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BCWH Osteoporosis program HTML

HTML icon OsteoporosisClinicReferral.html — HTML, 16 kB (16589 bytes)

File contents

<html>
<head>
<title>OsteoporosisClinicReferral</title>

<!--- Created December 2012, Written for version 12.0, Has x boxes,  --->

<script type="text/javascript" src="${oscar_javascript_path}eforms/faxControl.js"> </script>

<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','');
			}
		}

		/****************************
			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>


<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">
function formPrint(){
			window.print();
} 
</script>

<!-- scripts to confirm closing of window if it hadn't been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
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();">
<img id='BGImage' src="${oscar_image_path}OsteoporosisClinicReferral.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<form method="post" action="" name="FormName" id="FormName" >

<textarea name="LAbel" id="LAbel" class="noborder" style="position:absolute; left:402px; top:11px; width:306px; height:136px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=label></textarea>


<input name="OsteoClinic" id="OsteoClinic" type="type" style="position:absolute; left:17px; top:191px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="OsteoEductaion" id="OsteoEductaion" type="type" style="position:absolute; left:373px; top:192px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="PatientName" id="PatientName" type="text" class="noborder" style="position:absolute; left:63px; top:298px; width:370px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=first_last_name>


<input name="HIN" id="HIN" type="text" class="noborder" style="position:absolute; left:491px; top:298px; width:219px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=hin>


<input name="Address" id="Address" type="text" class="noborder" style="position:absolute; left:79px; top:333px; width:475px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=addressline>


<input name="Phone" id="Phone" type="text" class="noborder" style="position:absolute; left:54px; top:373px; width:154px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=phone>


<input name="OtherPhone" id="OtherPhone" type="text" class="noborder" style="position:absolute; left:250px; top:373px; width:169px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=phone>


<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:530px; top:373px; width:179px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=dob>


<input name="Yes" id="Yes" type="text" style="position:absolute; left:424px; top:413px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="No" id="No" type="text" style="position:absolute; left:470px; top:413px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Previous" id="Previous" type="text" style="position:absolute; left:18px; top:481px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Recent" id="Recent" type="text" style="position:absolute; left:202px; top:481px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Lateral" id="Lateral" type="text" style="position:absolute; left:340px; top:481px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Fractures" id="Fractures" type="text" style="position:absolute; left:15px; top:538px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="FamilyHistory" id="FamilyHistory" type="text" style="position:absolute; left:15px; top:557px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<textarea name="Medications" id="Medications" class="noborder" style="position:absolute; left:15px; top:673px; width:367px; height:109px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=recent_rx></textarea>


<input name="1year" id="1year" type="text" style="position:absolute; left:387px; top:679px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1to2year" id="1to2year" type="text" style="position:absolute; left:475px; top:679px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="plus2year" id="plus2year" type="text" style="position:absolute; left:566px; top:679px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1year2" id="1year2" type="text" style="position:absolute; left:387px; top:704px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1to2year2" id="1to2year2" type="text" style="position:absolute; left:475px; top:705px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="2yearplus2" id="2yearplus2" type="text" style="position:absolute; left:566px; top:705px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1year3" id="1year3" type="text" style="position:absolute; left:387px; top:730px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1to2year3" id="1to2year3" type="text" style="position:absolute; left:475px; top:730px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="2yearplus3" id="2yearplus3" type="text" style="position:absolute; left:566px; top:730px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1year4" id="1year4" type="text" style="position:absolute; left:387px; top:756px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="1to2year4" id="1to2year4" type="text" style="position:absolute; left:475px; top:757px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="2yearplus4" id="2yearplus4" type="text" style="position:absolute; left:566px; top:757px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="DocName" id="DocName" type="text" class="noborder" style="position:absolute; left:106px; top:796px; width:274px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=doctor>


<span style=" position: absolute; left:527px; top:796px; font-family:Arial; font-weight:bold; font-size:16px;"><i>&quotElectronically Signed&quot</i></span>


<input name="RefAddress" id="RefAddress" type="text" class="noborder" style="position:absolute; left:81px; top:823px; width:303px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=referral_address>


<input name="OHIP" id="OHIP" type="text" class="noborder" style="position:absolute; left:452px; top:823px; width:270px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=current_user_ohip_no>


<input name="DocPhone" id="DocPhone" type="text" class="noborder" style="position:absolute; left:417px; top:848px; width:130px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=doctor_work_phone>


<input name="DocFax" id="DocFax" type="text" class="noborder" style="position:absolute; left:590px; top:848px; width:132px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=referral_fax>


<input name="CopyDocName" id="CopyDocName" type="text" class="noborder" style="position:absolute; left:38px; top:896px; width:228px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=doctor>


<input name="CopyDocAddress" id="CopyDocAddress" type="text" class="noborder" style="position:absolute; left:328px; top:896px; width:209px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=referral_address>


<input name="CopyDocPhone" id="CopyDocPhone" type="text" class="noborder" style="position:absolute; left:576px; top:896px; width:147px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;"  oscarDB=doctor_work_phone>


<input name="OtherCheckbox" id="OtherCheckbox" type="text" style="position:absolute; left:15px; top:575px; width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);">


<textarea name="Other" id="Other" class="noborder" style="position:absolute; left:81px; top:578px; width:631px; height:63px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; text-decoration:underline; background-color:white;" ></textarea>




 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:960px; left:0px;">
 <div id="faxControl">&nbsp;</div>
	 <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> 
			<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick=" releaseDirtyFlag();"> 
			<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
			<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="formPrint();"> 
			<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 
	 </td></tr></table>
 </div>
 </form>

</body>
</html>

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