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RCH Psych referral HTML

HTML icon PsychRCH-Xbox.html — HTML, 22 kB (23347 bytes)

File contents

<html>
<head>
<!--created by Dr. Chris Sedergreen.  
Modified 2013-09 for X-boxes, push-pull EDC and LMP.------------>

<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>
 
  <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','');
			}
			setDocumentTitle('PsychRCH',document.getElementById('PtName').value);
			setDefaults();	
					
		}
		
		function setDocumentTitle(Title,PtName)
		{
			// set document title
			document.title = Title + ' - ' + PtName;					
							
		}
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				document.getElementById("NextAvailable").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 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 to optimize window on loading----------->
<script language="JavaScript">
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
top.window.outerHeight = screen.availHeight;
<!-- top.window.outerWidth = 1120; -->
top.window.outerWidth = 1000;
}
}
</script>
<!----------End optimize window 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 = false;
}
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" language="javascript">
function checkGender(){
	 if (document.getElementById('PatientGender').value == 'M'){
	 document.getElementById('Male').checked = true;
	 }else if (document.getElementById('PatientGender').value == 'F'){
	 document.getElementById('Female').checked = true;
	}
 }
</script>

<script language="javascript">
function formPrint(){
			window.print();
} 
</script>


</head>

<body onload="checkGender(); startUp();">
<img id='BGImage' src="${oscar_image_path}PsychRCH.png" style="position: absolute; left: 0px; top: 0px; width:750px">

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

<input name="PtName" id="PtName" type="text" class="noborder" style="position:absolute; left:39px; top:187px; width:195px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;"  oscarDB=patient_name >

<textarea name="label" id="label" class="noborder" style="position:absolute; left:39px; top:203px; width:195px; height:47px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;"  oscarDB=address></textarea>


<span style="position:absolute; left:39px; top:251px; font-family:Arial; font-size:11px; font-weight:bold;">Phone:</span>
<input name="PtPhone" id="PtPhone" type="text" class="noborder" style="position:absolute; left:82px; top:253px; width:152px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;"  oscarDB=phone >


<span style="position:absolute; left:39px; top:267px; font-family:Arial; font-size:11px; font-weight:bold;">Cell:</span>
<input name="PtCell" id="PtCell" type="text" class="noborder" style="position:absolute; left:82px; top:266px; width:152px; height:16px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;"  oscarDB=cell >


<input name="AutoName3" id="AutoName3" type="text" class="noborder" style="position:absolute; left:473px; top:171px; width:104px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="doctor" id="doctor" type="text" class="noborder" style="position:absolute; left:402px; top:191px; width:172px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;"  oscarDB=doctor>


<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:633px; top:189px; width:82px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=doctor_ohip_no>


<input name="doctor_work_phone" id="doctor_work_phone" type="text" class="noborder" style="position:absolute; left:422px; top:212px; width:108px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_phone>


<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style="position:absolute; left:586px; top:212px; width:97px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=clinic_fax>


<input name="FP" id="FP" type="text" class="noborder" style="position:absolute; left:409px; top:238px; width:173px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="FPTel" id="FPTel" type="text" class="noborder" style="position:absolute; left:424px; top:262px; width:108px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="FPFax" id="FPFax" type="text" class="noborder" style="position:absolute; left:589px; top:260px; width:103px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:12px; text-align:left; background-color:transparent;" value="">


<input type=RADIO name="Service" value="1" style="position:absolute; left:225px; top:299px; ">


<input type=RADIO name="Service" value="2" style="position:absolute; left:374px; top:299px; ">


<input type=RADIO name="Service" value="3" style="position:absolute; left:500px; top:299px; ">


<input type=RADIO name="Service" value="4" style="position:absolute; left:636px; top:299px; ">


<input type=RADIO name="Urgency" value="1" style="position:absolute; left:374px; top:328px; ">


<input type=RADIO name="Urgency" value="2" style="position:absolute; left:500px; top:328px; ">


<input type=RADIO name="Urgency" value="3" style="position:absolute; left:636px; top:328px; ">


<input type=RADIO name="Reproductive" value="1" style="position:absolute; left:183px; top:352px; ">


<input type=RADIO name="Reproductive" value="2" style="position:absolute; left:374px; top:352px; ">


<input type=RADIO name="Reproductive" value="3" style="position:absolute; left:460px; top:352px; ">


<input type=RADIO name="Reproductive" value="4" style="position:absolute; left:636px; top:352px; ">


<input name="m$LMP#value" id="LMP" type="text" class="noborder" style="position:absolute; left:216px; top:355px; width:100px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:white;"  oscarDB=m$LMP#value>


