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PalliativeCareReferalCommunication HTML

HTML icon PalliativeCareReferalCommunication.html — HTML, 38 kB (39847 bytes)

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<html>
<head>
<title>Palliative Care Referral/Communication</title>


<style type="text/css" media="print">
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}
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	scrollbar-track-color: transparent;
	background: transparent;
	overflow: hidden;
	border : 0px;
}
</style>
<style type="text/css">
h1{
	font-size: 20;
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	font-family: Arial;
}
h2{
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}
table{
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table.sample {
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table.sample th {
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table.sample td {
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}
input.Rx{
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	font-weight: bold;
	text-align: center;
	vertical-align: top;
	color: black;
        background-color: #8DEEEE;
	border-width: 3;
	border-style: solid;

}
input.Rx2{
	width: 180px;
	height: 100%;
	font-size: 12;
	font-family: Arial;
	font-weight: bold;
	text-align: center;
	vertical-align: top;
	color: black;
        background-color:#D1D0C6;
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	border-style: solid;

}
td{
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p {
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}
.caption2{
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}
.text{
	font-family: Arial;
	font-size: 12;
}
.labeltext{
	font-family:Arial;
	font-size: 16;
}
</style>



<script>
function onBodyLoad()
{
var re = new RegExp( "[?&]" + 'demographic_no' + "=([^&$]*)", "i" );
var offset=window.opener.location.search.search(re);
if(offset==-1){ 
re = new RegExp( "[?&]" + 'demographicNo' + "=([^&$]*)", "i" );
offset=window.opener.location.search.search(re);
}
var pathArray=window.opener.location.pathname.split('/');
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    theIFrame = document.createElement("IFRAME");
    theIFrame.setAttribute("id", "dynamicIFrame");
    theIFrame.setAttribute("src", 

'/'+pathArray[1]+'/eform/efmformslistadd.jsp?demographic_no='+RegExp.$1+'&curProvider=&intment=&parentAjaxId=eforms');
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function doIFrameOnLoad()
{
var re = new RegExp( "[?&]" + 'demographic_no' + "=([^&$]*)", "i" );
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re = new RegExp( "[?&]" + 'demographicNo' + "=([^&$]*)", "i" );
offset=window.opener.location.search.search(re);
}
var demographic=RegExp.$1;

//alert(demographic);
}



function eLink1()
{
window.open("../eform/efmformadd_data.jsp?fid=672&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("HospiceRegistrationCB").checked = true;
}
function eLink2()
{
window.open("../eform/efmformadd_data.jsp?fid=702&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("PalliativeCareOrdersCB").checked = true;
}
function elink3()
{
window.open("../eform/efmformadd_data.jsp?fid=674&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("PalliativeCareBenefitsCB").checked = true;
}
function elink4()
{
window.open("../eform/efmformadd_data.jsp?fid=522&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("DNRCB").checked = true;
}
function elink5()
{
window.open("../eform/efmformadd_data.jsp?fid=746&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("EOLCarePlanCB").checked = true;
}
function elink6()
{
alert("This form is only valid for 3 months from the date of creation!");
window.open("../eform/efmformadd_data.jsp?fid=523&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("NotificationCB").checked = true;
}
function elink7()
{
window.open("../eform/efmformadd_data.jsp?fid=588&demographic_no="+RegExp.$1+"&Provider=&intment=");
                document.getElementById("HospiceOrdersCB").checked = true;
}
function eLink8()
{
window.open("../eform/efmformadd_data.jsp?fid=588&demographic_no="+RegExp.$1+"&Provider=&intment=");
}
function eLink9()
{
window.open("../eform/efmformadd_data.jsp?fid=588&demographic_no="+RegExp.$1+"&Provider=&intment=");
}
function dLink1()
{
window.open("../dms/ManageDocument.do?method=display&doc_no=150997");
                document.getElementById("MyVoiceCB").checked = true;
}
function Rx()
{
window.open("..//oscarRx/choosePatient.do?providerNo=&demographicNo="+RegExp.$1+"");
}

</script>




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}
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<style type="text/css" media="print">
input.largerCheckbox { 
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} 
</style>
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<style type="text/css">
input.largerCheckbox { 
    height: 30px;                     /*30px checkboxes for IE 5 to IE 7 */ 
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} 
</style> 
<![endif]--> 

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var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
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}
function releaseDirtyFlag(){
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}
window.onbeforeunload = confirmExit;
function confirmExit(){
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         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?";
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}
</script>

