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SwallowingAssessment.html

HTML icon SwallowingAssessment.html — HTML, 10 kB (10634 bytes)

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<html>
<head>
<title>Swallowing Assessment - 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">
.DoNotPrint {
	display: none;
}
.noborder {
	scrollbar-3dlight-color: transparent;
	scrollbar-3dlight-color: transparent;
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	scrollbar-face-color: transparent;
	scrollbar-highlight-color: transparent;
	scrollbar-shadow-color: transparent;
	scrollbar-track-color: transparent;
	background: transparent;
	overflow: hidden;
	border : 0px;
}
</style>
<!-- ----------------------------------------------------------------------------------------- -->
</head>

<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
	<img src="${oscar_image_path}SwallowingAssessment.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.
<!-- Also note: the image filename IS CASE SENSITIVE INCLUDING THE EXTENSION. It may work otherwise in Windows, but not in OSCAR because it's based on a Linux platform -->


<form method="post" action="" name="FormName">

<!-- ----------------------------All textfields/checkboxes/textareas go here...---------------- -->
<div style="position: absolute; left: 117px; top: 137px;"> 
	<input name="PatientSurnameFirstName" type="text" class="noborder" style="width: 258px; height:18px; font-family: Arial; font-size: 12px;" oscarDB=patient_name >
</div>	

<div style="position: absolute; left: 483px; top: 137px;"> 
	<input name="DateOfBirth" type="text" class="noborder" style="width: 213px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=dob >
</div>

<div style="position: absolute; left: 117px; top: 156px;"> 
	<input name="Patient_1_Line_Address" type="text" class="noborder" style="width: 580px; height:18px; font-family: Arial; font-size: 12px;" oscardb=addressLine >
</div>

<div style="position: absolute; left: 550px; top: 172px;"> 
	<input name="PatientHomePhone" type="text" class="noborder" style="width: 146px; height:18px;; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone>
</div>

<div style="position: absolute; left: 117px; top: 191px;"> 
	<input name="PatientPHN" type="text" class="noborder" style="width: 255px; height:18px;; font-family: Arial; font-size: 12px; text-align: center;" oscardb=HIN>
</div>

<div style="position: absolute; left: 550px; top: 189px;"> 
	<input name="PatientWorkPhone" class="noborder" type="text" style="width:145px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone2>
</div>

<div style="position: absolute; left:222px; top: 207px;"> 
	<input name="ContactPerson" type="text" class="noborder"  style="width: 260px; height:18px; font-family: Arial; font-size: 12px; text-align: center;">
</div>

<div style="position: absolute; left:550px; top: 206px;"> 
	<input name="ContactPersonPhone" type="text" class="noborder"  style="width:145px; height:18px; font-family: Arial; font-size: 12px; text-align: center;">
</div>



<div style="position: absolute; left: 135px; top:255px;"> 
	<textarea name="DxHx" class="noborder" style="width:560px; height:33px;"></textarea>
</div>


<div style="position: absolute; left: 137px; top: 290px;">
        <input name="m-independent" type="checkbox">
</div>

<div style="position: absolute; left: 240px; top: 290px;">
        <input name="m-requireassistance" type="checkbox">
</div>

<div style="position: absolute; left: 387px; top: 290px;">
        <input name="wheeldependent" type="checkbox">
</div>

<div style="position: absolute; left: 137px; top: 310px;">
        <input name="cd-regular" type="checkbox">
</div>

<div style="position: absolute; left: 207px; top: 310px;">
        <input name="chopped\minced" type="checkbox">
</div>

<div style="position: absolute; left: 329px; top: 310px;">
        <input name="purred" type="checkbox">
</div>

<div style="position: absolute; left: 137px; top: 329px;">
        <input name="fl-regularthin" type="checkbox">
</div>

<div style="position: absolute; left: 237px; top: 329px;">
        <input name="fl-nectarthick" type="checkbox">
</div>

<div style="position: absolute; left: 329px; top: 329px;">
        <input name="fl-honeythick" type="checkbox">
</div>

<div style="position: absolute; left: 428px; top: 329px;">
        <input name="fl-puddingthick" type="checkbox">
</div>

<div style="position: absolute; left: 137px; top: 346px;">
        <input name="nu-oral" type="checkbox">
</div>

