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Advanced Care Planning HTML

HTML icon AdvanceCarePlan1-2.html — HTML, 23 kB (24079 bytes)

File contents

<html>
<head>
<title>Advance Care Planning Record</title>

<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>

<script type="text/javascript" language="javascript">
function Open1(){
var TempWin=window.open('','name');
  TempWin.document.write('<html><head><title>Patient Information Sheet 1</title></head><body>');
  TempWin.document.write('<img src="${oscar_image_path}AdvanceCarePlan_combined-2.png" width="750" >');
  TempWin.document.write('</body></html>');
  TempWin.document.close();

}


</script> 


</head>

<body onload="startUp()">
<img id='BGImage' src="${oscar_image_path}AdvanceCarePlan_combined-1.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<form method="post" action="" name="FormName" id="FormName" >

<a name="AdvanceCarePlanInstructions" class="DoNotPrint" style="position: absolute; left: 100px; top: 35px;" href="javascript:Open1();">Show Instructions</a>

<textarea name="PatientLabel" id="PatientLabel" oscarDB=label style="position:absolute; left:448px; top:6px; width:297px; height:189px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px;" class="noborder"></textarea>


<input name="Most" id="Most" type="text" class="noborder" style="position:absolute; left:604px; top:240px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" oscardb=m$MOST#value>


<input name="ProvincialNumCPR" id="ProvincialNumCPR" type="text" class="noborder" style="position:absolute; left:604px; top:254px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="ACP" id="ACP" type="text" class="noborder" style="position:absolute; left:604px; top:268px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="AdvanceCarePlan" id="AdvanceCarePlan" type="text" class="noborder" style="position:absolute; left:604px; top:282px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="AdvanceDirective" id="AdvanceDirective" type="text" class="noborder" style="position:absolute; left:604px; top:296px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="Representation" id="Representation" type="text" class="noborder" style="position:absolute; left:604px; top:310px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="Other" id="Other" type="text" class="noborder" style="position:absolute; left:604px; top:324px; width:127px; height:12px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" value="">


