</td>
</tr>
<tr>
<td><input name="viralLoadTestingIndication" id="vlTestingSuspectedTreatmentFailure" type="radio" value="vlTestingSuspectedTreatmentFailure" <?php
echo $viralLoadTestingIndication == "vlTestingSuspectedTreatmentFailure" ? " checked=\"checked\"" : "";
?>
/></td>
<td>Suspected Treatment Failure</td>
<td width="10%" align="right">Last Viral Load Date:</td>
<td width="10%" style="padding:0px 0px 0px 5px">
<table width="10%" border="0" cellspacing="0" cellpadding="0" class="vl">
<tr>
<td><select name="suspectedTreatmentFailureLastVLDateDay" id="suspectedTreatmentFailureLastVLDateDay" class="search">
<?
if($suspectedTreatmentFailureLastVLDate) {
echo "<option value=\"".getFormattedDateDay($suspectedTreatmentFailureLastVLDate)."\" selected=\"selected\">".getFormattedDateDay($suspectedTreatmentFailureLastVLDate)."</option>";
} else {
echo "<option value=\"\" selected=\"selected\">Select Date</option>";
}
for($j=1;$j<=31;$j++) {
echo "<option value=\"".($j<10?"0$j":$j)."\">$j</option>";
}
?>
</select></td>
<td style="padding:0px 0px 0px 5px"><select name="suspectedTreatmentFailureLastVLDateMonth" id="suspectedTreatmentFailureLastVLDateMonth" class="search">
<?
if($suspectedTreatmentFailureLastVLDate) {
echo "<option value=\"".getFormattedDateMonth($suspectedTreatmentFailureLastVLDate)."\" selected=\"selected\">".getFormattedDateMonthname($suspectedTreatmentFailureLastVLDate)."</option>";
} else {
echo "<option value=\"\" selected=\"selected\">Select Month</option>";
}
}
?>
</select></td>
</tr>
</table></td>
</tr>
<tr>
<td style="padding:10px 0px 15px 0px; border-bottom: 1px dashed #dfe6e6">Assay Date <font class="vl_red">*</font></td>
<td style="padding:10px 0px 15px 0px; border-bottom: 1px dashed #dfe6e6">
<table width="10%" border="0" cellspacing="0" cellpadding="0" class="vl">
<tr>
<td><select name="assayDateDay" id="assayDateDay" class="search">
<?
if($assayDate) {
echo "<option value=\"".getFormattedDateDay($assayDate)."\" selected=\"selected\">".getFormattedDateDay($assayDate)."</option>";
} else {
echo "<option value=\"\" selected=\"selected\">Select Day</option>";
}
for($j=1;$j<=31;$j++) {
echo "<option value=\"".($j<10?"0$j":$j)."\">$j</option>";
}
?>
</select></td>
<td style="padding:0px 0px 0px 5px">
<select name="assayDateMonth" id="assayDateMonth" class="search">
<?
if($assayDate) {
echo "<option value=\"".getFormattedDateMonth($assayDate)."\" selected=\"selected\">".getFormattedDateMonthname($assayDate)."</option>";
} else {
echo "<option value=\"\" selected=\"selected\">Select Month</option>";
<tr>
<td> </td>
</tr>
<tr>
<td>
<fieldset style="width: 85%">
<legend><strong>DISPATCH CREDENTIALS</strong></legend>
<table width="100%" border="0" class="vl">
<tr>
<td width="20%">Date Dispatched <font class="vl_red">*</font></td>
<td width="80%">
<table width="10%" border="0" cellspacing="0" cellpadding="0" class="vl">
<tr>
<td><select name="dispatchedDateDay" id="dispatchedDateDay" class="search">
<?
echo "<option value=\"".getFormattedDateDay($oldDispatchedDate?$oldDispatchedDate:$datetime)."\" selected=\"selected\">".getFormattedDateDay($oldDispatchedDate?$oldDispatchedDate:$datetime)."</option>";
for($j=1;$j<=31;$j++) {
echo "<option value=\"".($j<10?"0$j":$j)."\">$j</option>";
}
?>
</select></td>
<td style="padding:0px 0px 0px 5px"><select name="dispatchedDateMonth" id="dispatchedDateMonth" class="search">
<? echo "<option value=\"".getFormattedDateMonth($oldDispatchedDate?$oldDispatchedDate:$datetime)."\" selected=\"selected\">".getFormattedDateMonthname($oldDispatchedDate?$oldDispatchedDate:$datetime)."</option>"; ?>
<option value="01">Jan</option>
<option value="02">Feb</option>
<option value="03">Mar</option>
<option value="04">Apr</option>
<option value="05">May</option>
<option value="06">Jun</option>
<option value="07">Jul</option>
<option value="08">Aug</option>
}
?>
</select></td>
</tr>
</table></td>
</tr>
<tr>
<td style="padding:10px 0px 0px 0px">To:</td>
</tr>
<tr>
<td><table width="10%" border="0" cellspacing="0" cellpadding="0" class="vl">
<tr>
<td><select name="toDay" id="toDay" class="search">
<?
for($j=1;$j<=31;$j++) {
echo "<option value=\"".($j<10?"0$j":$j)."\" ".($j==getFormattedDateDay(getDualInfoWithAlias("last_day(now())","lastmonth"))?"selected=\"selected\"":"").">$j</option>";
}
?>
</select></td>
<td style="padding:0px 0px 0px 5px"><select name="toMonth" id="toMonth" class="search">
<? echo "<option value=\"".getFormattedDateMonth(getDualInfoWithAlias("last_day(now())","lastmonth"))."\" selected=\"selected\">".getFormattedDateMonthname(getDualInfoWithAlias("last_day(now())","lastmonth"))."</option>"; ?>
<option value="01">January</option>
<option value="02">February</option>
<option value="03">March</option>
<option value="04">April</option>
<option value="05">May</option>
<option value="06">June</option>
<option value="07">July</option>
<option value="08">August</option>
<option value="09">September</option>
<option value="10">October</option>
<option value="Missing Gender">Missing Gender</option>
</select>
</td>
</tr>
<tr>
<td>Date of Birth</td>
<td>
<table width="10%" border="0" cellspacing="0" cellpadding="0" class="vl">
<tr>
<td><select name="dateOfBirthDay" id="dateOfBirthDay" class="search" <?php
echo $noDateOfBirthSupplied ? "disabled=\"disabled\"" : "";
?>
>
<?
if($dateOfBirth) {
echo "<option value=\"".getFormattedDateDay($dateOfBirth)."\" selected=\"selected\">".getFormattedDateDay($dateOfBirth)."</option>";
} else {
echo "<option value=\"\" selected=\"selected\">Select Date</option>";
}
for($j=1;$j<=31;$j++) {
echo "<option value=\"".($j<10?"0$j":$j)."\">$j</option>";
}
?>
</select></td>
<td style="padding:0px 0px 0px 5px"><select name="dateOfBirthMonth" id="dateOfBirthMonth" class="search" <?php
echo $noDateOfBirthSupplied ? "disabled=\"disabled\"" : "";
?>
>
<?
if($dateOfBirth) {
echo "<option value=\"".getFormattedDateMonth($dateOfBirth)."\" selected=\"selected\">".getFormattedDateMonthname($dateOfBirth)."</option>";