<div style="position: absolute; left: 186px; top: 346px;">
        <input name="nu-tubefeeding" type="checkbox">
</div>

<div style="position: absolute; left: 290px; top: 346px;">
        <input name="nu-bothoral&tubefeeding" type="checkbox">
</div>


<div style="position: absolute; left: 145px; top:395px;"> 
	<textarea name="ReasonForReferral" class="noborder" style="width:555px; height:30px;"></textarea>
</div>



<div style="position: absolute; left: 23px; top: 430px;">
        <input name="rhforpuneumonis" type="checkbox">
</div>

<div style="position: absolute; left: 23px; top: 457px;">
        <input name="chronicrespiratory " type="checkbox">
</div>

<div style="position: absolute; left: 23px; top: 487px;">
        <input name="coughinggurglyvoiceduring/aftermeals" type="checkbox">
</div>

<div style="position: absolute; left: 23px; top: 519px;">
        <input name="lossofunexplainedwieght" type="checkbox">
</div>

<div style="position: absolute; left: 23px; top: 544px;">
        <input name="difficultieschewing/movinginmouth" type="checkbox">
</div>

<div style="position: absolute; left: 23px; top: 569px;">
        <input name="recentCVA/TIA" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 430px;">
        <input name="chokingepisodes" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 457px;">
        <input name="dehydration" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 487px;">
        <input name="concernsofaspiration" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 519px;">
        <input name="recurrentvomiting" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 544px;">
        <input name="complaintsfoodsticking" type="checkbox">
</div>

<div style="position: absolute; left: 359px; top: 569px;">
        <input name="changedrinkingeating" type="checkbox">
</div>

<div style="position: absolute; left: 563px; top: 591px;">
        <input name="ScopeYes" type="checkbox">
</div>
<div style="position: absolute; left: 651px; top: 591px;">
        <input name="ScopeNo" type="checkbox">
</div>

<div style="position: absolute; left: 351px; top: 645px;">
        <input name="TravelYes" type="checkbox">
</div>
<div style="position: absolute; left: 411px; top: 645px;">
        <input name="TravelNo" type="checkbox">
</div>



<div style="position: absolute; left: 120px; top:698px;"> 
	<input name="CurrentProviderDoctor" type="text" class="noborder"  style="width: 260px; height:18px; font-family: Arial; font-size: 12px; text-align: center;"  oscardb=provider_name>
</div>
<div style="position: absolute; left: 490px; top:698px;"> 
	<input name="ReferralRelationship" type="text" class="noborder"  style="width: 210px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" value="Family Doctor">
</div>
<div style="position: absolute; left: 557px; top: 715px;"> 
	<input name="ClinicPhone" class="noborder" type="text" style="width: 145px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=clinic_phone>
</div>
<div style="position: absolute; left: 120px; top: 715px;"> 
	<input name="ClinicAddress" class="noborder" type="text" style="width: 370px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscarDB=clinic_addressLineFull>
</div>
<div style="position: absolute; left: 227px; top: 733px;"> 
	<input name="ReferralDate" class="noborder" type="text" style="width: 260px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscarDB=today>
</div>

<div style="position: absolute; left: 122px; top:780px;"> 
	<input name="Doctor" type="text" class="noborder"  style="width: 368px; height:18px; font-family: Arial; font-size: 12px; text-align: center;"  oscardb=provider_name>
</div>
<div style="position: absolute; left: 557px; top: 780px;"> 
	<input name="ClinicPhone" class="noborder" type="text" style="width: 145px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=clinic_phone>
</div>
<div style="position: absolute; left: 120px; top: 799px;"> 
	<input name="ClinicAddress" class="noborder" type="text" style="width: 370px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscarDB=clinic_addressLineFull>
</div>
<div style="position: absolute; left: 557px; top: 796px;"> 
	<input name="ClinicFax" type="text" class="noborder" style="width: 145px; height:18px; font-family: Arial; font-size: 12px; text-align: center;" oscardb=clinic_fax >
</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">
			<input value="Submit" name="B1" type="submit">
			<input value="Reset" name="B2" type="reset">
			<input value="Print" onclick="window.print()" type="button">
		</td>
	</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</body></html>

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