<input name="Date1" id="Date1" type="text" class="noborder" style="position:absolute; left:33px; top:411px; width:133px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key1" id="Key1" type="text" class="noborder" style="position:absolute; left:174px; top:411px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next1" id="Next1" type="text" class="noborder" style="position:absolute; left:509px; top:411px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date2" id="Date2" type="text" class="noborder" style="position:absolute; left:34px; top:435px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key2" id="Key2" type="text" class="noborder" style="position:absolute; left:174px; top:435px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next2" id="Next2" type="text" class="noborder" style="position:absolute; left:509px; top:435px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date3" id="Date3" type="text" class="noborder" style="position:absolute; left:34px; top:460px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key3" id="Key3" type="text" class="noborder" style="position:absolute; left:174px; top:460px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next3" id="Next3" type="text" class="noborder" style="position:absolute; left:509px; top:460px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date4" id="Date4" type="text" class="noborder" style="position:absolute; left:34px; top:484px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key4" id="Key4" type="text" class="noborder" style="position:absolute; left:174px; top:484px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next4" id="Next4" type="text" class="noborder" style="position:absolute; left:509px; top:484px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date5" id="Date5" type="text" class="noborder" style="position:absolute; left:34px; top:508px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key5" id="Key5" type="text" class="noborder" style="position:absolute; left:174px; top:508px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next5" id="Next5" type="text" class="noborder" style="position:absolute; left:509px; top:508px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date6" id="Date6" type="text" class="noborder" style="position:absolute; left:34px; top:532px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key6" id="Key6" type="text" class="noborder" style="position:absolute; left:174px; top:532px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next6" id="Next6" type="text" class="noborder" style="position:absolute; left:509px; top:532px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date7" id="Date7" type="text" class="noborder" style="position:absolute; left:34px; top:557px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key7" id="Key7" type="text" class="noborder" style="position:absolute; left:174px; top:557px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next7" id="Next7" type="text" class="noborder" style="position:absolute; left:509px; top:557px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date8" id="Date8" type="text" class="noborder" style="position:absolute; left:34px; top:581px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key8" id="Key8" type="text" class="noborder" style="position:absolute; left:174px; top:581px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next8" id="Next8" type="text" class="noborder" style="position:absolute; left:509px; top:581px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date9" id="Date9" type="text" class="noborder" style="position:absolute; left:34px; top:605px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key9" id="Key9" type="text" class="noborder" style="position:absolute; left:174px; top:605px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next9" id="Next9" type="text" class="noborder" style="position:absolute; left:509px; top:605px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date10" id="Date10" type="text" class="noborder" style="position:absolute; left:34px; top:629px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key10" id="Key10" type="text" class="noborder" style="position:absolute; left:174px; top:630px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next10" id="Next10" type="text" class="noborder" style="position:absolute; left:509px; top:630px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date11" id="Date11" type="text" class="noborder" style="position:absolute; left:34px; top:654px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key11" id="Key11" type="text" class="noborder" style="position:absolute; left:174px; top:654px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next11" id="Next11" type="text" class="noborder" style="position:absolute; left:509px; top:654px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date12" id="Date12" type="text" class="noborder" style="position:absolute; left:34px; top:678px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key12" id="Key12" type="text" class="noborder" style="position:absolute; left:174px; top:678px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next12" id="Next12" type="text" class="noborder" style="position:absolute; left:509px; top:678px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date13" id="Date13" type="text" class="noborder" style="position:absolute; left:34px; top:702px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key13" id="Key13" type="text" class="noborder" style="position:absolute; left:174px; top:703px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Next13" id="Next13" type="text" class="noborder" style="position:absolute; left:509px; top:703px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date14" id="Date14" type="text" class="noborder" style="position:absolute; left:34px; top:727px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key14" id="Key14" type="text" class="noborder" style="position:absolute; left:174px; top:727px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next14" id="Next14" type="text" class="noborder" style="position:absolute; left:509px; top:726px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date15" id="Date15" type="text" class="noborder" style="position:absolute; left:34px; top:751px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key15" id="Key15" type="text" class="noborder" style="position:absolute; left:174px; top:751px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Next15" id="Next15" type="text" class="noborder" style="position:absolute; left:509px; top:751px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date16" id="Date16" type="text" class="noborder" style="position:absolute; left:34px; top:774px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Key16" id="Key16" type="text" class="noborder" style="position:absolute; left:174px; top:775px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next16" id="Next16" type="text" class="noborder" style="position:absolute; left:509px; top:775px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date17" id="Date17" type="text" class="noborder" style="position:absolute; left:34px; top:799px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Key17" id="Key17" type="text" class="noborder" style="position:absolute; left:174px; top:799px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next17" id="Next17" type="text" class="noborder" style="position:absolute; left:509px; top:799px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date18" id="Date18" type="text" class="noborder" style="position:absolute; left:34px; top:823px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Key18" id="Key18" type="text" class="noborder" style="position:absolute; left:174px; top:823px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Next18" id="Next18" type="text" class="noborder" style="position:absolute; left:509px; top:823px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date19" id="Date19" type="text" class="noborder" style="position:absolute; left:34px; top:848px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Key19" id="Key19" type="text" class="noborder" style="position:absolute; left:174px; top:847px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next19" id="Next19" type="text" class="noborder" style="position:absolute; left:509px; top:847px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date20" id="Date20" type="text" class="noborder" style="position:absolute; left:34px; top:871px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key20" id="Key20" type="text" class="noborder" style="position:absolute; left:174px; top:872px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next20" id="Next20" type="text" class="noborder" style="position:absolute; left:509px; top:872px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date21" id="Date21" type="text" class="noborder" style="position:absolute; left:34px; top:895px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key21" id="Key21" type="text" class="noborder" style="position:absolute; left:174px; top:896px; width:326px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next21" id="Next21" type="text" class="noborder" style="position:absolute; left:509px; top:896px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Date22" id="Date22" type="text" class="noborder" style="position:absolute; left:34px; top:920px; width:131px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Key22" id="Key22" type="text" class="noborder" style="position:absolute; left:174px; top:920px; width:326px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">


<input name="Next22" id="Next22" type="text" class="noborder" style="position:absolute; left:509px; top:920px; width:229px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">





 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:1000px; 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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