<script language="javascript">
 function start(){
    if (document.getElementById("counter").value ==''){
       (document.getElementById("counter").value = 1);

	var history1 = document.getElementById('history1').value;
        var history1Split = history1.split("]]-----");
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        document.getElementById('Current').value = History1;

	var history2 = document.getElementById('history2').value;
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        document.getElementById('MedicalHistory').value = History2;

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        document.getElementById('OtherMedicationHistory').value = History3;

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        var History4 = history4Split.pop();
        document.getElementById('SocialFamilyHistory').value = History4;
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         if (document.getElementById("HospiceRegistrationCB").checked){
                document.getElementById("HospiceRegistration").style.background='#D1D0C6';
         }
         if (document.getElementById("PalliativeCareOrdersCB").checked){
                document.getElementById("PalliativeCareOrders").style.background='#D1D0C6';
         }
         if (document.getElementById("PalliativeCareBenefitsCB").checked){
                document.getElementById("PalliativeCareBenefits").style.background='#D1D0C6';
         }
         if (document.getElementById("DNRCB").checked){
                document.getElementById("DNR").style.background='#D1D0C6';
         }
         if (document.getElementById("EOLCarePlanCB").checked){
                document.getElementById("EOLCarePlan").style.background='#D1D0C6';
         }
}

</script>



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<script language="JavaScript">

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</script>



</head>


<body onload = 'onBodyLoad();start();'>
<form method="post" action="" name="FormName">

<!-- ---------------------------Hidden inputs   ------ -->
<input type="hidden" name="history1" id="history1"  oscarDB=OngoingConcerns>
<input type="hidden" name="history2" id="history2"  oscarDB=Medical_History>
<input type="hidden" name="history3" id="history3"  oscarDB=Other_Medications_History>
<input type="hidden" name="history4" id="history4"  oscarDB=Social_Family_History>
<input class="nodisplay" type="hidden" name="counter" id = "counter" >
<input type="hidden" name="date" id="date"  oscardb=today >
<!-- ---------------------- -->


<table  width="800" class="noborder">
			<tr>
				<td width="500"><p class="caption2" style="text-align: center;">HPC-EoL Communication Form</p></td>
				<td width="300" height="140"><br><textarea name="PatientLabel" class="labeltext noborder" oscarDB=label  style="width:300px; height:100%;text-align: center;font-weight: bold;"></textarea></td>
			</tr>
</table>


	<td>
		<p class="caption1"><b>Main Critical Diagnosis:<b>
		<textarea name="Events" class="text noborder" style="width:550; height: 25px;font-size:14pt;"></textarea></p>
	</td>	



<div class="DoNotPrint2">

                  <tr>
                         <td><u><b>Instructions for making a Palliative Care Referral:</b></u></td>
                  </tr>
<br>
                  <tr>
                         <td>Complete all five of the forms highlighted in blue and fax them to BOTH Home Care (604 702 4801) and Palliative Care (604 701 3637).</td>
		  </tr>
<br>
                  <tr>
                         <td>Fax a copy of the Palliative Care Benefits to Victoria and give the patient copies of the DNR and EoL Care Plan. </td>
		  </tr>
<br>
                  <tr>
                         <td>(The EoL Care Plan is optional, but will facilitate the billing of 14063, the code for palliative care planning.) </td>
		  </tr>

</div>


<table  width="800" class="sample">
	      <tr>
                     <td width = 3%><input type="checkbox"  name="HospiceRegistrationCB" id="HospiceRegistrationCB"></td>
                     <td><input class="Rx" value="Palliative/Hospice Referral" name="HospiceRegistration" id="HospiceRegistration" type="button" onclick="onBodyLoad();eLink1();"></td>
                     <td width = 3%><input type="checkbox"  name="PalliativeCareOrdersCB" id="PalliativeCareOrdersCB"></td>
                     <td><input class="Rx" value="PhysicianPalliativeCareOrders" name="PalliativeCareOrders" id="PalliativeCareOrders" type="button" onclick="onBodyLoad();eLink2();"></td>
                     <td width = 3%><input type="checkbox"  name="PalliativeCareBenefitsCB" id="PalliativeCareBenefitsCB"></td>
		     <td width = 20%><input class="Rx" value="Palliative Care Benefits" name="PalliativeCareBenefits" id="PalliativeCareBenefits"type="button" onclick="onBodyLoad();elink3();"></td>
                     <td width = 3%><input type="checkbox"  name="DNRCB" id="DNRCB"></td>
		     <td width = 20%><input class="Rx" value="Do Not Resuscitate Form" name="DNR" id="DNR" type="button" onclick="onBodyLoad();elink4();"></td>
             </tr>
	      <tr>
                     <td width = 3%><input type="checkbox"  name="EOLCarePlanCB" id="EOLCarePlanCB"></td>
		     <td width = 20%><input class="Rx" value="EoL Care Plan" name="EOLCarePlan" id="EOLCarePlan" type="button" onclick="onBodyLoad();elink5();"></td>
                     <td width = 3%><input type="checkbox"  name="NotificationCB" id="NotificationCB"></td>
		     <td width = 20%><input class="Rx2" value="Notification Expected Death" type="button" onclick="onBodyLoad();elink6();"></td>
                     <td width = 3%><input type="checkbox"  name="HospiceOrdersCB" id="HospiceOrdersCB"></td>
                     <td width = 20%><input class="Rx2" value="Hospice Standing Orders" type="button" onclick="onBodyLoad();elink7();"></td>
                     <td width = 3%><input type="checkbox"  name="MyVoiceCB" id="MyVoiceCB"></td>
                     <td width = 20%><input class="Rx2" value="MyVoice/Adv Directives" type="button" onclick="onBodyLoad();dLink1();"></td>
             </tr>
</table>

