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SpeechLanguageAdults.html

HTML icon SpeechLanguageAdults.html — HTML, 8 kB (8804 bytes)

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<html>
<head>
<title>Speech Language Services for Adults - CGH</title>
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<!-- CSS Script that removes textarea and textbox borders when printing -------------->
<style type="text/css" media="print">
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	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>



<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" style="position: absolute; top: 1000px; left: 41px;">
<table>
	<tr>
		<td>
			Subject: <input name="subject" size="40" type="text">
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</table>
</div>
</form>
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</body></html>

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