SpeechLanguageAdults.html
SpeechLanguageAdults.html
—
HTML,
8 kB (8804 bytes)
File contents
<html>
<head>
<title>Speech Language Services for Adults - CGH</title>
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<script language="JavaScript">
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<!-- CSS Script that removes textarea and textbox borders when printing -------------->
<style type="text/css" media="print">
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scrollbar-shadow-color: transparent;
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background: transparent;
overflow: hidden;
border : 0px;
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</style>
<!-- ----------------------------------------------------------------------------------------- -->
</head>
<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
<img src="${oscar_image_path}SpeechLanguageAdults.png" width="700">
</div>
<!-- You can remove ${oscar_image_path} as you develop the form, but make sure you put it back before uploading to OSCAR otherwise the image wouldn't show.
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<form method="post" action="" name="FormName">
<!-- ----------------------------All textfields/checkboxes/textareas go here...---------------- -->
<div style="position: absolute; left: 127px; top: 167px;">
<input name="PatientSurnameFirstName" type="text" class="noborder" style="width: 240px; height:18px; font-family: Arial; font-size: 12px;" oscarDB=patient_name >
</div>
<div style="position: absolute; left: 470px; top: 167px;">
<input name="DateOfBirth" type="text" class="noborder" style="width: 205px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=dob >
</div>
<div style="position: absolute; left: 127px; top: 186px;">
<input name="Patient_1_Line_Address" type="text" class="noborder" style="width: 550px; height:18px; font-family: Arial; font-size: 12px;" oscardb=addressLine >
</div>
<div style="position: absolute; left: 539px; top: 201px;">
<input name="PatientHomePhone" type="text" class="noborder" style="width: 137px; height:18px;; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone>
</div>
<div style="position: absolute; left: 125px; top: 219px;">
<input name="PatientPHN" type="text" class="noborder" style="width: 240px; height:18px;; font-family: Arial; font-size: 12px; text-align: center;" oscardb=HIN>
</div>
<div style="position: absolute; left: 539px; top: 216px;">
<input name="PatientWorkPhone" class="noborder" type="text" style="width:137px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone2>
</div>
<div style="position: absolute; left:223px; top: 237px;">
<input name="ContactPerson" type="text" class="noborder" style="width: 245px; height:18px; font-family: Arial; font-size: 12px; text-align: center;">
</div>
<div style="position: absolute; left:540px; top: 237px;">
<input name="ContactPersonPhone" type="text" class="noborder" style="width:137px; height:18px; font-family: Arial; font-size: 12px; text-align: center;">
</div>
<div style="position: absolute; left:223px; top: 253px;">
<input name="Doctor" type="text" class="noborder" style="width: 245px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=doctor>
</div>
<div style="position: absolute; left:540px; top: 253px;">
<input name="ClinicPhone" type="text" class="noborder" style="width:137px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=clinic_phone>
</div>
<div style="position: absolute; left: 225px; top:304px;">
<textarea name="DxHx" class="noborder" style="width:455px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 225px; top:338px;">
<textarea name="CommunicationProb" class="noborder" style="width:455px; height:50px;"></textarea>
</div>
<div style="position: absolute; left: 225px; top:389px;">
<textarea name="Onset" class="noborder" style="width:110px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 580px; top:389px;">
<textarea name="SpeechTherapyBefore" class="noborder" style="width:100px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 225px; top:455px;">
<textarea name="LiveWith" class="noborder" style="width:134px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 547px; top:455px;">
<textarea name="Occupation" class="noborder" style="width:134px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 225px; top:489px;">
<textarea name="FirstLanguage" class="noborder" style="width:134px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 547px; top:489px;">
<textarea name="AssistanceNeeded" class="noborder" style="width:134px; height:33px;"></textarea>
</div>
<div style="position: absolute; left: 35px; top: 555px;">
<input name="Slurred" type="checkbox">
</div>
<div style="position: absolute; left: 35px; top: 582px;">
<input name="ExpressiveDiff" type="checkbox">
</div>
<div style="position: absolute; left: 35px; top: 612px;">
<input name="WordFindingDiff" type="checkbox">
</div>
<div style="position: absolute; left: 35px; top: 640px;">
<input name="UnderstandDiff" type="checkbox">
</div>
<div style="position: absolute; left: 35px; top: 673px;">
<input name="FollowingDiff" type="checkbox">
</div>
<div style="position: absolute; left: 360px; top: 555px;">
<input name="DiffWriting" type="checkbox">
</div>
<div style="position: absolute; left: 360px; top: 582px;">
<input name="AltComm" type="checkbox">
</div>
<div style="position: absolute; left: 360px; top: 612px;">
<input name="ExecutiveDiff" type="checkbox">
</div>
<div style="position: absolute; left: 360px; top: 640px;">
<input name="NonVerbal" type="checkbox">
</div>
<div style="position: absolute; left: 360px; top: 673px;">
<input name="VoiceProb" type="checkbox">
</div>
<div style="position: absolute; left: 534px; top: 695px;">
<input name="AwareStrokeClubsYes" type="checkbox">
</div>
<div style="position: absolute; left: 590px; top: 695px;">
<input name="AwareStrokeClubsNo" type="checkbox">
</div>
<div style="position: absolute; left:130px; top: 748px;">
<input name="ProviderName" type="text" class="noborder" style="width: 250px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=Provider_Name>
</div>
<div style="position: absolute; left:480px; top: 748px;">
<input name="Relationship" type="text" class="noborder" style="width: 200px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" value="Family Doctor">
</div>
<div style="position: absolute; left:130px; top: 765px;">
<input name="ClinicAddress" type="text" class="noborder" style="width: 250px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscarDB=clinic_addressLineFull>
</div>
<div style="position: absolute; left:545px; top: 765px;">
<input name="ClinicPhone" type="text" class="noborder" style="width: 138px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscarDB=clinic_phone>
</div>
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<div class="DoNotPrint" style="position: absolute; top: 1000px; left: 41px;">
<table>
<tr>
<td>
Subject: <input name="subject" size="40" type="text">
<input value="Submit" name="B1" type="submit">
<input value="Reset" name="B2" type="reset">
<input value="Print" onclick="window.print()" type="button">
<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print(); document.FormName.submit()">
</td>
</tr>
</table>
</div>
</form>
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</body></html>
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