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Handy Dart Application Form HTML

HTML icon HandyDart.html — HTML, 18 kB (19213 bytes)

File contents

<html>
<head>

	<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />
	<!--<script language="javascript" type="text/javascript" media="print" src="${oscar_image_path}JSMPC.js"></script>	-->
	
<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('$%7Boscar_image_path%7D','');
				// page2
				var src2 = document.getElementById('BGImage2').src;
				document.getElementById('BGImage2').src = src2.replace('$%7Boscar_image_path%7D','');
				// page3
				var src3 = document.getElementById('BGImage3').src;
				document.getElementById('BGImage3').src = src3.replace('$%7Boscar_image_path%7D','');
				// page4 reference
				var src4 = document.getElementById('BGImage4').href;
				document.getElementById('BGImage4').href = src4.replace('$%7Boscar_image_path%7D','');
				
			}
			setDocumentTitle('HandyDart Form',document.getElementById('surname').value);
			setDefaults();			
		}
		
		function setDocumentTitle(Title,surname)
		{
			// set document title
			document.title = Title + ' - ' + surname;					
							
		}
		
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				//document.getElementById('').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 = 875;
}
}
</script>
<!----------End optimize window script---------->

<!-- scripts to confirm closing of window if haven't 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>

</head>

<body onload="startUp();" onMouseDown="showButtons();">
<form method="post" action="" name="FormName" id="FormName" >

<div id="page1" style="position:relative; left:0px; top:0px; width:850px;" class="pagebreak">
	<img id="BGImage" SRC="${oscar_image_path}HandyDART1.png">

<!-- Select Program -->
<input name="HandyDart" id="HandyDart" type="text" style="position:absolute; left:100px; top:308px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="HandyCard" id="HandyCard" type="text" style="position:absolute; left:238px; top:308px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- Applicant Info -->
<input name="Prefix" id="Mr" value="Mr" type="radio" style="position:absolute; left:97px; top:528px;">
<input name="Prefix" id="Mrs" value="Mrs" type="radio" style="position:absolute; left:148px; top:528px;">
<input name="Prefix" id="Ms" value="Ms" type="radio" style="position:absolute; left:206px; top:528px;">

<input name="surname" id="surname" type="text" class="noborder" style="position:absolute; left:350px; top:528px; width:190px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;" oscarDB=patient_nameL>
<input name="PatientFirstName" id="PatientFirstName" type="text" class="noborder" style="position:absolute; left:634px; top:528px; width:146px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;" oscarDB=patient_nameF>
<input name="PatientMiddleName" type="text" class="noborder" style="position:absolute; left:206px; top:567px; width:174px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;">
<input name="AKA" type="text" class="noborder" style="position:absolute; left:637px; top:567px; width:143px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;">
<input name="DOB" type="text" class="noborder" style="position:absolute; left:206px; top:606px; width:173px; font-family:Arial; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" oscardb=dob>

<textarea name="Address" type="text" class="noborder" style="position:absolute; left:165px; top:648px; width:530px; height:25px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" oscarDB=addressline></textarea>
<input name="City" type="text" class="noborder" style="position:absolute; left:137px; top:682px; width:150px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;">
<input name="Postal" type="text" class="noborder" style="position:absolute; left:592px; top:682px; width:100px; font-family:Arial; font-size:14px; background-color:transparent; background-color:transparent;">

<input name="HomePhone" type="text" class="noborder" style="position:absolute; left:150px; top:717px; width:210px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" oscarDB=phone>
<input name="OtherPhone" type="text" class="noborder" style="position:absolute; left:485px; top:717px; width:207px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" oscarDB=phone2>
<input name="EMail" type="text" class="noborder" style="position:absolute; left:150px; top:749px; width:330px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">

<input name="Facility" type="text" class="noborder" style="position:absolute; left:528px; top:816px; width:252px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="Intercom" type="text" class="noborder" style="position:absolute; left:225px; top:852px; width:138px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="OtherDetail" type="text" class="noborder" style="position:absolute; left:504px; top:888px; width:276px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="OtherAddress" type="text" class="noborder" style="position:absolute; left:165px; top:956px; width:329px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="OtherApartment" type="text" class="noborder" style="position:absolute; left:582px; top:956px; width:110px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="OtherCity" type="text" class="noborder" style="position:absolute; left:136px; top:993px; width:156px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
<input name="OtherPostal" type="text" class="noborder" style="position:absolute; left:592px; top:993px; width:100px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">
</div>
<!-- END OF PAGE 1 -->

<!-- START OF PAGE 2 -->
<div id="page2" style="position:relative;" class="pagebreak">
	<img id="BGImage2" src="${oscar_image_path}HandyDART2.png" width="850px">

