Analyze some Data

I want a form created. It is for medical dosage calculations of Iron infusion dosage. I have attached an example of the form i want. It would ideally be a pdf but a word document would be ok. The nurse creating the order needs to enter in to the calculation 2 fields; patient weight and current Hb level. From the information the nurse has entered the form should then be able to calculate the correct dosage. The formula being used is called 'The Ganzoni Equation' and is as follows: CALCULATED DOSE = Body Weight kg x (Target Hb – Actual Hb g/L) x 0.24 + Iron Stores mg The formula will vary target Hb and Iron Stores depending upon what body weight the nurse has provided. Target Hb is: 130 for body weight less than 35kg, and 150 for body weight greater than or equal to 35kg. Iron Stores is: 15mg/kg for body weight less than 35kg and 500mg for body weight greater than or equal to 35kg. The Calculated dose should be rounded down to the nearest 100mg if body weight is less than or equal to 66kg and round up to the nearest 100mg if body weight is greater than 66kg. The maximum calculated dose cannot exceed 1000mg so if the calculated dose is greater than this the form should give a result of 1000mg (with a note that the 'actual calculated dose was higher but due to current recommendations 1000mg dosage should not be exceeded in any one week period. The actual calculated dose was ....... mg').