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OASIS HTML

HTML icon OasisV3.html — HTML, 47 kB (48792 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','');
			// Referral Instructions
			var src3 = document.getElementById('BGImage3').href;
			document.getElementById('BGImage3').href = src3.replace('$%7Boscar_image_path%7D','');
			// X-ray Instructions
			var src4 = document.getElementById('BGImage4').href;
			document.getElementById('BGImage4').href = src4.replace('$%7Boscar_image_path%7D','');
		}
		setDocumentTitle('Oasis Referral',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("EnglishYes").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 = true;
	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>

<!-- Pre-checking Gender script -->
<script type="text/javascript" language="javascript">
function checkGender(){
	if (document.getElementById('PatientGender').value == 'M'){
		document.getElementById('Male').value = 'X';
	}else if (document.getElementById('PatientGender').value == 'F'){
		document.getElementById('Female').value = 'X';
	}
}
</script>
</head>

<body onload="startUp(); checkGender();" 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}OASISpg1b.png" width="850">	

<a name="BGImage3" id="BGImage3" class="DoNotPrint" style="position:absolute; left:360px; top:60px; font-size:16px;" href="${oscar_image_path}OASIS_Instructions.png" target="_blank">Referral Instructions</a>

<!-- ---------------Section 1: Patient Demographics----------------------------- -->
<input name="PtName" id="PtName" type="text" class="noborder" style="position:absolute; left:110px; top:155px; width:400px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=patient_name>
<textarea name="Address" type="text" class="noborder" style="position:absolute; left:120px; top:197px; width:390px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=addressline></textarea>

<input name="HomePhone" type="text" class="noborder" style="position:absolute; left:185px; top:252px; width:140px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=phone>
<input name="CellPhone" type="text" class="noborder" style="position:absolute; left:370px; top:252px; width:140px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=cell>
<input name="WorkPhone" type="text" class="noborder" style="position:absolute; left:185px; top:276px; width:140px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=phone2>
<input name="Pager" type="text" class="noborder" style="position:absolute; left:370px; top:276px; width:140px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<input name="OasisPtID" type="text" class="noborder" style="position:absolute; left:610px; top:149px; width:185px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">
<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:560px; top:173px; width:165px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=hinc>
<input name="PCPChartNo" type="text" class="noborder" style="position:absolute; left:620px; top:197px; width:175px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<input name="DOB" type="text" class="noborder" style="position:absolute; left:590px; top:222px; width:200px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:center; background-color:transparent;" oscarDB=dob>

<input name="PatientAge" type="text" class="noborder" style="position:absolute; left:555px; top:249px; width:35px; font-family:sans-serif; font-size:16px; text-align:center; background-color:transparent;" oscardb=age >
<input name="PatientSex" type="text" class="noborder" style="position:absolute; left:720px; top:249px; width:20px; font-family:sans-serif; font-size:16px; text-align:center; background-color:transparent;" oscardb=sex >

<input name="Ethnicity" type="text" class="noborder" style="position:absolute; left:585px; top:274px; width:210px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<input name="EnglishYes" id="EnglishYes" type="text" style="position:absolute; left:324px; top:300px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; font-size:14px; 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="EnglishNo" id="EnglishNo" type="text" style="position:absolute; left:370px; top:300px; width:16px; height:16px; border:1px solid #000000; font-weight:bold; font-size:14px; 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="Language" type="text" class="noborder" style="position:absolute; left:560px; top:296px; width:230px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" value="">
<input name="AlternateContact" type="text" class="noborder" style="position:absolute; left:280px; top:325px; width:510px; font-family:Arial; font-size:16px; text-align:left; background-color:transparent;" value="">

<!-- ---------------MD Info----------------------------- -->
<input name="FamilyPhysician" type="text" class="noborder" style="position:absolute; left:175px; top:349px; width:250px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=current_user>
<input name="FamilyPhysicianPhone" type="text" class="noborder" style="position:absolute; left:480px; top:349px; width:115px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=clinic_phone>
<input name="FamilyPhysicianFax" type="text" class="noborder" style="position:absolute; left:660px; top:349px; width:130px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=clinic_fax>

<input name="PCP" type="text" class="noborder" style="position:absolute; left:205px; top:375px; width:220px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=referral_name>
<input name="PCPPhone" type="text" class="noborder" style="position:absolute; left:480px; top:375px; width:115px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=referral_phone>
<input name="PCPFax" type="text" class="noborder" style="position:absolute; left:660px; top:375px; width:130px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" oscarDB=referral_fax>

