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PCRM MFM Referral 2013 HTML

HTML icon PCRM-MFM-Referral-Form-2013.html — HTML, 19 kB (19801 bytes)

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<html>
<head>
<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />

<!--- Created June 2013 by John Robertson, Written for version 12, Has x boxes,  fills in subject line, --->


<title>PCRM MFM Referral 2013</title>

<style type="text/css" media="print">
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	 display: none;
 }
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	 border : 0px;
	 background: transparent;
	 scrollbar-3dlight-color: transparent;
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	 overflow: hidden;
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 <script language="javascript" type="text/javascript">
		/****************************
		startup functions 
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		function startUp()
		{			
			// shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments
			var strLoc = window.location.href.toLowerCase();
			if(strLoc.indexOf("https") == -1)
			{
				//page1
				var src = document.getElementById('BGImage').src;				
				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');
			}
			setDocumentTitle('PCRM MFM Referral 2013',document.getElementById('PtName').value);
					
		}
		
		function setDocumentTitle(Title,PtName)
		{
			// set document title
			document.title = Title + ' - ' + PtName;					
							
		}
	
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			if (charCode != 9)
			{
				changeValue(x);
				return false;
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		}
		</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);
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if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){
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top.window.outerWidth = 1400;
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<!-- scripts to confirm closing of window if it hadn't been saved yet -->
<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
		needToConfirm = false;
}
function releaseDirtyFlag(){
		needToConfirm = false; //Call this function if doesn't requires an alert.
//this could be called when save button is clicked
}
window.onbeforeunload = confirmExit;
function confirmExit(){
	 if (needToConfirm){
		 return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
	 }
}
</script>

</head>

<body onLoad="startUp();"  onMouseDown="showButtons();">
<img id='BGImage' src="${oscar_image_path}PCRM_MFM_Referral_BnW.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<div id="chkCanvas" style="position:absolute; left:0px; top:0px; width:750; height:969;" onmouseover="putInBack();"></div>

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



<input name="PtName" id="PtName" type="text" class="noborder" style="position:absolute; left:176px; top:161px; width:266px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=first_last_name>


<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:167px; top:200px; width:78px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=dob>


<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:266px; top:200px; width:177px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=hinc>


<input name="PtAddress" id="PtAddress" type="text" class="noborder" style="position:absolute; left:180px; top:234px; width:263px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=addressline>


<input name="PtEmail" id="PtEmail" type="text" class="noborder" style="position:absolute; left:170px; top:252px; width:273px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  value="">


<input name="HomePhone" id="HomePhone" type="text" class="noborder" style="position:absolute; left:182px; top:269px; width:105px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=phone>


<input name="Cel" id="Cel" type="text" class="noborder" style="position:absolute; left:336px; top:269px; width:102px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=phone2>


<input name="DoctorName" id="DoctorName" type="text" class="noborder" style="position:absolute; left:537px; top:161px; width:164px; height:35px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=doctor>


<input name="BillingNo" id="BillingNo" type="text" class="noborder" style="position:absolute; left:518px; top:200px; width:182px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=doctor_ohip_no>


<input name="ClinicPhone" id="ClinicPhone" type="text" class="noborder" style="position:absolute; left:553px; top:234px; width:146px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=clinic_phone>

<input name="m$LMP#value" id="LMP" type="text" class="noborder" style="position:absolute; left:167px; top:306px; width:78px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=m$LMP#value>


<input name="m$EDD#value" id="EDD" type="text" class="noborder" style="position:absolute; left:356px; top:306px; width:88px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=m$EDD#value>


<input name="CopyToName" id="CopyToName" type="text" class="noborder" style="position:absolute; left:147px; top:344px; width:273px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=referral_name>

 <span style="position:absolute; left:425px; top:347px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px;"> MSP Number</span>


<input name="CopyToNumber" id="CopyToNumber" type="text" class="noborder" style="position:absolute; left:515px; top:344px; width:130px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=referral_no>


