Speech and Language Referral
SLP-Referral-X-boxV2.html
—
HTML,
21 kB (21633 bytes)
File contents
<html> <head> <!---------Created 2012-02 by John Yap. X-boxed. -----------------------------------------> <!---------Updated 2013-06 by Herb Chang to add address drop-down list for Health Units-----> <link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" /> <!--<script language="javascript" type="text/javascript" media="print" src="${oscar_image_path}JSMPC.js"></script> --> <style type="text/css" media="print"> .DoNotPrint { display:none; } .noborder { border :0px; background:transparent; scrollbar-3dlight-color:transparent; scrollbar-3dlight-color:transparent; scrollbar-arrow-color:transparent; scrollbar-base-color:transparent; scrollbar-darkshadow-color:transparent; scrollbar-face-color:transparent; scrollbar-highlight-color:transparent; scrollbar-shadow-color:transparent; scrollbar-track-color:transparent; background:transparent; overflow:hidden; } </style> <script language="javascript" type="text/javascript"> /**************************** startup functions ****************************/ function startUp() { // shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments var strLoc = window.location.href.toLowerCase(); if(strLoc.indexOf("https") == -1) { // page1 var src = document.getElementById('BGImage').src; document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D',''); } setDocumentTitle('Fraser Health SLP Referral',document.getElementById('Name').value); setDefaults(); } function setDocumentTitle(Title,Name) { // set document title document.title = Title + ' - ' + Name; } function setDefaults() { // check the newform flag to ensure this is the initial load of the form if (document.getElementById("newForm").value == 'True') { //document.getElementById('').value = 'X'; } } /**************************** submit and print functions ****************************/ function printSubmit() { printLetter(); releaseDirtyFlag(); submission(); } function printLetter() { // hide the bottom buttons if (document.getElementById('BottomButtons').style.display == '') document.getElementById('BottomButtons').style.display = 'none'; // print the letter window.print(); } function submission() { setFlag(); setTimeout('document.FormName.submit()',1000); } function setFlag() { // indicate that the form has been submitted if (document.getElementById("newForm").value == 'True') document.getElementById("newForm").value = 'False'; } function showButtons() { //show the bottom buttons if they are hidden if (document.getElementById('BottomButtons').style.display == 'none') document.getElementById('BottomButtons').style.display = ''; } /**************************** checkbox functions ****************************/ function changeValue(x) { if (document.getElementById(x).value == '') document.getElementById(x).value = 'X'; else document.getElementById(x).value = ''; } function displayKeyCode(evt,x) { var charCode = (evt.which) ? evt.which :event.keyCode // any key press except tab will constitute a value change to the checkbox if (charCode != 9) { changeValue(x); return false; } } </script> <!-------Script to optimize window on loading-----------> <script language="JavaScript"> top.window.moveTo(0,0); if (document.all) { top.window.resizeTo(screen.availWidth,screen.availHeight); } else if (document.layers||document.getElementById) { if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){ top.window.outerHeight = screen.availHeight; top.window.outerWidth = 900; } } </script> <!----------End optimize window script----------> <!-- js graphics scripts --> <script type="text/javascript" src="jsgraphics.js"></script> <script language="javascript"> function formPrint(){ if (document.getElementById('DrawCheckmark').checked){ printCheckboxes(); }else{ window.print(); } } </script> <!-- scripts to confirm closing of window if haven't saved yet --> <script language="javascript"> //keypress events trigger dirty flag var needToConfirm = true; document.onkeyup=setDirtyFlag; function setDirtyFlag() { needToConfirm = true; } function releaseDirtyFlag() { needToConfirm = false; //Call this function if doesn't requires an alert. //this could be called when save button is clicked } window.onbeforeunload = confirmExit; function confirmExit() { if (needToConfirm) { return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?"; } } </script> </head> <body onload="startUp();" onMouseDown="showButtons();"> <form method="post" action="" name="FormName" id="FormName" > <div id="page1" style="position:relative; left:0px; top:20px; width:750px;" class="pagebreak"> <img id="BGImage" SRC="${oscar_image_path}SLP_referral.png" width:750px"> <textarea name="SLPClinic" class="noborder" style="position:absolute; left:200px; top:00px; width:350px; height:85px; font-family:sans-serif; font-size:16px; font-weight:bold; background-color:transparent;"></textarea> <!