<!-- Applicant Info Continued-->
<input name="EmergencyLast" type="text" class="noborder" style="position:absolute; left:302px; top:105px; width:165px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="EmergencyFirst" type="text" class="noborder" style="position:absolute; left:557px; top:105px; width:223px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="EmergencyPhone" type="text" class="noborder" style="position:absolute; left:127px; top:140px; width:123px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="EmergencyCell" type="text" class="noborder" style="position:absolute; left:342px; top:140px; width:125px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="EmergencyRelation" type="text" class="noborder" style="position:absolute; left:660px; top:140px; width:120px; font-family:Arial; font-size:14px; background-color:transparent;">
 
<input name="Attendant" id="AttendantYes" type="radio" style="position:absolute; left:659px; top:175px;">
<input name="Attendant" id="AttendantNo" type="radio" style="position:absolute; left:717px; top:175px;">

<input name="Crutches" id="Crutches" type="text" style="position:absolute; left:73px; top:263px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Cane" id="Cane" type="text" style="position:absolute; left:170px; top:263px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PortableOx" id="PortableOx" type="text" style="position:absolute; left:246px; top:263px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RegisteredAnimal" id="RegisteredAnimal" type="text" style="position:absolute; left:402px; top:263px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="NotApplicable" id="NotApplicable" type="text" style="position:absolute; left:623px; top:263px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="WalkerLt" type="text" class="noborder" style="position:absolute; left:303px; top:346px; width:120px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="WalkerWd" type="text" class="noborder" style="position:absolute; left:457px; top:346px; width:125px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="WalkerBrand" type="text" class="noborder" style="position:absolute; left:611px; top:348px; width:146px; font-family:Arial; font-size:14px; background-color:transparent;">

<input name="WheelchairLt" type="text" class="noborder" style="position:absolute; left:303px; top:381px; width:120px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="WheelchairWd" type="text" class="noborder" style="position:absolute; left:457px; top:381px; width:125px; font-family:Arial; font-size:14px; background-color:transparent;">
<input name="WheelchairBrand" type="text" class="noborder" style="position:absolute; left:613px; top:381px; width:144px; font-family:Arial; font-size:14px; background-color:transparent;">

<textarea name="Notes" type="text" class="noborder" style="position:absolute; left:407px; top:882px; width:370px; height:113px; font-family:Arial; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;"></textarea>
</div>
<!-- END OF PAGE 2 -->

<!-- START OF PAGE 3 -->
<div id="page3" style="position:relative;" class="pagebreak">
	<img id="BGImage3" src="${oscar_image_path}HandyDART3.png" width="850px">

<a name="BGImage4" id="BGImage4" class="DoNotPrint" style="position:absolute; left:564px; top:125px; font-size:13px;" href="${oscar_image_path}HandyDART4.png" target="_blank">see page 4</a>

<textarea name="Nature" type="text" class="noborder" style="position:absolute; left:92px; top:140px; width:688px; height:63px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;"></textarea>
<input name="YesExplain" type="text" class="noborder" style="position:absolute; left:208px; top:256px; width:572px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;">
<textarea name="NoExplain" type="text" class="noborder" style="position:absolute; left:96px; top:323px; width:685px; height:63px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;"></textarea>

<input name="Duration" id="DurationPermanent" type="radio" style="position:absolute; left:90px; top:418px;">
<input name="Duration" id="DurationTemporary" type="radio" style="position:absolute; left:218px; top:418px;">
<input name="DurationEstimate" type="text" class="noborder" style="position:absolute; left:373px; top:446px; width:407px; font-family:Arial; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;">

<input name="Code99" id="Code99Yes" type="radio" style="position:absolute; left:90px; top:562px;">
<input name="Code99" id="Code99No" type="radio" style="position:absolute; left:145px; top:562px;">

<input name="Physician" type="text" class="noborder" style="position:absolute; left:186px; top:603px; width:189px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;" oscarDB=current_user>
<input name="Organization" type="text" class="noborder" style="position:absolute; left:485px; top:603px; width:295px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">

<input name="Position" type="text" class="noborder" style="position:absolute; left:135px; top:633px; width:240px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;">

<textarea name="ClinicAddress" class="noborder" style="position:absolute; left:135px; top:661px; height:22px; width:645px; font-family:Arial; font-size:14px; background-color:transparent;" oscarDB=clinic_addresslineFULL></textarea>

<input name="ClinicFax" type="text" class="noborder" style="position:absolute; left:105px; top:692px; width:202px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;" oscardb=clinic_fax>
<input name="ClinicPhone" type="text" class="noborder" style="position:absolute; left:388px; top:692px; width:163px; font-family:Arial; font-size:14px; text-align:left; background-color:transparent;" oscardb=clinic_phone>
<input name="TodaysDate" type="text" class="noborder" style="position:absolute; left:617px; top:692px; width:159px; font-family:Arial; font-size:14px; text-align:center; background-color:transparent;" oscardb=today>
</div>
<!-- END OF PAGE 3 -->

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons" >
		<table>
		<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="button" onclick="releaseDirtyFlag();submission()">
		<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="printSubmit()">
		</td></tr>
		</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->
</form>
</body></html>

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