             <tr>
	             <td><p class="caption1">Collaborative Care Notes </a></p></td>
             </tr>

<table width="800" class="sample">
             <tr>
                  <td align="center"><b>Date<b></td>
                  <td align="center"><b>Who was present?<b></td>
                  <td align="center"><b>Issues/Outcomes<b></td>
                  <td align="center"><b>Followup<b></td>
             </tr>
             <tr>      
                  <td><input type="text" name="name1" id="name1" size="7" onclick="displayDate();" ></td>
                  <td><input type="text" name="name2" size="24" ></td>
                  <td><input type="text" name="name3" size="78" ></td>
                  <td><input type="text" name="name4" size="8" ></td>
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             <tr>
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             <tr>
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             <tr>
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                  <td><input type="text" name="name14" size="24" ></td>
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             <tr>
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             <tr>
                  <td><input type="text" name="name41" id="name41" size="7" onclick="displayDate41();" ></td>
                  <td><input type="text" name="name42" size="24" ></td>
                  <td><input type="text" name="name43" size="78" ></td>
                  <td><input type="text" name="name44" size="8" ></td>
             </tr>
             <tr>
                  <td><input type="text" name="name45" id="name45" size="7" onclick="displayDate45();" ></td>
                  <td><input type="text" name="name46" size="24" ></td>
                  <td><input type="text" name="name47" size="78" ></td>
                  <td><input type="text" name="name48" size="8" ></td>
             </tr>

       </table>


<tr>
	<td><p class="caption1">Assessment&nbsp&nbsp&nbsp<input value="Laboratory Requisition" type="button" onclick="onBodyLoad();eLink8();"></p></td>
</tr>

      <table width="800" class="sample">
             <tr>
                  <td align="center"><b>Date<b></td>
                  <td align="center"><b>Pain<b></td>
                  <td align="center"><b>Dyspnoea<b></td>
                  <td align="center"><b>Constipation<b></td>
                  <td align="center"><b>PPS<b></td>
                  <td align="center"><b>Wt<b></td>
                  <td align="center"><b>Other<b></td>

