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Chinatown (Vancouver) Imaging form Generic Version html

HTML icon USchinatown5.html — HTML, 17 kB (17696 bytes)

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<HTML>
<head>
<title>Chinatown Radiology</title>
<!-- This form was revised September 6, 2011 by Northwest Electronics Records & Design, www.nerdbc.ca  -->
<!-- Updated by Kat Montgomery -->

<link rel="stylesheet" href="${oscar_image_path}eforms.css" media="screen" type="text/css" charset="utf-8"/>
<link rel="stylesheet" href="${oscar_image_path}eforms-print.css" media="print" type="text/css" charset="utf-8"/>

<script src="${oscar_image_path}functions.js"></script>
<script type = "text/javascript">
var startX = 745		//set x offset of topbar in pixels
</script>

<!---------DATEPICKER - source, individualize, & call---------------------------------->
<script src="http://ajax.googleapis.com/ajax/libs/jquery/1.4.2/jquery.min.js" type="text/javascript"></script>
<script src="http://ajax.googleapis.com/ajax/libs/jqueryui/1.8/jquery-ui.min.js"></script>
<link href="http://ajax.googleapis.com/ajax/libs/jqueryui/1.8/themes/base/jquery-ui.css" rel="stylesheet" type="text/css"/>
<link href="${oscar_image_path}datepicker.css" rel="stylesheet" type="text/css"/> 
	<script type = "text/javascript">
		$(function()
			{
				$("#datepicker1").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});
		$(function()
			{
				$("#datepicker2").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});
		$(function()
			{
				$("#datepicker3").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});
		$(function()
			{
				$("#datepicker4").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});
		$(function()
			{
				$("#datepicker5").datepicker({dateFormat: 'd M yy'}).val;
				$('#date').datepicker({dateFormat: 'd M yy'});			});				
	</script>
<!---------end: DATEPICKER-------------------------------------------------------------->


<!-- scripts to confirm closing of window if haven't 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>
<style type="Text/css">
input.largerCheckbox {
	-moz-transform:scale(1.3);         /*scale up image 1.3x - Firefox specific */
	-webkit-transform:scale(1.3);      /*Webkit based browser eg Chrome, Safari */
	-o-transform:scale(1.3);           /*Opera browser */
}
input.largerCheckbox1 {	-moz-transform:scale(1.3);         /*scale up image 1.3x - Firefox specific */
	-webkit-transform:scale(1.3);      /*Webkit based browser eg Chrome, Safari */
	-o-transform:scale(1.3);           /*Opera browser */
}
</style>
<style type="text/css" media="print">
input.largerCheckbox {
	-moz-transform:scale(1.8);         /*scale up image 1.8x - Firefox specific */
	-webkit-transform:scale(1.3);      /*Webkit based browser eg Chrome, Safari */
	-o-transform:scale(1.3);           /*Opera browser */
}
</style>
<!--[if IE]>
 <style type="text/css">
 input.largerCheckbox {
	height: 30px;                     /*30px checkboxes for IE 5 to IE 7 */
	width: 30px;
 }
 </style>
<![endif]-->

	
<SCRIPT LANGUAGE="JavaScript">
 	function setSIN()	{
		document.getElementById('Page1_9').value=document.getElementById('Page1_9').value
		document.getElementById('Page2_19').value=document.getElementById('Page1_9').value
		document.getElementById('Page3_1').value=document.getElementById('Page1_9').value
		document.getElementById('Page4_1').value=document.getElementById('Page1_9').value
 	}
</SCRIPT>

<!-- scripts for Xbox functions -->
<script language="javascript">
$(document).ready(function() {
	  $( ".Xbox" ).click(function() {
		  var st = $( this ).val();
		  if (st=="X") {
			  $( this ).val("");
		  } else {
			  $( this ).val("X");
		  }
	});

$( ".Xbox" ).keypress(function(event) {
	  // any key press except tab will constitute a value change to the checkbox
	  if (event.which != 0){
		  $( this ).click();
		  return false;
		  }
	});

