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New Westminster Healthy Heart Referral eForm html

HTML icon HealthyHeartNWver2.HTML — HTML, 12 kB (12686 bytes)

File contents

<html>
<head>
<META http-equiv="Content-Type" content="text/html; charset=UTF-8">
<title></title>
<style>
 input {
	 -moz-box-sizing: content-box;
	 -webkit-print-color-adjust: exact;
	 -webkit-box-sizing: content-box;
	 box-sizing: content-box
}
 .sig {
	 border: 2px dotted blue;
	 background-color: lightgrey;
 }
 </style>

<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;
 }
.sig {
	 border-style: solid;
	 border-color: transparent;
	 background-color: transparent;
 }
 </style>

<!-- jQuery file for testing outside of OSCAR -->
<script type="text/javascript" src="jquery-1.7.1.min.js"></script>
<script type="text/javascript" src="jSignature.min.js"></script>

<!-- OSCAR based files for greater functionality -->
<script type="text/javascript" src="${oscar_javascript_path}jquery/jquery-1.4.2.js"></script>
<script language="javascript">
function formPrint(){
	window.print();
} 
</script>

<!-- scripts to confirm closing of window if it hadnt 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 to prevent 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>

<!-- scripts for Xbox functions -->
<script language="javascript">
$(document).ready(function() {
	  $( ".Xbox" ).click(function() {
		  var st = $( this ).val();
		  if (st=="X") {
			  $( this ).val("");
		  } else {
			  $( this ).val("X");
		  }
	});

$( ".Xbox" ).keypress(function(event) {
	  // any key press except tab will constitute a value change to the checkbox
	  if (event.which != 0){
		  $( this ).click();
		  return false;
		  }
	});

});
</script>

<script type="text/javascript">
function reImg(){
// for stand alone development without uploading to OSCAR
	var strLoc = window.location.href.toLowerCase();
	if(strLoc.indexOf("https") == -1) {
		var src1 = document.getElementById("BGImage1").src;
		document.getElementById("BGImage1").src = src1.replace("$%7Boscar_image_path%7D","");
	}
}
</script>
</head>

<body onload="reImg();">
<form method="post" action="" name="FormName" id="FormName" >
<div>
</div>


<div id="page1" style="page-break-after:always;position:relative;" >

<img id="BGImage1" src="${oscar_image_path}HealthyHeartNWRef2.png" style="position: relative; left: 0px; top: 0px; width:750px">

<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:137px; top:130px; width:109px; height:21px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=today>

<textarea name="label" id="label" class="noborder" style="position:absolute; left:44px; top:175px; width:286px; height:102px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=label></textarea>

<textarea name="clinic_label" id="clinic_label" class="noborder" style="position:absolute; left:435px; top:175px; width:263px; height:112px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=clinic_label></textarea>

<input name="InterpreterY" id="InterpreterY" type="text" class="Xbox" style="position:absolute; left:198px; top:286px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:center; border:1px solid  #000000; background-color:transparent;" value="">

<input name="InterpreterN" id="InterpreterN" type="text" class="Xbox" style="position:absolute; left:250px; top:286px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:center; border:1px solid  #000000; background-color:transparent;" value="X">

<input name="Language" id="Language" type="text" class="noborder" style="position:absolute; left:113px; top:309px; width:131px; height:25px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" value="">

<input name="FPName" id="FPName" type="text" class="noborder" style="position:absolute; left:434px; top:310px; width:263px; height:32px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" value="">

<input name="CardiacDx" id="CardiacDx" type="text" class="noborder" style="position:absolute; left:209px; top:353px; width:489px; height:34px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" value="">

<input name="m$Pulse#value" id="m$Pulse#value" type="text" class="noborder" style="position:absolute; left:114px; top:403px; width:34px; height:15px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$Pulse#value>

<input name="Reg" id="Reg" type="text" class="Xbox" style="position:absolute; left:200px; top:404px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:center; border:1px solid  #000000; background-color:transparent;" value="">

<input name="Irreg" id="Irreg" type="text" class="Xbox" style="position:absolute; left:271px; top:403px; width:12px; height:12px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:center; border:1px solid  #000000; background-color:transparent;" value="">

<input name="m$BP#value" id="m$BP#value" type="text" class="noborder" style="position:absolute; left:420px; top:401px; width:72px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$BP#value>

<input name="m$HT#value" id="m$HT#value" type="text" class="noborder" style="position:absolute; left:124px; top:433px; width:37px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$HT#value>

<input name="m$WT#value" id="m$WT#value" type="text" class="noborder" style="position:absolute; left:253px; top:434px; width:30px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$WT#value>

<input name="m$WAIS#value" id="m$WAIS#value" type="text" class="noborder" style="position:absolute; left:363px; top:434px; width:47px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$WAIS#value>

<input name="m$BMI#value" id="m$BMI#value" type="text" class="noborder" style="position:absolute; left:506px; top:433px; width:22px; height:17px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$BMI#value>

<textarea name="druglist_generic" id="druglist_generic" class="noborder" style="position:absolute; left:44px; top:492px; width:653px; height:55px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=druglist_generic></textarea>

<input name="m$TCHL#value" id="m$TCHL#value" type="text" class="noborder" style="position:absolute; left:274px; top:595px; width:53px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$TCHL#value>

<input name="m$LDL#value" id="m$LDL#value" type="text" class="noborder" style="position:absolute; left:358px; top:594px; width:42px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$LDL#value>

<input name="m$HDL#value" id="m$HDL#value" type="text" class="noborder" style="position:absolute; left:430px; top:594px; width:43px; height:17px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$HDL#value>

<input name="m$TCHD#value" id="m$TCHD#value" type="text" class="noborder" style="position:absolute; left:507px; top:595px; width:33px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$TCHD#value>

<input name="m$TG#value" id="m$TG#value" type="text" class="noborder" style="position:absolute; left:627px; top:595px; width:48px; height:17px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$TG#value>

<input name="m$FBS#value" id="m$FBS#value" type="text" class="noborder" style="position:absolute; left:71px; top:627px; width:37px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$FBS#value>

<input name="m$A1C#value" id="m$A1C#value" type="text" class="noborder" style="position:absolute; left:157px; top:626px; width:34px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$A1C#value>

<input name="m$SCR#value" id="m$SCR#value" type="text" class="noborder" style="position:absolute; left:255px; top:626px; width:44px; height:18px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$SCR#value>

<input name="m$EGFR#value" id="m$EGFR#value" type="text" class="noborder" style="position:absolute; left:346px; top:627px; width:43px; height:17px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;"  oscarDB=m$EGFR#value>

<textarea name="OtherTests" id="OtherTests" class="noborder" style="position:absolute; left:247px; top:658px; width:451px; height:32px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="OtherProblems" id="OtherProblems" class="noborder" style="position:absolute; left:191px; top:703px; width:507px; height:45px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" ></textarea>

<textarea name="Signature" id="Signature" class="noborder" style="position:absolute; left:38px; top:832px; width:307px; height:44px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" >Signed digitally in OSCAR electronic medical record</textarea>

<input name="DateMeasured" id="DateMeasured" type="text" class="noborder" style="position:absolute; left:579px; top:399px; width:97px; height:21px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:10px; text-align:left; background-color:transparent;" value="">

</div>


 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:1000px; left:0px;">
	 <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> <br> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="submit" onclick=" releaseDirtyFlag();"> 
			<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
			<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="formPrint();"> 
			<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 
	 </td></tr></table>
 </div>
 </form>

</body>
</html>

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