             </tr>
             <tr>
		  <td><input name="date1" size="7" type="text" id="date1" style="text-align: center;" onclick="displayDated1();"></td>
		  <td><input name="pain1" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea1" value="" size="16" type="text"></td>
		  <td><input name="constipation1" value="" size="15" type="text"></td>
		  <td><input name="pps1" value="" size="3" type="text"></td>
		  <td><input name="weight1" value="" size="5" type="text"></td>
		  <td><input name="other1" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date2" size="7"  type="text" id="date2" style="text-align: center;" onclick="displayDated2();"></td>
		  <td><input name="pain2" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea2" value="" size="16" type="text"></td>
		  <td><input name="constipation2" value="" size="15" type="text"></td>
		  <td><input name="pps2" value="" size="3" type="text"></td>
		  <td><input name="weight2" value="" size="5" type="text"></td>
		  <td><input name="other2" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date3" size="7"  type="text" id="date3" style="text-align: center;" onclick="displayDated3();"></td>
		  <td><input name="pain3" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea3" value="" size="16" type="text"></td>
		  <td><input name="constipation3" value="" size="15" type="text"></td>
		  <td><input name="pps3" value="" size="3" type="text"></td>
		  <td><input name="weight3" value="" size="5" type="text"></td>
		  <td><input name="other3" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date4" size="7"  type="text" id="date4" style="text-align: center;" onclick="displayDated4();"></td>
		  <td><input name="pain4" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea4" value="" size="16" type="text"></td>
		  <td><input name="constipation4" value="" size="15" type="text"></td>
		  <td><input name="pps4" value="" size="3" type="text"></td>
		  <td><input name="weight4" value="" size="5" type="text"></td>
		  <td><input name="other4" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date5" size="7"  type="text" id="date5" style="text-align: center;" onclick="displayDated5();"></td>
		  <td><input name="pain5" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea5" value="" size="16" type="text"></td>
		  <td><input name="constipation5" value="" size="15" type="text"></td>
		  <td><input name="pps5" value="" size="3" type="text"></td>
		  <td><input name="weight5" value="" size="5" type="text"></td>
		  <td><input name="other5" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date6" size="7"  type="text" id="date6" style="text-align: center;" onclick="displayDated6();"></td>
		  <td><input name="pain6" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea6" value="" size="16" type="text"></td>
		  <td><input name="constipation6" value="" size="15" type="text"></td>
		  <td><input name="pps6" value="" size="3" type="text"></td>
		  <td><input name="weight6" value="" size="5" type="text"></td>
		  <td><input name="other6" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date7" size="7"  type="text" id="date7" style="text-align: center;" onclick="displayDated7();"></td>
		  <td><input name="pain7" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea7" value="" size="16" type="text"></td>
		  <td><input name="constipation7" value="" size="15" type="text"></td>
		  <td><input name="pps7" value="" size="3" type="text"></td>
		  <td><input name="weight7" value="" size="5" type="text"></td>
		  <td><input name="other7" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date8" size="7"  type="text" id="date8" style="text-align: center;" onclick="displayDated8();"></td>
		  <td><input name="pain8" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea8" value="" size="16" type="text"></td>
		  <td><input name="constipation8" value="" size="15" type="text"></td>
		  <td><input name="pps8" value="" size="3" type="text"></td>
		  <td><input name="weight8" value="" size="5" type="text"></td>
		  <td><input name="other8" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date9" size="7"  type="text" id="date9" style="text-align: center;" onclick="displayDated9();"></td>
		  <td><input name="pain9" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea9" value="" size="16" type="text"></td>
		  <td><input name="constipation9" value="" size="15" type="text"></td>
		  <td><input name="pps9" value="" size="3" type="text"></td>
		  <td><input name="weight9" value="" size="5" type="text"></td>
		  <td><input name="other9" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date10" size="7"  type="text" id="date10" style="text-align: center;" onclick="displayDated10();"></td>
		  <td><input name="pain10" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea10" value="" size="16" type="text"></td>
		  <td><input name="constipation10" value="" size="15" type="text"></td>
		  <td><input name="pps10" value="" size="3" type="text"></td>
		  <td><input name="weight10" value="" size="5" type="text"></td>
		  <td><input name="other10" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date11" size="7"  type="text" id="date11" style="text-align: center;" onclick="displayDated11();"></td>
		  <td><input name="pain11" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea11" value="" size="16" type="text"></td>
		  <td><input name="constipation11" value="" size="15" type="text"></td>
		  <td><input name="pps11" value="" size="3" type="text"></td>
		  <td><input name="weight11" value="" size="5" type="text"></td>
		  <td><input name="other11" value="" size="47" type="text"></td>
             </tr>
             <tr>
		  <td><input name="date12" size="7"  type="text" id="date12" style="text-align: center;" onclick="displayDated12();"></td>
		  <td><input name="pain12" value="" size="10" type="text"></td>
		  <td><input name="dyspnoea12" value="" size="16" type="text"></td>
		  <td><input name="constipation12" value="" size="15" type="text"></td>
		  <td><input name="pps12" value="" size="3" type="text"></td>
		  <td><input name="weight12" value="" size="5" type="text"></td>
		  <td><input name="other12" value="" size="47" type="text"></td>
             </tr>

       </table>
<br>


<div class='DoNotPrint' id='contacts' style='position: absolute; top:20px; left:820px;'>

		<table  width="420">
	      <tr>
		     <td width = 100%><p class="normal"><b>Palliative Care Contact No's:&nbsp&nbsp Fax 604 701 3637<b></p></td>
             </tr>
                  </table>