});
</script>

</HEAD>
<body onLoad="">
<form method="post" action="" name="FormName">
<div style="position: absolute; left: 10px; top: 10px;" > 
<img src="${oscar_image_path}USChinatownPage1.png" width="750">
<!--<img src="USChinatownPage1.png" width="750">-->
 
<input name="first_last_name" id="first_last_name" type="text" class="noborder" style="position:absolute; left:159px; top:238px; width:186px;"  oscarDB=first_last_name>

<input name="hinc" id="hinc" type="text" class="noborder" style="position:absolute; left:525px; top:238px; width:152px;"  oscarDB=hinc>

<input name="address_street_number_and_name" id="address_street_number_and_name" type="text" class="noborder" style="position:absolute; left:124px; top:268px; width:222px;"  oscarDB=address_street_number_and_name>

<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:124px; top:292px; width:183px;"  oscardb=city>

<input name="province" id="province" type="text" class="noborder" style="position:absolute; left:311px; top:292px; width:31px;"  oscarDB=province>

<input name="phone" id="phone" type="text" class="noborder" style="position:absolute; left:98px; top:323px; width:190px;"  oscarDB=phone>

<input name="dob" id="dob" type="text" class="noborder" style="position:absolute; left:150px; top:353px; width:164px;"  oscarDB=dob>
<input name="MSP" id="MSP"  type="text" class="Xbox" style="position:absolute; left:392px; top:320px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;" value="X">
<input name="WCB" id="WCB"  type="text" class="Xbox" style="position:absolute; left:466px; top:320px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="ICBC" id="ICBC"  type="text" class="Xbox" style="position:absolute; left:534px; top:320px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Other" id="Other"  type="text" class="Xbox" style="position:absolute; left:611px; top:320px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Fax" id="Fax"  type="text" class="Xbox" style="position:absolute; left:563px; top:416px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;" value="X">

<input name="Mail" id="Mail"  type="text" class="Xbox" style="position:absolute; left:620px; top:417px;  width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Phone" id="Phone"  type="text" class="Xbox" style="position:absolute; left:685px; top:417px;  width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="doctor" id="doctor" type="text" class="noborder" style="position:absolute; left:186px; top:419px; width:193px;"  oscarDB=doctor>

<input name="doctor_ohip_no" id="doctor_ohip_no" type="text" class="noborder" style="position:absolute; left:161px; top:449px; width:205px;"  oscarDB=doctor_ohip_no>

<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style="position:absolute; left:431px; top:449px; width:147px;"  oscarDB=clinic_fax>

<input name="AdditionalCopy" id="AdditionalCopy" type="text" class="noborder" style="position:absolute; left:166px; top:479px; width:208px;" value="">
<span style="position:absolute; left:421px; top:538px; "> LMP:<input name="LMP" id="datepicker2" type="text" class="editable" style="width:153px;" oscarDB=m$LMP#value ></span>

<textarea name="Instructions" id="Instructions" class="editable" style="position:absolute; left:421px; top:582px; width:290px; height:92px;" ></textarea>

<input name="Date1" id="datepicker1" type="text" class="editable" style="position:absolute; left:101px; top:924px; width:110px; " value="">
<input name="Time" id="Time" type="text" class="editable" style="position:absolute; left:250px; top:924px; width:71px; " value="">
<input name="Abdomen" id="Abdomen"  type="text" class="Xbox" style="position:absolute; left:47px; top:540px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="GB" id="GB"  type="text" class="Xbox" style="position:absolute; left:144px; top:571px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Pancreas" id="Pancreas"  type="text" class="Xbox" style="position:absolute; left:144px; top:605px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Aorta" id="Aorta"  type="text" class="Xbox" style="position:absolute; left:144px; top:639px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Liver" id="Liver"  type="text" class="Xbox" style="position:absolute; left:307px; top:572px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Spleen" id="Spleen"  type="text" class="Xbox" style="position:absolute; left:307px; top:605px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Pelvis" id="Pelvis"  type="text" class="Xbox" style="position:absolute; left:47px; top:673px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Kidneys" id="Kidneys"  type="text" class="Xbox" style="position:absolute; left:47px; top:709px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Breast" id="Breast"  type="text" class="Xbox" style="position:absolute; left:47px; top:743px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Obstetrics" id="Obstetrics"  type="text" class="Xbox" style="position:absolute; left:237px; top:672px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;" >