<input name="MFMConsult" id="MFMConsult" type="text" style="position:absolute; left:20px; top:429px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' MFM Consult '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<textarea name="Notes" id="Notes" class="noborder" style="position:absolute; left:143px; top:422px; width:442px; height:74px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" >Notes:</textarea>

<input name="OB_US" id="OB_US" type="text" style="position:absolute; left:20px; top:517px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' OB US '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<textarea name="Notes2" id="Notes2" class="noborder" style="position:absolute; left:143px; top:510px; width:553px; height:96px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" >Notes:</textarea>

<input name="First_Tri" id="First_Tri" type="text" style="position:absolute; left:145px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' First Trimester '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Dating" id="Dating" type="text" style="position:absolute; left:265px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Dating '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Viability" id="Viability" type="text" style="position:absolute; left:330px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Viability '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Bleeding" id="Bleeding" type="text" style="position:absolute; left:405px; top:618px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Bleeding '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Anatomy" id="Anatomy" type="text" style="position:absolute; left:145px; top:642px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+='Anatomy'" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Third_Tri" id="Third_Tri" type="text" style="position:absolute; left:145px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Third Trimester '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Growth" id="Growth" type="text" style="position:absolute; left:258px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Growth '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Placenta" id="Placenta" type="text" style="position:absolute; left:324px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Placental '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Presentation" id="Presentation" type="text" style="position:absolute; left:421px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Presentation '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Cx_Length" id="Cx_Length" type="text" style="position:absolute; left:516px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Cervical Length '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="AFI" id="AFI" type="text" style="position:absolute; left:598px; top:668px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' AFI '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Placenta_Evaluation" id="Placenta_Evaluation" type="text" style="position:absolute; left:145px; top:693px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Placental Evaluation '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="AbnSips" id="AbnSips" type="text" style="position:absolute; left:293px; top:693px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Abnormal SIPS '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Prior_PET" id="Prior_PET" type="text" style="position:absolute; left:496px; top:693px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Prior PET '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Chronic_HTN" id="Chronic_HTN" type="text" style="position:absolute; left:591px; top:693px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Chronic HTN '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<input name="Other_US" id="Other_US" type="text" style="position:absolute; left:20px; top:732px;  width:16px; height:16px; border:1px solid #000000; font-weight:bold; text-align:center; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);setDirtyFlag(); subject.value+=' Other Ultrasound '" onkeypress="javascript:return displayKeyCode(event,this.id);"  >


<textarea name="Notes3" id="Notes3" class="noborder" style="position:absolute; left:145px; top:725px; width:553px; height:40px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" >Notes:</textarea>

<textarea name="Notes4" id="Notes4" class="noborder" style="position:absolute; left:20px; top:777px; width:485px; height:170px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" >Notes:</textarea>

 <div  class="DoNotPrint" id="BottomButtons2" style="position: absolute; left:20px; top:920px;" >
<br><br>
<a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US"><img alt="Creative Commons License" style="border-width:0" src="http://i.creativecommons.org/l/by-sa/3.0/80x15.png" /></a><br /><span xmlns:dct="http://purl.org/dc/terms/" property="dct:title">PCRM MFM Referral 2013</span> by <span xmlns:cc="http://creativecommons.org/ns#" property="cc:attributionName">Dr J.G.M. Robertson</span> is licensed under a <a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US">Creative Commons Attribution-ShareAlike 3.0 Unported License</a>.<br />Permissions beyond the scope of this license may be available at <a xmlns:cc="http://creativecommons.org/ns#" href="http://www.oscarcanada.org/" rel="cc:morePermissions">http://www.oscarcanada.org/</a>.
 </div>


 <!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons" >
		<table style="position: absolute; left:20px; top:1020px;text-align: left; width: 90%;   font-size:12px; font-family:Arial;" border="0" cellpadding="0" cellspacing="0">
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 </form>


</body>
</html>

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