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Chilliwack Area Specific eForms

Chilliwack Addictions and Prevention Services
Referral to the CAPS program in Chilliwack
Dermatology Clinic Referral at CGH
Developmental Assessment and Services
Healthy Living Program
Healthy Living Program run by the psychiatry department at CGH.
Netcare Referral Form
Psychiatric Day Hospital - CGH
Speech Language Services for Adults - CGH
Swallowing Assessment - CGH
Chilliwack Hospice Referral
As stated, png is just logo.
Consent For Viewing
Based on a form for the UBC Family Practice Program in Chilliwack
Chilliwack Child and Youth Mental Health Referral Form.
Rapid Access Clinic Psychiatry Chilliwack
This is for a one time assessment and is not for emergency referrals. Current medications are imported and may have to be edited. JohnR.
Sleep Apnea Testing Chilliwack June 2015
Referral to Oxylife sleep apnea testing. Updated June 2015
Cheam Respiratory Services Referral Form
<!--- Created March 2014, Written by Kevin Meyerink for version 12.0, Using the eform 5.1 Generator. Has x boxes Pure Html form --->
Prohealth Bone Density Requisition 2014
Has a link to the FRAX calculator.
Chilliwack General Hospital Pediatric Observation Unit Referral eForm
Referral to the New (2016) Pediatrics Observation unit in Chilliwack. Referral require a phone call and faxing this form.
Chilliwack Outreach Team Referral 2016
Referral for those 19 or older with: Problematic substance use disorder or dependence of significant duration, or high users of psychiatric services, or inability to participate in traditional office based services, or inability to obtain a safe residence, or inability to maintain a safe living situation.
Chilliwack specific interactive guideline based imaging requisition.
Update February 2nd, various bug fixes and further information added - you will need to delete the previous eform from your library (if you tried an earlier version) to upload this new form. No other files need to be deleted. Update January 9th - increased functionality wrt obstetrical ultrasounds added. Created by David Page - I have just released a Chilliwack specific guideline based imaging requisition to John for posting on OCUS. It incorporates the Canadian Association of Radiologists referral guidelines as found here: -- http://www.car.ca/en/standards-guidelines/guidelines.aspx -- (I have not included cancer or breast imaging at this time) -- These might not be the best guidelines (done 2012) but were the easiest for me to access. This now forms a framework that can be built on and improved. 95% of the form is universal, but 5% is specific to Chilliwack (you will see watermarks, read-only fields etc. Also the DVT order process). The reality is that each region will require some customization based on the local resources as well as the arrangement with the local radiologists. I am hoping that other regions will take this form on as I see a lot of potential in the form and collaboration with other sites will be very helpful. Even sites in Ontario should look at the form- it should not be too complicated to adapt to your specific radiology form. The eForm is provided as a zip file that hopefully can be a simple zip import into OSCAR- I have not been able to test this yet but don't foresee any problems. To work on/adjust the eForm the best way that I found is to do an Export to your computer, then unzip the files to a folder. In this folder there are three main files that you might want to open in a text editor like Notepad++ . XrayInteractive.html, XrayInteractive.js and InsertText.html I have adapted the code(not sure who posted it) that automatically changes the src links so that it will work on the desktop without modification. I then swap out whatever files I have edited into OSCAR. I am willing to help people adjust the code if needed. I am hoping that we can get some EBM review locally through our resident training program to modify or add some of the guidelines and see this as a start and not a finished product, but one that will take years to mature. If other sites take this on we will all be able to collaborate together on the changes. If you plan on using the form please read the Read_me file that you will see on the eForm. David
Chilliwack Primary Care Clinic Referral Form 2017
Updated March 11th - Fax number corrected. *** Updated February 10th 2017 - both html and image corrected for spelling errors. Delete January 2017 versions of both html and image and replace with February 2017 version (zip).
Preoperative Medication Prescription
Designed By Petrus Retief at Chilliwack General Hospital as a guide for surgeons to use when deciding how to deal with patient's medications prior to surgery. Converted to an eform by me (JohnR). First form posted that uses *** $("#CanvasSignature1").jSignature({'decor-color':'rgba(255, 255, 255, 0)'}) *** The 0 is what makes the signature line transparent.
Home Health Referral Chilliwack 2017
At the request of Chantal Chris I have modified the Home Health Referral for Chilliwack. The modifications include: 1) adding a check box for "prognosis less than 6 months", 2)Moving "other" down to accommodate this, 3) Adding (attached) to the end of the line that talks about the most form and the line that talks about the bc benefits form, 4) Adding a (non printing) reminder to attach those forms. I have added the Xbox code to the form to decrease the amount of code.
