Personal tools
Navigation
 

Swallowing Intervention Service (SIS) HTML

HTML icon SISReferral.html — HTML, 14 kB (15326 bytes)

File contents

<html>
<head>
<title>Swallowing Intervention Service</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="${oscar_image_path}jsgraphics.js"></script>
<script language="javascript" type="text/javascript" src="${oscar_image_path}JSMPC.js"></script>

<script language="javascript"><script language="javascript" type="text/javascript">
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('Swallowing Intervention Service',document.getElementById('patient_nameL').value);
			setDefaults();			
		}

</script>


<script language="javascript">
function formPrint(){
	 if (document.getElementById('DrawCheckmark').checked){ 
			printCheckboxes();
	 }else{
			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>

<style type="Text/css">
input.largerCheckbox {
	-moz-transform:scale(1.3);         /*scale up image 1.3x - Firefox specific */ 
	-webkit-transform:scale(1.3);      /*Webkit based browser eg Chrome, Safari */ 
	-o-transform:scale(1.3);           /*Opera browser */ 
}
</style>
<style type="text/css" media="print">
input.largerCheckbox { 
	-moz-transform:scale(1.8);         /*scale up image 1.8x - Firefox specific */ 
	-webkit-transform:scale(1.3);      /*Webkit based browser eg Chrome, Safari */ 
	-o-transform:scale(1.3);           /*Opera browser */ 
} 
</style>
<!--[if IE]>
<style type="text/css">
input.largerCheckbox { 
	height: 30px;                     /*30px checkboxes for IE 5 to IE 7 */ 
	width: 30px; 
} 
</style> 
<![endif]--> 

</head>

<body onload="startUp();" >
<img id='BGImage' src="${oscar_image_path}SIS-Referral-Form-1-A.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<div id="chkCanvas" style="position:absolute; left:0px; top:0px; width:750; height:750;" onmouseover="putInBack();"></div>

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

<input name="patient_name" id="patient_name" type="text" class="noborder" style="position:absolute; left:101px; top:134px; width:287px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_name>


<input name="today" id="today" type="text" class="noborder" style="position:absolute; left:499px; top:134px; width:219px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=today>


<input name="hin" id="hin" type="text" class="noborder" style="position:absolute; left:60px; top:155px; width:190px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=hin>


<input name="dob1" id="dob1" type="text" class="noborder" style="position:absolute; left:322px; top:155px; width:174px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=dob>


<input name="phone" id="phone" type="text" class="noborder" style="position:absolute; left:560px; top:155px; width:155px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=phone>


<input name="address_street_number_and_name" id="address_street_number_and_name" type="text" class="noborder" style="position:absolute; left:74px; top:176px; width:271px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=address_street_number_and_name>


<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:384px; top:176px; width:142px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=city>


<input name="postal" id="postal" type="text" class="noborder" style="position:absolute; left:609px; top:176px; width:107px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=postal>


<input name="ContactPerson" id="ContactPerson" type="text" class="noborder" style="position:absolute; left:112px; top:195px; width:197px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Relationship" id="Relationship" type="text" class="noborder" style="position:absolute; left:395px; top:195px; width:158px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="Phone" id="Phone" type="text" class="noborder" style="position:absolute; left:612px; top:195px; width:105px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<input name="current_user" id="current_user" type="text" class="noborder" style="position:absolute; left:79px; top:216px; width:348px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=current_user>


<input name="referral_phone" id="referral_phone" type="text" class="noborder" style="position:absolute; left:495px; top:216px; width:205px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=referral_phone>


<input name="AutoName0" id="AutoName0" type="text" class="noborder" style="position:absolute; left:195px; top:235px; width:321px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="Family Physician">


<input name="PhoneNumber" id="PhoneNumber" type="text" class="noborder" style="position:absolute; left:591px; top:235px; width:125px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" value="">


<textarea name="DX" id="DX" class="noborder" style="position:absolute; left:16px; top:275px; width:706px; height:39px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="Difficulties" id="Difficulties" class="noborder" style="position:absolute; left:16px; top:330px; width:706px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="SpeechPath" id="SpeechPath" class="noborder" style="position:absolute; left:17px; top:380px; width:705px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="SwallowingConcerns" id="SwallowingConcerns" class="noborder" style="position:absolute; left:18px; top:431px; width:706px; height:37px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<textarea name="Goal" id="Goal" class="noborder" style="position:absolute; left:21px; top:483px; width:699px; height:38px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" ></textarea>


<input name="Independent" id="Independent" type="checkbox" class="largerCheckbox" style="position:absolute; left:65px; top:535px; ">


<input name="Assistance" id="Assistance" type="checkbox" class="largerCheckbox" style="position:absolute; left:157px; top:535px; ">


<input name="Wheelchair" id="Wheelchair" type="checkbox" class="largerCheckbox" style="position:absolute; left:331px; top:535px; ">


<input name="Regular" id="Regular" type="checkbox" class="largerCheckbox" style="position:absolute; left:61px; top:563px; ">


