

<div class="page-content-wrapper">
    <div class="page-content">
        <div class="row">
            <div class="col-md-12">
                <!-- BEGIN EXAMPLE TABLE PORTLET-->
                <div class="portlet box blue">
                    <div class="portlet-title">
                        <div class="caption">
                            <i class="fa fa-user"></i>Investigations
                        </div>
                    </div>
                    <div class="portlet-body">

                        <!--Begin Semen-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> Semen</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End Semen-->


                        <!--Begin HSG-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> HSG</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End HSG-->


                        <!--Begin US/TVS-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> US/TVS</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End US/TVS-->

                        <!--Begin Laparoscopy-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> Laparoscopy</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End Laparoscopy-->

                        <!--Begin Hysteroscopy-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> Hysteroscopy</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End Hysteroscopy-->

                        <!--Begin MRI/CT-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> MRI/CT</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End MRI/CT-->

                        <!--Begin Hormones-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> Hormones</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End Hormones-->

                        <!--Begin Pathology-->

                        <div class="row">


                            <div class="portlet-title tbox">
                                <div class="caption font-green-haze col-md-6">
                                    <span class="caption-subject bold uppercase"> Pathology</span>
                                </div>
                                <div class="actions col-md-6">
                                    <button type="button" class="btn btn-xs blue fright"><i class="fa fa-plus"></i> Add</button>
                                </div>
                            </div>

                            <div class="clearfix"></div>


                            <div class="row clinick">

                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control datepicker">
                                        <label for="form_control_1">date</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">count</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA</label>
                                    </div>
                                </div>
                                <div class="col-md-2">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">motilityA+B</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Normal</label>
                                    </div>
                                </div>
                                <div class="col-md-1">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">pus cells</label>
                                    </div>
                                </div>

                                <div class="col-md-5">
                                    <div class="form-group form-md-line-input form-md-floating-label has-info">
                                        <input type="text" class="form-control">
                                        <label for="form_control_1">Notes</label>
                                    </div>
                                </div>


                                <div class="form-group form-md-line-input">
                                    <label class="col-md-1 control-label"></label>
                                    <div class="col-md-10">
                                        <div class="md-checkbox-inline">
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox1" class="md-check">
                                                <label for="checkbox1">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Normal </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox2" class="md-check">
                                                <label for="checkbox2">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Oligo sprerm</label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox3" class="md-check">
                                                <label for="checkbox3">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    astheno sperm </label>
                                            </div>
                                            <div class="md-checkbox">
                                                <input type="checkbox" id="checkbox4" class="md-check">
                                                <label for="checkbox4">
                                                    <span></span>
                                                    <span class="check"></span>
                                                    <span class="box"></span>
                                                    Tetrato sperm </label>
                                            </div>

                                        </div>
                                    </div>
                                </div>
                            </div>

                            <div class="clearfix"></div>
                        </div>

                        <!--End Pathology-->


                        <div class="clearfix"></div>




                    </div>



                </div>
            </div>
        </div>
    </div>
</div>
