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Fraser Health Ophthalmology Referral HTML

HTML icon OphthalmologyFraserHealthSurgicalBookingVer3.html — HTML, 21 kB (21917 bytes)

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<html>
<head>

<!--- Created January 2013, Written for version 12.0, Has x boxes,  fills in subject line, uses js script to click through a list of choices for input box, uses onclick to fill second box with same information as first box, click address box and it will be filled depending on surgeon name box, need to edit surgeon names and addresses for local surgeons, imports History, uses JSMPC.css --->


	<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

	
<title></title>
<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>
 
 <!-- js graphics scripts -->
<script type="text/javascript" src="jsgraphics.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','');

				}
			// the input ID must match the ID for last name in the e-form.
			setDocumentTitle('OphthalmologySurgicalBooking-History',document.getElementById('first_last_name').value);
			setDefaults();			
		}

		function setDocumentTitle(Title,first_last_name)
		{
			// set document title
			document.title = Title + ' - ' + first_last_name;					
		}
		
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			// can add further default, prechecked boxes by copying the last line and inserting the proper ID names
			if (document.getElementById("newForm").value == 'True')
			{
				document.getElementById('MSP').value = 'X';	
			}   
		}


		/****************************
			submit and print functions 
		****************************/
		function printSubmit()
		{
			printLetter();
			releaseDirtyFlag();			
			submission();
		}

		function printLetter()
		{
			// hide the bottom buttons
			if (document.getElementById('BottomButtons').style.display == '')
				document.getElementById('BottomButtons').style.display = 'none';
			// print the letter
			window.print();
		} 

		function submission()
		{
			setFlag();
			setTimeout('document.FormName.submit()',1000);			
		}

		function setFlag()
		{
		// indicate that the form has been submitted
		if (document.getElementById("newForm").value == 'True')
			document.getElementById("newForm").value = 'False';
		}
		
		function showButtons()
		{
			//show the bottom buttons if they are hidden
			if (document.getElementById('BottomButtons').style.display == 'none')
				document.getElementById('BottomButtons').style.display = '';
		}

		/****************************
			checkbox functions 
		****************************/
		function changeValue(x)
		{
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'X';
			else
				document.getElementById(x).value = '';
		}
		
		function changeName(x)
		{
			if (document.getElementById(x).value == '')
				document.getElementById(x).value = 'Dr. K. M. Parkinson';
			else if (document.getElementById(x).value == 'Dr. K. M. Parkinson')
				document.getElementById(x).value = 'Dr. K. S. Scott';
			else
				document.getElementById(x).value = '';
		}
		
		function changeAddress()
		{
			if (document.getElementById("SurgeonName").value == 'Dr. K. M. Parkinson')
				document.getElementById("SurgeonAddress").value = '205-1015 Austin Avenue\nCoquitlam, BC, V3K 3N9\nTel:604-937-3211 Fax:604-937-3231';
			else if (document.getElementById("SurgeonName").value == 'Dr. K. S. Scott')
				document.getElementById("SurgeonAddress").value = '205-1015 Austin Ave\nCoquitlam, BC, V3K 3N9\nTel:604-937-3211 Fax:604-937-3231';
			else
				document.getElementById("SurgeonAddress").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>


<script language="javascript">
function show(x){
	document.getElementById(x).style.display = 'block';
}
function hide(x){
	document.getElementById(x).style.display = 'none';
}
</script>

<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">
function preloadImg(){
	// create object
	imageObj = new Image();
	// set image list
	images = new Array();
	// start preloading
	for(i=0; i<=images.length; i++){
		imageObj.src=images[i];
	}
}

function reloadSignature(){
	preloadImg();
	var SubmittedBy = document.getElementById('SubmittedBy').value;
	if (!SubmittedBy){
		SignForm('current_user');
	} else {
		SignForm(SubmittedBy);
	}
	resizeSignature();
}

function SignForm(SignBy){
	var SignatureHolder = document.getElementById('SignatureHolder');
	var DoctorName = document.getElementById('DoctorName').value;
	var CurrentUserName = document.getElementById('CurrentUserName').value;
		if(SignBy == 'doctor'){
			}else {
				SignatureHolder.innerHTML = "<div id='SignatureImage'></div>"
			}
			document.getElementById('SubmittedBy').value = SignBy;
		}else if (SignBy == 'current_user'){
			}else {
				SignatureHolder.innerHTML = "<div id='SignatureImage'></div>"
			}
			document.getElementById('SubmittedBy').value = SignBy;
		}else if (SignBy == 'none'){
			SignatureHolder.innerHTML = "<div id='SignatureImage'></div>";
		}
		resizeSignature();
}
function resizeSignature(){
	//resize signature image to fit inside SignatureHolder
	if (document.getElementById('SignatureImage')){
		var Holder = document.getElementById('SignatureHolder')
		var Image = document.getElementById('SignatureImage')
		var HolderW = parseInt(document.getElementById('SignatureHolder').style.width);
		var HolderH = parseInt(document.getElementById('SignatureHolder').style.height);
		var ImageW = document.getElementById('SignatureImage').width;
		var ImageH = document.getElementById('SignatureImage').height;
		if (ImageW > HolderW){
			Image.style.width = HolderW;
			var NewH = (HolderW * (ImageH/ImageW));
			Image.style.height = parseInt(NewH);
			if (NewH > HolderH){
				Image.style.height = HolderH;
				var NewW = (HolderH * (ImageW/ImageH));
				Image.style.width = parseInt(NewW);
			}
		}else if (ImageW < HolderW){
			if (ImageH > HolderH){
				Image.style.height = HolderH;
				var NewW = (HolderH * (ImageW/ImageH));
				Image.style.width = parseInt(NewW);
			}
		}
		reorderSignature();
	}
}
</script>