<input name="Chopped" id="Chopped" type="checkbox" class="largerCheckbox" style="position:absolute; left:158px; top:563px; ">


<input name="Pureed" id="Pureed" type="checkbox" class="largerCheckbox" style="position:absolute; left:333px; top:563px; ">


<input name="Liquid" id="Liquid" type="checkbox" class="largerCheckbox" style="position:absolute; left:476px; top:563px; ">


<input name="Nothing" id="Nothing" type="checkbox" class="largerCheckbox" style="position:absolute; left:564px; top:563px; ">


<input name="Thin" id="Thin" type="checkbox" class="largerCheckbox" style="position:absolute; left:60px; top:591px; ">


<input name="NectarThick" id="NectarThick" type="checkbox" class="largerCheckbox" style="position:absolute; left:201px; top:591px; ">


<input name="HoneyThick" id="HoneyThick" type="checkbox" class="largerCheckbox" style="position:absolute; left:333px; top:591px; ">


<input name="PuddingThick" id="PuddingThick" type="checkbox" class="largerCheckbox" style="position:absolute; left:476px; top:591px; ">


<input name="Oral" id="Oral" type="checkbox" class="largerCheckbox" style="position:absolute; left:158px; top:606px; ">


<input name="Enteral" id="Enteral" type="checkbox" class="largerCheckbox" style="position:absolute; left:283px; top:606px; ">


<input name="Both" id="Both" type="checkbox" class="largerCheckbox" style="position:absolute; left:477px; top:606px; ">


<input name="RecentHosp" id="RecentHosp" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:648px; ">


<input name="ChronicResp" id="ChronicResp" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:672px; ">


<input name="Coughing" id="Coughing" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:703px; ">


<input name="SuddenWeight" id="SuddenWeight" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:724px; ">


<input name="DifficultiesChewing" id="DifficultiesChewing" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:745px; ">


<input name="RecentCVA" id="RecentCVA" type="checkbox" class="largerCheckbox" style="position:absolute; left:16px; top:766px; ">


<input name="ChokingEpisodes" id="ChokingEpisodes" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:648px; ">


<input name="Dehydration" id="Dehydration" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:672px; ">


<input name="AspirationConcerns" id="AspirationConcerns" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:703px; ">


<input name="RecurrentVomiting" id="RecurrentVomiting" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:724px; ">


<input name="FoodSticking" id="FoodSticking" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:745px; ">


<input name="ChangeEating" id="ChangeEating" type="checkbox" class="largerCheckbox" style="position:absolute; left:408px; top:766px; ">


<input name="VidNo" id="VidNo" type="checkbox" class="largerCheckbox" style="position:absolute; left:62px; top:802px; ">


<input name="VidYes" id="VidYes" type="checkbox" class="largerCheckbox" style="position:absolute; left:119px; top:802px; ">




 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:880px; 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);"> 
			<input name="DrawCheckmark" id="DrawCheckmark" type="checkbox" checked><span style="font-family:sans-serif; font-size:12px;">Draw Checkmarks</span> 
	 </td></tr></table>
 </div>
 </form>

<script type="text/javascript">
<!-- Drawing in checkmarks -->
var chkcnv = document.getElementById('chkCanvas');
var chkjg = new jsGraphics(chkcnv);
var chkcnvLeft = parseInt(chkcnv.style.left);
var chkcnvTop = parseInt(chkcnv.style.top);
chkjg.setPrintable(true);
function drawCheckmark(x,y){
var offset = 6;
var x = parseInt(x) + offset;
var y = parseInt(y) + offset;
chkjg.setColor('black');
chkjg.setStroke(3);
		// draws checkmark
		var x1 = x;
		var y1 = y+4;
		var x2 = x1 + 3;
		var y2 = y1 + 4;
		var x3 = x2 + 4;
		var y3 = y2 - 12;
		chkjg.drawLine(x1,y1,x2,y2);
		chkjg.drawLine(x2,y2,x3,y3);
		chkjg.paint();
}
function replaceCheckmarks(){
var f = document.getElementById("FormName");
		 for (var i=0;i<f.length;i++){
				if ((f.elements[i].type == 'checkbox') && (f.elements[i].checked)){
					var a = f.elements[i].style.left;
					var b = f.elements[i].style.top;
					drawCheckmark(a,b);
				}
		 }
}
function printCheckboxes(){
		putInFront();
		replaceCheckmarks();
		window.print();
}
function putInFront(){
		chkcnv.style.zIndex = "999999";	
}
function putInBack(){
		chkcnv.style.zIndex = "-999999";	
}
</script>
</body>
</html>

Document Actions

 

Download button

DOWNLOAD OSCAR FOR TESTING

 

eForms button

DOWNLOAD SHARED E-FORMS


 Customize button

FIND PLUG-INS AND TWEAKS
FOR YOUR OSCAR EMR

 

Subscribe Button

SUBSCRIBE TO DISCUSSION LIST 
(SEE ALL LISTS)

  

Help button

ACCESS THE ONLINE MANUALS
(PAID SUPPORT)