<!-- ---------------Affected Joints----------------------------- -->
<input name="LtHip" id="LtHip" type="text" style="position:absolute; left:191px; top:401px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RtHip" id="RtHip" type="text" style="position:absolute; left:278px; top:401px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="LtKnee" id="LtKnee" type="text" style="position:absolute; left:378px; top:401px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RtKnee" id="RtKnee" type="text" style="position:absolute; left:472px; top:401px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- ---------------Section 2: Request for Education----------------------------- -->
<input name="Education" id="Education" type="text" style="position:absolute; left:53px; top:467px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Written" id="Written" type="text" style="position:absolute; left:53px; top:510px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="Intro" id="Intro" type="text" style="position:absolute; left:378px; top:465px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Pain" id="Pain" type="text" style="position:absolute; left:378px; top:490px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Nutrition" id="Nutrition" type="text" style="position:absolute; left:378px; top:515px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherReq" id="OtherReq" type="text" style="position:absolute; left:378px; top:540px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherReqText" type="text" class="noborder" style="position:absolute; left:490px; top:539px; width:300px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<input name="Exercise" id="Exercise" type="text" style="position:absolute; left:565px; top:490px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Weight" id="Weight" type="text" style="position:absolute; left:565px; top:515px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="EducComments" type="text" class="noborder" style="position:absolute; left:190px; top:565px; width:600px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<!-- ---------------Section 3: a) Request for Assessment Appointment----------------------------- -->
<input name="non_operative" id="non_operative" type="text" style="position:absolute; left:53px; top:647px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="possible_surgery" id="possible_surgery" type="text" style="position:absolute; left:53px; top:674px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="surgery" id="surgery" type="text" style="position:absolute; left:53px; top:694px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="urgent_surgery" id="urgent_surgery" type="text" style="position:absolute; left:53px; top:714px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- ---------------Preferred Location----------------------------- -->
<input name="Region" id="Region" type="text" style="position:absolute; left:628px; top:649px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Vancouver" id="Vancouver" type="text" style="position:absolute; left:628px; top:667px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Richmond" id="Richmond" type="text" style="position:absolute; left:628px; top:686px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="NorthShore" id="NorthShore" type="text" style="position:absolute; left:628px; top:705px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="PreferredSurgeon" type="text" class="noborder" style="position:absolute; left:490px; top:750px; width:300px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:center; text-decoration:underline; background-color:transparent;" value="">

<!-- ---------------Referrals from Surgeons----------------------------- -->
<input name="ConsultYes" id="ConsultYes" type="text" style="position:absolute; left:278px; top:794px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="ConsultNo" id="ConsultNo" type="text" style="position:absolute; left:335px; top:794px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SurgeryYes" id="SurgeryYes" type="text" style="position:absolute; left:278px; top:818px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SurgeryNo" id="SurgeryNo" type="text" style="position:absolute; left:335px; top:818px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- ---------------Coordinator----------------------------- -->
<input name="OASIS" id="OASIS" type="text" style="position:absolute; left:53px; top:874px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PCPCoordinator" id="PCPCoordinator" type="text" style="position:absolute; left:53px; top:892px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- ---------------X-Rays----------------------------- -->
<a name="BGImage4" id="BGImage4" class="DoNotPrint" style="position:absolute; left:628px; top:922px; font-size:12px;" href="${oscar_image_path}OASIS_Instructions.png" target="_blank">(X-ray views)</a>
<input name="FilmLocation" type="text" class="noborder" style="position:absolute; left:400px; top:940px; width:390px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; text-decoration:underline; background-color:transparent;" value="">
<input name="NewXR" id="NewXR" type="text" style="position:absolute; left:128px; top:983px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<span style="position:absolute; left:215px; top:1032px; font-size:18px; font-family:Arial; font-style:italic; font-weight:bold; ">"Electronically signed"</span>
<input name="TodaysDate1" type="text" class="noborder" style="position:absolute; left:560px; top:1035px; width:150px; font-family:sans-serif; font-size:16px; text-align:left; background-color:transparent;" oscardb=today>
</div>
<!-- -----------------End of Page 1----------------------------------------------- -->

<div id="page2" style="position:relative;" class="pagebreak">
	<img id="BGImage2" src="${oscar_image_path}OASISpg2.png" width="850">

<input name="PtName2" id="PtName2" type="text" class="noborder" style="position:absolute; left:550px; top:40px; width:245px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" oscarDB=patient_name>