<input name="m$EDC#value" id="EDC" type="text" class="noborder" style="position:absolute; left:495px; top:355px; width:93px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:white;"  oscarDB=m$EDC#value>


<textarea name="Reason " id="Reason " class="noborder" style="position:absolute; left:42px; top:387px; width:674px; height:83px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<input name="Additional_docs" id="Additional_docs" type="text" style="position:absolute; left:274px; top:474px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Additional" id="Additional" type="text" class="noborder" style="position:absolute; left:301px; top:472px; width:416px; height:19px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="MentalStatus1" id="MentalStatus1" type="text" style="position:absolute; left:281px; top:530px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MentalStatus2" id="MentalStatus2" type="text" style="position:absolute; left:416px; top:530px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MentalStatus3" id="MentalStatus3" type="text" style="position:absolute; left:558px; top:530px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MentalStatus4" id="MentalStatus4" type="text" style="position:absolute; left:675px; top:530px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Depression" id="Depression" type="text" class="noborder" style="position:absolute; left:163px; top:545px; width:158px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="Anxiety" id="Anxiety" type="text" class="noborder" style="position:absolute; left:325px; top:545px; width:128px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="Psychosis" id="Psychosis" type="text" class="noborder" style="position:absolute; left:456px; top:545px; width:132px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="MentalOther" id="MentalOther" type="text" class="noborder" style="position:absolute; left:592px; top:545px; width:124px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<textarea name="CurrentMeds" id="CurrentMeds" class="noborder" style="position:absolute; left:165px; top:490px; width:551px; height:39px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<input name="Harm1" id="Harm1" type="text" style="position:absolute; left:281px; top:565px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Harm2" id="Harm2" type="text" style="position:absolute; left:438px; top:565px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Aggression" id="Aggression" type="text" style="position:absolute; left:558px; top:565px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="RiskOther" id="RiskOther" type="text" style="position:absolute; left:675px; top:565px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="SelfHarm" id="SelfHarm" type="text" class="noborder" style="position:absolute; left:163px; top:580px; width:159px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="HarmOthers" id="HarmOthers" type="text" class="noborder" style="position:absolute; left:325px; top:580px; width:127px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="AggressionDescribe" id="AggressionDescribe" type="text" class="noborder" style="position:absolute; left:456px; top:580px; width:131px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<input name="OtherDescribe" id="OtherDescribe" type="text" class="noborder" style="position:absolute; left:592px; top:580px; width:125px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" value="">


<textarea name="AxisI" id="AxisI" class="noborder" style="position:absolute; left:164px; top:615px; width:157px; height:46px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="AxisII" id="AxisII" type="text" class="noborder" style="position:absolute; left:327px; top:615px; width:126px; height:46px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" > </textarea>


<textarea name="AxisIII" id="AxisIII" type="text" class="noborder" style="position:absolute; left:458px; top:615px; width:131px; height:46px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" >  </textarea>


<textarea name="AxisV" id="AxisV" type="text" class="noborder" style="position:absolute; left:594px; top:615px; width:122px; height:46px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" > </textarea>


<textarea name="PsychHx" id="PsychHx" class="noborder" style="position:absolute; left:243px; top:664px; width:474px; height:36px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="Substances" id="Substances" class="noborder" style="position:absolute; left:261px; top:702px; width:455px; height:36px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="PMH" id="PMH" class="noborder" style="position:absolute; left:220px; top:740px; width:496px; height:36px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:transparent;" ></textarea>


<input name="Forensic" id="Forensic" type="text" style="position:absolute; left:77px; top:787px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="WCB" id="WCB" type="text" style="position:absolute; left:228px; top:787px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="MCFD" id="MCFD" type="text" style="position:absolute; left:376px; top:787px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Private" id="Private" type="text" style="position:absolute; left:510px; top:787px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="OtherIns" id="OtherIns" type="text" style="position:absolute; left:640px; top:787px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:32px; top:816px; width:128px; height:20px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:white;"  oscarDB=today>


<input name="Signature" id="Signature" type="text" class="noborder" style="position:absolute; left:501px; top:806px; width:216px; height:27px; font-family:sans-serif; font-style:normal; font-weight:bold; font-size:11px; text-align:left; background-color:white;" value="Signed digitally in EMR">


<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="text" style="position:absolute; left:331px; top:172px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >

<input name="Female" id="Female" type="text" style="position:absolute; left:407px; top:172px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag()" onkeypress="javascript:return displayKeyCode(event,this.id);"  >



 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:980px; left:0px;">
	 <table><tr><td>
		 Subject: <input name="subject" size="40" type="text"> 
			<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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