<script type="text/javascript">
function reorderSignature(){
	document.getElementById('BGImage').style.zIndex = '-10';
	document.getElementById('SignatureHolder').style.zIndex = '-9';
	document.getElementById('SignatureImage').style.zIndex = '-8';
}
</script>



</head>

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

<!-- ---------------------------Hidden inputs   ------ -->
<input class="nodisplay" type="hidden" name="counter" id = "counter" >
<input type="hidden" name="date" id="date"  oscardb=today >
<input type="hidden" name="age" id="age"  oscardb=age >

<!-- ---------------------- -->


<div  style="position:absolute;  left:80px; top:18px; font-family:sans-serif; font-size:10px; font-weight:bold;" >
	<span><b>
		Please Return to:<br>
		<input name="SurgeonName" id = "SurgeonName"  type="text" style="width:200px; height:16px; font-size10px; font-weight:bold; text-align:left; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeName(this.id); setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  onclick="SurgeonName1.value=SurgeonName.value; subject.value=SurgeonName.value;" ><br>
		<textarea name="SurgeonAddress" id="SurgeonAddress" class="noborder" style=" width:200px; height:45px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:10px; text-align:left; background-color:white;" onclick="changeAddress(); " ></textarea>
		
	</b></span>
</div>

<input name="Label" id="Label" type="text" style="position:absolute; left:390px; top:0px; width:360px; height:170px;border: 1px solid #000000;font-weight:bold;">

<span style="position:absolute; left:85px; top:145px; font-family:sans-serif; font-size:14px;">
<b>Ridge Meadows Hospital</b></span>

<span style="position:absolute; left:162px; top:195px; font-family:sans-serif; font-size:16px;">
<b>FAMILY PHYSICIAN HISTORY&PHYSICAL(SURGICAL BOOKING)</b></span>

<span style="position:absolute; left:80px; top:220px; font-family:sans-serif; font-size:12px;"><b>Family Physician:</b>
<input name="doctor" id="doctor" type="text" class="noborder" style=" width:191px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor><b>Surgeon:
		<input name="SurgeonName1" id = "SurgeonName1"  type="text" style=" height:22px; font-size10px; font-weight:bold; text-align:left; background-color:white;"><br></span>