<!-- ---------------Section 3: b) Request for Assessment Appointment----------------------------- -->
<!-- ---------------Referral Prioritization Tool----------------------------- -->
<input name="MotionNone" id="MotionNone" type="text" style="position:absolute; left:132px; top:168px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="MotionMod" id="MotionMod" type="text" style="position:absolute; left:239px; top:168px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="MotionSevere" id="MotionSevere" type="text" style="position:absolute; left:339px; top:168px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="RestNone" id="RestNone" type="text" style="position:absolute; left:132px; top:209px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RestMild" id="RestMild" type="text" style="position:absolute; left:226px; top:209px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RestMod" id="RestMod" type="text" style="position:absolute; left:301px; top:209px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="RestSevere" id="RestSevere" type="text" style="position:absolute; left:401px; top:209px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="Walk5" id="Walk5" type="text" style="position:absolute; left:132px; top:253px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Walk1_5" id="Walk1_5" type="text" style="position:absolute; left:256px; top:253px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Walk1" id="Walk1" type="text" style="position:absolute; left:364px; top:253px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Housebound" id="Housebound" type="text" style="position:absolute; left:514px; top:253px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="FunctionNo" id="FunctionNo" type="text" style="position:absolute; left:132px; top:312px; width:14px; height:14px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="FunctionMild" id="FunctionMild" type="text" style="position:absolute; left:132px; top:326px; width:14px; height:14px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="FunctionMod" id="FunctionMod" type="text" style="position:absolute; left:132px; top:340px; width:14px; height:14px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="FunctionSevere" id="FunctionSevere" type="text" style="position:absolute; left:132px; top:354px; width:14px; height:14px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="PxNone" id="PxNone" type="text" style="position:absolute; left:132px; top:407px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PxMod" id="PxMod" type="text" style="position:absolute; left:251px; top:407px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PxSevere" id="PxSevere" type="text" style="position:absolute; left:357px; top:407px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="SupportNone" id="SupportNone" type="text" style="position:absolute; left:132px; top:462px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SupportBrace" id="SupportBrace" type="text" style="position:absolute; left:267px; top:462px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SupportCrutch" id="SupportCrutch" type="text" style="position:absolute; left:389px; top:462px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="SupportWheelchair" id="SupportWheelchair" type="text" style="position:absolute; left:539px; top:462px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="MedPrn" id="MedPrn" type="text" style="position:absolute; left:132px; top:501px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="MedReg" id="MedReg" type="text" style="position:absolute; left:301px; top:501px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="MedMax" id="MedMax" type="text" style="position:absolute; left:463px; top:501px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="NotThreatened" id="NotThreatened" type="text" style="position:absolute; left:132px; top:588px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Threatened" id="Threatened" type="text" style="position:absolute; left:301px; top:588px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="ImmedThreat" id="ImmedThreat" type="text" style="position:absolute; left:463px; top:588px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<span class="DoNotPrint" style="position:absolute; left:515px; top:648px; font-family:sans-serif; font-style:normal; font-size:12px; color:#6495ED;;">Use spacebar to position X</span>
<input name="UrgencyScale" type="text" class="noborder" style="position:absolute; left:160px; top:663px; width:505px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<!-- ---------------Previous Arthroplasties----------------------------- -->
<input name="PrevLtHip" id="PrevLtHip" type="text" style="position:absolute; left:58px; top:732px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PrevRtHip" id="PrevRtHip" type="text" style="position:absolute; left:58px; top:751px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PrevLtKnee" id="PrevLtKnee" type="text" style="position:absolute; left:58px; top:770px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PrevRtKnee" id="PrevRtKnee" type="text" style="position:absolute; left:58px; top:790px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<!-- ---------------Health History----------------------------- -->
<input name="Cardiac" id="Cardiac" type="text" style="position:absolute; left:200px; top:718px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="DVT" id="DVT" type="text" style="position:absolute; left:307px; top:718px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Hema" id="Hema" type="text" style="position:absolute; left:410px; top:718px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Mental" id="Mental" type="text" style="position:absolute; left:544px; top:718px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Neuro" id="Neuro" type="text" style="position:absolute; left:692px; top:718px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">


<input name="Resp" id="Resp" type="text" style="position:absolute; left:200px; top:737px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="HIV" id="HIV" type="text" style="position:absolute; left:307px; top:737px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="HTN" id="HTN" type="text" style="position:absolute; left:410px; top:737px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Cognition" id="Cognition" type="text" style="position:absolute; left:544px; top:737px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="DM" id="DM" type="text" style="position:absolute; left:200px; top:755px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Renal" id="Renal" type="text" style="position:absolute; left:307px; top:755px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="GI" id="GI" type="text" style="position:absolute; left:410px; top:755px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="CVA" id="CVA" type="text" style="position:absolute; left:544px; top:755px; width:16px; height:16px; border:1px solid #000000;font-weight:bold; font-size:14px; text-align:center; background-color:transparent; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<textarea name="PMHxComments" class="noborder" style="position:absolute; left:285px; top:784px; width:510px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;"></textarea>

<textarea name="CurrentMed" class="noborder" style="position:absolute; left:242px; top:860px; width:180px; height:100px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;"></textarea>
<textarea name="FailedMed" class="noborder" style="position:absolute; left:427px; top:860px; width:185px; height:100px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;"></textarea>
<textarea name="NonRxMed" class="noborder" style="position:absolute; left:617px; top:860px; width:180px; height:100px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; background-color:transparent;"></textarea>

<input name="AddComments" type="text" class="noborder" style="position:absolute; left:190px; top:975px; width:605px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:16px; text-align:left; background-color:transparent;" value="">

<span style="position:absolute; left:220px; top:1027px; font-size:18px; font-family:Arial; font-style:italic; font-weight:bold; ">"Electronically signed"</span>
<input name="TodaysDate1" type="text" class="noborder" style="position:absolute; left:565px; top:1030px; width:150px; font-family:sans-serif; font-size:16px; text-align:left; background-color:transparent;" oscardb=today>
</div>
<!-- -----------------End of Page 2----------------------------------------------- -->

<!-- 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="javascript:submission();"> 			
				<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
				<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
				<input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="printSubmit()"> 
	 </td></tr></table>
</div>
</form>
</body></html>

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