Chilliwack General Hospital (CGH) Arthroplasty Clinic 2017 - Joint Replacement - Hips and knees
I was asked by The Chilliwack division of Family Practice to make this form. There is a BMI calculator, there are some drop down lists. There is a circle function for Male/Female that automatically circles the appropriate one. It checks to see if they are a smoker and checks that box ( it checks both measurements SKST and SMK - why are there 2 again?) If one says yes and one says no it will check off that the patient is a smoker. It will pull the HbA1c if there is a value in the chart (and if it is mapped, but I think A1c mapping is standard). It will also check off the A1c box if the value for A1c is >0. There are also some radio X boxes. JohnR.
Chilliwack Mammography Referral eForm 2017
From David Page - Here is the final version of the mammogram form- ( Chilliwack specific ) - the difference only being in the image with some customisation for the Chilliwack Breast Clinic. I looked at the Generic BC Mammogram form- has all the same fields but really badly laid out. The main benefit is the field checking which hopefully reduces delays from rejections (something that the Xray department said was happening a lot). David From David Page: -------- Breast imaging requisition created through the Chilliwack Radiology Shared Care Project between the GPs and Radiologists and Radiology clerical staff ------ The form should be usable by everyone in Fraser Health but you may need to negotiate some of the short cuts: 1) No need for date of imaging if done in BCl- the staff pull up the latest imaging reqs anyway and dates are on them. Need to specify the grid the imaging was done on. 2) Can just specifiy “followup as per radiologist” as they have the previous mammo anyway 3) Can just specify “followup as per attached” if mammogram done out of BC and attach the req 4) No need for LMP just put “Premenopausal” ------ It has field checking to make sure form is complete and it pulls information across to the next time you open the imaging form in that patient like family history and biopsy history. ------- David
Canadian Back Institute Chilliwack referral eForm 2017
Updated referral form for the Canadian Back Institute Chilliwack.
Primary Care Seniors Clinic 2018
Update 2018-May-16 08:02 - Phone and Fax numbers have changed. For referral to the Primary Care Seniors Clinic in Chilliwack
CGH Adult Parenteral Iron PPO October 2018
This form has been updated again and all calculations have been removed.
Fusion Physiotherapy eForm
Created for Remmert Hinlopen and Fusion Physiotherapy. Referral to Physiotherapy in Chilliwack BC
CGH-Outpatient-Requisition-for-Cardiology-DX-Services-2019
2019-Jun-27 14:46 New Requisition for Cardiology Diagnostic Services for Chilliwack General Hospital
Restorative Health Pelvic Health Physiotherapy Referral eForm
Referral form for Pelvic Floor Physiotherapy, Pilates and more in Chilliwack
Graduated Care Clinic Chilliwack 2019
Referral form for the Graduated Care Clinic in Chilliwack.
Chilliwack Obstetrics Group (COGs) referral 2019
2020-Sep-17 11:21 Updated with new Fax number . 2019-Nov-29 14:25 Added LNMP as a REQUIRED field. 2019-Oct-31 08:37 - Updated - there are now 4 buttons - connection to the Antenatal Record, to the Documents, to the Lab Row display (where you choose which labs you want from the left side menu) and the Lab Grid display, where all the labs are available to be printed. There have been some personnel changes in the COGs group and the form was in need of an update
SNORESTOP Sleep Apnea and Oxygen Referral Form
Referral to SNORESTOP for Sleep Apnea and respirology screening. Created by OSCAR BC. Key words BC, Eforms, Sleep Apnea, Respirology, Oxygen, Screening.
Chilliwack Obstetrics Group Discharge Summary
Created for the Chilliwack Obstetrics group when they are returning their post partum patients back to their regular primary care providers. Has a drop down list that accepts freehand inputs. This form is mostly HTML with a basic header and image. JohnR.
Chilliwack Obstetrics Group Generic Letter 2020
Created for the Chilliwack Obstetrics group for general communications. This form is mostly HTML with a basic header and a Logo. JohnR.
Chilliwack Midwifery Group Discharge letter 2019
Created for the Chilliwack Midwifery group. Communication back to the referring primary care provider at the end of the post partum period.
Chilliwack Midwifery Group Post Partum Maternal Record 2020
Updated 2020-Jul-02 21:59 corrected mistake that did not allow retention of the "circles" around inputs when form was re-opened. Changed class="noborder" to class=circle_box" for those inputs. Made for the Chilliwack Midwifery group - to record post partum visits - Mom's record
Chilliwack Midwifery Group Post Partum Newborn Record 2020
Updated 2020-Jul-02 22:03 corrected mistake that did not allow retention of the "circles" around inputs when form was re-opened. Changed class="noborder" to class=circle_box" for those inputs. Made for the Chilliwack Midwifery group - to record post partum visits - Baby's record
Chilliwack Mental Health Perinatal Referral
Created 2020-Jul-16 15:27

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