<input name="Extremities" id="Extremities"  type="text" class="Xbox" style="position:absolute; left:237px; top:708px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="Thyroid" id="Thyroid"  type="text" class="Xbox" style="position:absolute; left:237px; top:742px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">
<input name="Shoulder" id="Shoulder"  type="text" class="Xbox" style="position:absolute; left:237px; top:774px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">
<input name="LShoulder" id="LShoulder"  type="text" class="Xbox" style="position:absolute; left:273px; top:802px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">
<input name="RShoulder" id="RShoulder"  type="text" class="Xbox" style="position:absolute; left:273px; top:831px; width:14px; height:14px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:14px; text-align:center; border:1px solid  #000000; background-color:white;">

<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="sex" id="sex" type="text" class="noborder" style="position:absolute; left:390px; top:352px; width:44px; "  oscarDB=sex>

</div>


</form>
 
<!-- -----------Floating Controls Box ------------------->
<div id="topbar" class="DoNotPrint">
<form name="LazyForm">
<p><u>Ultrasound:</u><br/>
  <input type="radio" name="RadioGroup2" id="RadioGroup2_1" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'VIABILITY ULTRASOUND';
				document.FormName.Obstetrics.value = 'X'; ">
				Viability<br/>
                
<input type="radio" name="RadioGroup2" id="RadioGroup2_2"onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'DATING ULTRASOUND';
				document.FormName.Obstetrics.value = 'X'; ">
				Dating <br/>
                
 <input type="radio" name="RadioGroup2" id="RadioGroup2_10"onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'NUCHAL TRANSLUCENCY';
				document.FormName.Obstetrics.value = 'X'; ">
				Nuchal Translucency <br/>
  
                <input type="radio" name="RadioGroup2" id="RadioGroup2_3" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'DETAILED ULTRASOUND';  
				document.FormName.Obstetrics.value = 'X'; ">
    Detailed - FULL<br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_4" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value += 'DETAILED Ultrasound - does NOT want soft-marker assessment';
				document.FormName.Obstetrics.value = 'X'; ">
  Detailed - NO markers<br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_5" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value +='GROWTH & FLUID ASSESSMENT';
				document.FormName.Obstetrics.value = 'X'; ">
  Growth &/or Fluid <br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_9" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value ='CERVICAL LENGTH';
				document.FormName.Obstetrics.value = 'X'; ">
  Cervical length<br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_8" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value ='PLACENTAL LOCATION';
				document.FormName.Obstetrics.value = 'X'; ">
  Placental location/APH<br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_6" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'PRESENTATION & POSITION ASSESSMENT';
				document.FormName.Obstetrics.value = 'X'; ">
  Presentation <br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_7" onClick="
                document.FormName.reset();
                document.FormName.Instructions.value = 'POSTDATES FLUID ASSESSMENT';
				document.FormName.Obstetrics.value = 'X'; ">
  Postdates <br/>
  
    <input type="radio" name="RadioGroup2" id="RadioGroup2_8" onClick="
                 document.FormName.reset();
               document.FormName.Instructions.value ='POSTPARTUM ASSESSMENT';
                document.FormName.LMP.value= ' - NA';
				document.FormName.Obstetrics.value = 'X';
				document.FormName.Pelvis.value = 'X'; ">
  Postpartum </p>
<p><u>Patient:</u><br/>
                
<input name="Sex" type="checkbox" onClick="
                document.FormName.Instructions.value += ', wants to know SEX';">
  				Wants to know sex of fetus</p>
                
<br/>

<input value="Reset Form" name="ResetButton" id="ResetButton" type="reset" onClick="document.FormName.reset()"> <br/><br/>
 
<input value="Print/Fax" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();setTimeout('SubmitButton.click()',1000);"> 
<input value="Save" name="SubmitButton" id="SubmitButton" type="button" onclick="document.FormName.submit();"><br/>
</p>

</form>

</body>
</html>

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