div class="form-group">
<label for="firstname" class="col-sm-2 control-label">醫院兒科床位數:</label>
<div class="col-sm-9">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入醫院兒科床位數">
</div>
</div>
</br>
<div class="form-group">
<label for="firstname" class="col-sm-2 control-label">PICU床位數:</label>
<div class="col-sm-9">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入PICU床位數">
</div>
</div>
</br>
<div class="form-group">
<label for="firstname" class="col-sm-2 control-label">今日PICU在院人數:</label>
<div class="col-sm-9">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入今日PICU在院人數">
</div>
</div>
</br>
<div class="panel col-sm-11 panel-default">
<div class="panel-heading">
<h3 class="panel-title">氧療人數</h3>
</div>
</br>
<div class="form-group">
<label for="firstname" class="col-sm-2 control-label">氣管插管機械通氣（MV）人數:</label>
<div class="col-sm-4">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入人數">
</div>
<label for="firstname" class="col-sm-2 control-label">無創呼吸機治療人數:</label>
<div class="col-sm-4">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入人數">
</div>
</div>
<div class="form-group">
<label for="firstname" class="col-sm-2 control-label">面罩吸氧人數:</label>
<div class="col-sm-4">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入人數">
</div>
<label for="firstname" class="col-sm-2 control-label">鼻導管吸氧人數:</label>
<div class="col-sm-4">
<input type="text" class="form-control" id="erkebingchuanshu" placeholder="請輸入人數">
</div>
</div>
</div>
</div>
</form>
<ul class="pager">
<li class="previous disabled"><a href="#">← 上一步</a></li>
<li class="next"><a href="#">下一步 →</a></li>
</ul>
</div>
</body>
</html>移動欄：
http://vinceg.github.io/twitter-bootstrap-wizard/
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