-- ---------------SLPClinic Drop-down list----------------------------- --> <select class="DoNotPrint" style="position:absolute; left:555px; top:00px; background-color:#F6CECE; "> <option onClick="document.FormName.SLPClinic.value = ''">choose Health Unit</option> <option onClick="document.FormName.SLPClinic.value = 'Port Moody Health Unit \n#200 - 205 Newport Drive \nPort Moody, BC   V3H 5C9 \nPhone: 604-949-7210   Fax: 604-949-7211 '">Port Moody</option> <option onClick="document.FormName.SLPClinic.value = 'Port Coquitlam Health Unit \n2266 Wilson Avenue \nPort Coquitlam, BC   V3C 1Z5 \nPhone: 604-777-8703   Fax: 604-941-2409 '">Port Coquitlam</option> <option onClick="document.FormName.SLPClinic.value = 'New Westminster Health Unit \n#105 - 80A - Sixth Street \nNew Westminster, BC   V3L 5B3 \nPhone: 604-777-6855   Fax: 604-525-3803 '">New Westminster</option> <option onClick="document.FormName.SLPClinic.value = 'Maple Ridge Health Unit \n#400 - 22470 Dewdney Trunk Road \nMaple Ridge, BC   V2X 5Z6 \nPhone: 604-476-7000   Fax: 604-476-7077 '">Maple Ridge</option> <option onClick="document.FormName.SLPClinic.value = 'Burnaby Health Unit \n#105 - 4946 Canada Way \nBurnaby, BC   V5G 4H7 \nPhone: 604-918-7663   Fax: 604-918-7660 '">Burnaby</option> <option onClick="document.FormName.SLPClinic.value = ''">blank</option> </select> <!-- ---------------PATIENT INFO----------------------------- --> <input name="Name" id="Name" type="text" class="noborder" style="position:absolute; left:10px; top:196px; width:350px; font-family:Arial; font-size:16px; background-color:transparent; background-color:transparent;" oscarDB=patient_name> <input name="gender" type="text" oscardb=sex style="position:absolute; left:405px; top:196px; width:40px; font-family:Arial; font-size:16px; font-weight:bold; text-align:center; background-color:transparent;" class="noborder"> <input name="TodaysDate" id="TodaysDate" type="text" class="noborder" style="position:absolute; left:500px; top:196px; width:200px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=today> <input name="Language" type="text" class="noborder" style="position: absolute; left:180px; top:230px; width:100px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;" value=""> <textarea name="Aboriginal" style="position: absolute; left:425px; top:230px; width:45px; height:20px; font-family: Arial; font-size: 14px; font-weight: bold;" class="noborder"></textarea> <select style="position: absolute; left:475px; top:230px;" class="DoNotPrint"> <option onClick="document.FormName.Aboriginal.value = ''"></option> <option onClick="document.FormName.Aboriginal.value = 'YES'">YES</option> <option onClick="document.FormName.Aboriginal.value = 'NO'">NO</option> </select> <input name="Patient_Address" type="text" class="noborder" style="position: absolute; left:10px; top:270px; width:450px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=addressLine> <input name="PatientHomePhone" type="text" class="noborder" style="position:absolute; left:580px; top:250px; width:168px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=phone> <input name="PatientWorkPhone" type="text" class="noborder" style="position:absolute; left:580px; top:285px; width:168px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=cell> <input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:10px; top:338px; width:150px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent; background-color:transparent;" oscardb=dob> <input name="Age" id="Age" type="text" class="noborder" style="position:absolute; left:250px; top:338px; width:30px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent; background-color:transparent;" oscardb=age> <input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:308px; top:338px; width:150px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent; background-color:transparent;" oscarDB=hinc> <input name="PatientsDoctor" type="text" class="noborder" style="position:absolute; left:498px; top:338px; width:230px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=current_user> <input name="IfMinor" type="text" class="noborder" style="position:absolute; left:10px; top:390px; width:280px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;"> <input name="SpouseContact" type="text" class="noborder" style="position:absolute; left:306px; top:390px; width:178px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent;"> <input name="PreschoolEtc" type="text" class="noborder" style="position:absolute; left:10px; top:432px; width:280px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;"> <input name="TeacherGrade" type="text" class="noborder" style="position:absolute; left:306px; top:432px; width:178px; font-family:Arial; font-size:16px; text-align:center; background-color:transparent;"> <textarea name="ParentNotified" style="position: absolute; left:570px; top:418px; width:45px; height:20px; font-family: Arial; font-size:14px; font-weight:bold;" class="noborder"></textarea> <select style="position: absolute; left:620px; top:418px;" class="DoNotPrint"> <option onClick="document.FormName.ParentNotified.value = ''"></option> <option onClick="document.FormName.ParentNotified.value = 'YES'">YES</option> <option onClick="document.FormName.ParentNotified.value = 'NO'">NO</option> </select> <!