<table  style=" border:2px solid black; border-collapse:collapse;  position: absolute; left:65px; top:245px; width:625; font-family:Arial; font-size:12px;">
<tr style=" border:2px solid black;">
<td colspan=2 ><b>Patient name:</b></td><td colspan=8><input type="text" name="first_last_name" id="first_last_name" style="width:310px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline;"oscarDB=first_last_name></td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=2 style=" width:16%"><b>Date of Birth:</b></td><td style=" width:17%"><input type="text" name="dob" id="dob" style="width:80px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline;"oscarDB=dob></td>
<td style=" width:16%"><b>Telephone(H):</b></td><td style=" width:17%"><input type="text" name="phone" id="phone" style=" font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline;"oscarDB=phone></td>
<td style=" width:17%"><b>(W):</b></td><td style=" width:17%"><input type="text" name="phone2" id="phone2" style=" font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline;"oscarDB=phone2></td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=2 ><b>Address:</b></td><td colspan=8 style=" width:80%"><input type="text" name="first_last_name" id="first_last_name" style="width:500px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline;"oscarDB=addressline></td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=2 ><b>Diagnosis:</b></td><td colspan=8 style=" width:80%"><b>Cataracts</td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=2 ><b>Surgery:</b></td><td colspan=8 style=" width:80%"><b>Cataract extraction and lens implant</b></td>
</tr>
<tr >
<td colspan=10 ><b>Past Medical/Surgical/Anaesthetic History:</b></td>
</tr>
<tr >
<td colspan=10 ><textarea name="MedicalHistory" id="MedicalHistory" class="noborder" style="height: 70px; width:600px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" wrap="virtual" oscarDB=Medical_History ></textarea>		
</td>
</tr>
<tr style=" border:2px solid black;"></tr>
<tr>
<td colspan=3 style=" vertical-align:text-top;"><b>Allergies: Meds:</b></td><td colspan=2 ><textarea name="allergies_des_no_archived" id="allergies_des_no_archived" class="noborder" style=" width:250px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=allergies_des_no_archived></textarea></td><td colspan=5 style=" vertical-align:text-top;"><b>Smoker? </b><input name="Smoker" id="Smoker" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"><b> Alcohol? </b><input name="Alcohol" id="Alcohol" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
</tr>
<tr >
<td colspan=2><b>Latex? </b><input name="Latex" id="Latex" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
<td colspan=8><b>Other </b><input name="Other1" id="Other1" type="text" class="noborder" style=" width:470px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value=""></td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=3 style=" vertical-align:text-top;"><b>Current Medications:</b></td><td colspan=7 ><textarea name="druglist_generic" id="druglist_generic" class="noborder" style=" width:440px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=druglist_generic></textarea></td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=3><b>Regional Anaesthetic: </b><input name="Regional" id="Regional" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
<td colspan=2><b>General Anaesthetic: </b><input name="General" id="General" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
<td colspan=2><b>No Preference: </b><input name="NoPreference" id="NoPreference" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
</tr>
<tr >
<td colspan=10 ><b>Family & Social History:</b></td>
</tr>
<tr >
<td colspan=4 ><textarea name="other_medications_history" id="other_medications_history" class="noborder" style="height: 70px; width:300px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=other_medications_history></textarea></td>
<td colspan=5 ><textarea name="social_family_history1" id="social_family_history1" class="noborder" style="height: 70px; width:300px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=social_family_history></textarea></td>
</td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=10 ><b>Physical Examination:  Ht: </b><input name="m$HT#value" id="m$HT#value" type="text" class="noborder" style="width:77px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=m$HT#value> <b> Wt: </b><input name="m$WT#value" id="m$WT#value" type="text" class="noborder" style=" width:75px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=m$WT#value><b> P: </b> <input name="m$P#value" id="m$P#value" type="text" class="noborder" style="width:83px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=m$p#value> <b> BP: </b> <input name="m$BP#value" id="m$BP#value" type="text" class="noborder" style=" width:101px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=m$BP#value>
 </td>
</tr>
<tr style=" border:2px solid black;">
<td colspan=10 ><textarea name="PhysicalExam" id="PhysicalExam" class="noborder" style=" width:618px; height:127px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>
</td></tr>
<tr >
<td colspan=10 ><b>Relevant Lab/Radiology Data Please attach </b><input name="Lab" id="Lab" type="text" class="noborder" style=" width:16px; height:16px;border: 1px solid #000000;font-weight:bold;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"></td>
</tr>
<tr >
<td colspan=5 ><b>Physician's Signature: </b></td><td><b>Date:</b></td><td colspan=5><input name="today" id="today" type="text" class="noborder" style=" width:160px; height:29px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=today>
</tr>

</table>

<span style="position: absolute; left:65px; top:900px; font-family:Arial; font-size:12px;">PS:1167 (Revised: 29Oct98)</span>
		





<input name="AutoName13" id="AutoName13" type="text" class="noborder" style="position:absolute; left:742px; top:257px; width:0px; height:0px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input type="hidden" name="DoctorName" id="DoctorName" oscarDB=doctor>
<input type="hidden" name="CurrentUserName" id="CurrentUserName" oscarDB=current_user>
<input type="hidden" name="SubmittedBy" id="SubmittedBy">
<div name="SignatureHolder" id="SignatureHolder" style="position:absolute; left:215px; top:883px; width:229px; height:31" onmouseover="show('SignaturePicker');" onmouseout="hide('SignaturePicker');">
</div>
<div class="DoNotPrint" name="SignaturePicker" id="SignaturePicker" style="position:absolute; background-color:#dddddd; left:215px; top:883px; height:31; display:none;" onmouseover="show(this.id)" onmouseout="hide(this.id)">
	<span style="font-family:sans-serif; font-size:12px; font-weight:bold">
		Signature:<br>
		<input type="radio" name="SignBy" id="SignDoctor" value="doctor" onclick="SignForm(this.value);" onmouseout="resizeSignature();">Patient's Doctor
		<input type="radio" name="SignBy" id="SignCurrentUser" value="current_user" onclick="SignForm(this.value);" onmouseout="resizeSignature();">Current User
		<input type="radio" name="SignBy" id="SignNone" value="none" onclick="SignForm(this.value);">None
	</span>
</div>



 <!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons" >
 <div id="faxControl">&nbsp;</div>	

		<table style="position: absolute; left:20px; top:950px;text-align: left; width: 90%;   font-size:12px; font-family:Arial;" border="0" cellpadding="0" cellspacing="0">
		<tr><td>
		<input type="hidden" id="newForm" name="newForm" value="True" />				
		Subject: <input name="subject" size="40" type="text" > 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick="releaseDirtyFlag();document.FormName.submit();SubmitImage(); document.forms[0].submit();">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
		<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printLetter(); releaseDirtyFlag(); setTimeout('SubmitButton.click()',1000);"> 
		</td></tr>
		</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
 </form>

</body>
</html>

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