		<table  width="420">
	      <tr>
		     <td width = 15%><p class="normal"><b>Clerk<b></p></td>
		     <td width = 30%><p class="normal"><b>Lorill Britz<b></p></td>
		     <td width = 25%><p class="normal"><b>Ph:795 4141 &nbsp&nbsp ext &nbsp 612718<b></p></td>
		     <td width = 25%><p class="normal"><b><b></p></td>
             </tr>
	      <tr>
		     <td width = 15%><p class="normal"><b>Nurse<b></p></td>
		     <td width = 30%><p class="normal"><b>Kim Giesbrecht<b></p></td>
		     <td width = 25%><p class="normal"><b>Ph:795 4141 &nbsp&nbsp ext &nbsp 612719<b></p></td>
		     <td width = 25%><p class="normal"><b>Cell: 316 0996<b></p></td>
             </tr>
	      <tr>
		     <td width = 15%><p class="normal"><b>Social Worker<b></p></td>
		     <td width = 30%><p class="normal"><b>Cindy Nichol<b></p></td>
		     <td width = 25%><p class="normal"><b>Ph:795 4141 &nbsp&nbsp ext &nbsp 612720<b></p></td>
		     <td width = 25%><p class="normal"><b>Cell: 316 2497<b></p></td>
             </tr>
                  </table>
</div>


<div class='DoNotPrint' id='PPS2' style='position: absolute; top:620px; left:830px;'>

		<table  width="350" border ='7'>

	      <tr>
		     <td width = 20%><p class="normal"><b>PPS Level<b></p></td>
		     <td width = 20%><p class="normal"><b>Ambulation<b></p></td>
		     <td width = 20%><p class="normal"><b>Activity Disease<b></p></td>
		     <td width = 20%><p class="normal"><b>Self care<b></p></td>
		     <td width = 20%><p class="normal"><b>Intake<b></p></td>
		     <td width = 20%><p class="normal"><b>Conscious level<b></p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">100%<b></p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal activity</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">90%<b></p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal activity</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">80%<b></p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal activity</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal/reduced</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">70%<b></p></td>
		     <td width = 20%><p class="normal">Reduced</p></td>
		     <td width = 20%><p class="normal">Decr activity</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
		     <td width = 20%><p class="normal">Normal/reduced</p></td>
		     <td width = 20%><p class="normal">Full</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">60%<b></p></td>
		     <td width = 20%><p class="normal">Reduced</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Occ assistence</p></td>
		     <td width = 20%><p class="normal">Normal/reduced</p></td>
		     <td width = 20%><p class="normal">Full/confusion</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">50%<b></p></td>
		     <td width = 20%><p class="normal">Sit/Lie</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Considerable help</p></td>
		     <td width = 20%><p class="normal">Normal/reduced</p></td>
		     <td width = 20%><p class="normal">Full/confusion</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">40%<b></p></td>
		     <td width = 20%><p class="normal">Mainly bed</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Mainly help</p></td>
		     <td width = 20%><p class="normal">Normal/reduced</p></td>
		     <td width = 20%><p class="normal">Full/drowsy</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">30%<b></p></td>
		     <td width = 20%><p class="normal">Total bed</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Total care</p></td>
		     <td width = 20%><p class="normal">Reduced</p></td>
		     <td width = 20%><p class="normal">Full/drowsy</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">20%<b></p></td>
		     <td width = 20%><p class="normal">Total bed</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Total care</p></td>
		     <td width = 20%><p class="normal">Minimal sips</p></td>
		     <td width = 20%><p class="normal">Full/drowsy</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">10%<b></p></td>
		     <td width = 20%><p class="normal">Total bed</p></td>
		     <td width = 20%><p class="normal">Minimal activity</p></td>
		     <td width = 20%><p class="normal">Total care</p></td>
		     <td width = 20%><p class="normal">Mouth care</p></td>
		     <td width = 20%><p class="normal">Drowsy/coma</p></td>
             </tr>
 	     <tr>                    
		     <td width = 20%><p class="normal">0%<b></p></td>
		     <td width = 20%><p class="normal">Death</p></td>
		     <td width = 20%><p class="normal">-</p></td>
		     <td width = 20%><p class="normal">-</p></td>
		     <td width = 20%><p class="normal">-</p></td>
		     <td width = 20%><p class="normal">-</p></td>
             </tr>


                  </table>
</div>


<div class="DoNotPrint">
     
<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>
          <tr>
               <td>
                        <input name="space" size="66" type="text"> 
			<input value="Print X2" name="PrintButton2" id="PrintButton2" type="button" style="background-color: #8DEEEE;" onclick="setTimeout('formPrint()',500);formPrint();"> 
			<input value="Print X2 & Submit" name="PrintSubmitButton2" id="PrintSubmitButton2" type="button" style="background-color: #8DEEEE;" onclick="setTimeout('formPrint()',500);formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);">
               </td>
         </tr>
</table>  
</div>
</form>

</body>
</html>
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