-- -----Problem------------------------ --> <textarea name="Problem" class="noborder" style="position:absolute; left:10px; top:520px; width:425px; height:125px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;"></textarea> <!-- -----Audiological Services------------------------ --> <input name="SwimMolds" id="SwimMolds" type="text" style="position:absolute; left:6px; top:677px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HearingProtect" id="HearingProtect" type="text" style="position:absolute; left:236px; top:677px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HearingEval" id="HearingEval" type="text" style="position:absolute; left:6px; top:705px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="EvalHearingAid" id="EvalHearingAid" type="text" style="position:absolute; left:236px; top:705px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="BCCH" id="BCCH" type="text" style="position:absolute; left:461px; top:547px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ENT" id="ENT" type="text" style="position:absolute; left:461px; top:563px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Elks" id="Elks" type="text" style="position:absolute; left:461px; top:579px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="IDP" id="IDP" type="text" style="position:absolute; left:461px; top:594px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Paed" id="Paed" type="text" style="position:absolute; left:461px; top:611px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SHH" id="SHH" type="text" style="position:absolute; left:461px; top:627px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SCCP" id="SCCP" type="text" style="position:absolute; left:461px; top:642px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherGroup" id="OtherGroup" type="text" style="position:absolute; left:461px; top:673px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <textarea name="OtherGroupText" class="noborder" style="position:absolute; left:510px; top:668px; width:250px; height:50px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;"></textarea> <!-- ---------SignOff------------------------------- --> <span style="position:absolute; left:120px; top:771px; font-size:18px; font-family:Arial; font-style:italic; font-weight:bold; ">"Electronically signed"</span> <input name="PatientsDoctor" type="text" class="noborder" style="position:absolute; left:50px; top:824px; width:420px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=current_user> <!-- ---------------CLINIC INFO----------------------------- --> <input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:610px; top:824px; width:180px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_phone> <input name="ClinicAddress" type="text" class="noborder" style="position:absolute; left:70px; top:857px; width:485px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_address> <span style="position:absolute; left:570px; top:857px; font-size:14px; font-family:Arial; font-size:14px; font-weight:bold; ">Fax: </span> <input name="ClinicFax" id="ClinicFax" type="text" class="noborder" style="position:absolute; left:610px; top:857px; width:180px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" oscardb=clinic_fax> <!-- ---------------Referral Relationship----------------------------- --> <input name="ParentGuardian" id="ParentGuardian" type="text" style="position:absolute; left:370px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Physician" id="Physician" type="text" style="position:absolute; left:517px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Audiologist" id="Audiologist" type="text" style="position:absolute; left:600px; top:887px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="PublicHealth" id="PublicHealth" type="text" style="position:absolute; left:370px; top:900px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SLP" id="SLP" type="text" style="position:absolute; left:517px; top:900px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherReferral" id="OtherReferral" type="text" style="position:absolute; left:370px; top:915px; width:12px; height:12px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherReferralText" type="text" class="noborder" style="position:absolute; left:428px; top:910px; width:362px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value=""> <!-- ---------------End of Inputs----------------------------- --> </div> <!-- The submit/print/reset buttons -------------------------------------------------------------> <div class="DoNotPrint" id="BottomButtons" style="position:absolute; left:10px; top:1000px;"> <table> <tr><td> <input type="hidden" id="newForm" name="newForm" value="True" /> Subject:<input name="subject" size="40" type="text"> <input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="releaseDirtyFlag();document.FormName.submit()"> <input value="Reset" name="ResetButton" id="ResetButton" type="reset"> <input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> <input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printSubmit()"> </td></tr> </table> </div> <!-- ------End of submit/print/reset buttons-----------------------------------------------------> </form> </body></html>
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