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BCMA / Health Ministry guide for health risk assessment - male

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<html>
<head>
<title>Rx_for_Health_RiskAssessment_Men</title>
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<!-- js graphics scripts -->
<script type="text/javascript" src="${oscar_image_path}jsgraphics.js"></script>
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function formPrint(){
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<script type="text/javascript" language="javascript">
function OpenPrint1(){
var TempWin=window.open('','name');
  TempWin.document.write('<html><head><title>Patient Information Sheet 1</title></head><body>');
  TempWin.document.write('<img src="${oscar_image_path}Rx_for_Health_PatientForm-2.png" width="750" onLoad="javascript:window.print();self.close(); ">');
  TempWin.document.write('</body></html>');
  TempWin.document.close();

}


</script> 

</head>

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

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

<a name="printPtInformation1" class="DoNotPrint" style="position: absolute; left: 10px; top: 35px;" href="javascript:OpenPrint1();">Print Prevention Schedule</a>

<input name="FirstLastName" id="FirstLastName" type="text" class="noborder" style="position:absolute; left:375px; top:15px; width:362px; height:21px; 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:375px; top:51px; width:175px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=dob>


<input name="ChartNo" id="ChartNo" type="text" class="noborder" style="position:absolute; left:559px; top:51px; width:177px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=chartno>


<input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; left:375px; top:86px; width:178px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=hinc>


<input name="Date" id="Date" type="text" class="noborder" style="position:absolute; left:559px; top:86px; width:175px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=today>


<input name="Etoh" id="Etoh" type="checkbox" style="position:absolute; left:14px; top:163px; ">


<input name="Arthritis" id="Arthritis" type="checkbox" style="position:absolute; left:14px; top:179px; ">


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<input name="CAD" id="CAD" type="checkbox" style="position:absolute; left:14px; top:227px; ">


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<input name="CHF" id="CHF" type="checkbox" style="position:absolute; left:14px; top:259px; ">


<input name="COPD" id="COPD" type="checkbox" style="position:absolute; left:14px; top:275px; ">


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<input name="Lipid" id="Lipid" type="checkbox" style="position:absolute; left:14px; top:355px; ">


<input name="Liver" id="Liver" type="checkbox" style="position:absolute; left:14px; top:371px; ">


<input name="Obesity" id="Obesity" type="checkbox" style="position:absolute; left:14px; top:387px; ">


<input name="Rhythm" id="Rhythm" type="checkbox" style="position:absolute; left:14px; top:403px; ">


<input name="PeripheralVasc" id="PeripheralVasc" type="checkbox" style="position:absolute; left:14px; top:419px; ">


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<input name="BMI" id="BMI" type="text" class="noborder" style="position:absolute; left:488px; top:170px; width:121px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;"  oscarDB=m$BMI#value>


<input name="Framingham" id="Framingham" type="text" class="noborder" style="position:absolute; left:670px; top:170px; width:64px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">


<input name="ActivityY" id="ActivityY" type="checkbox" style="position:absolute; left:245px; top:214px; ">


<input name="ActivityN" id="ActivityN" type="checkbox" style="position:absolute; left:271px; top:214px; ">


<input name="BadDietY" id="BadDietY" type="checkbox" style="position:absolute; left:245px; top:237px; ">


<input name="BadDietN" id="BadDietN" type="checkbox" style="position:absolute; left:271px; top:237px; ">


<input name="ObesityY" id="ObesityY" type="checkbox" style="position:absolute; left:245px; top:261px; ">


<input name="ObesityN" id="ObesityN" type="checkbox" style="position:absolute; left:271px; top:261px; ">


<input name="ModWC" id="ModWC" type="checkbox" style="position:absolute; left:384px; top:261px; ">


<input name="HighWC" id="HighWC" type="checkbox" style="position:absolute; left:384px; top:277px; ">


<input name="BMIover25" id="BMIover25" type="checkbox" style="position:absolute; left:571px; top:261px; ">


<input name="BMIover30" id="BMIover30" type="checkbox" style="position:absolute; left:571px; top:277px; ">


<input name="SmokingY" id="SmokingY" type="checkbox" style="position:absolute; left:245px; top:306px; ">


<input name="SmokingN" id="SmokingN" type="checkbox" style="position:absolute; left:271px; top:306px; ">


<input name="SmokingPast" id="SmokingPast" type="checkbox" style="position:absolute; left:384px; top:306px; ">


<input name="SmokingCurrent" id="SmokingCurrent" type="checkbox" style="position:absolute; left:446px; top:306px; ">


<input name="SmokingYears" id="SmokingYears" type="text" class="noborder" style="position:absolute; left:515px; top:306px; width:72px; height:16px; text-decoration:underline; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">


<input name="SmokingPacksDay" id="SmokingPacksDay" type="text" class="noborder" style="position:absolute; left:599px; top:306px; width:72px; height:16px; text-decoration:underline; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" value="">


<input name="FOBTUTD" id="FOBTUTD" type="checkbox" style="position:absolute; left:458px; top:402px; ">


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<textarea name="FOBTResults" id="FOBTResults" class="noborder" style="position:absolute; left:548px; top:395px; width:147px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" ></textarea>


<input name="FOBTNA" id="FOBTNA" type="checkbox" style="position:absolute; left:701px; top:402px; ">


<input name="FlexSigUTD" id="FlexSigUTD" type="checkbox" style="position:absolute; left:458px; top:438px; ">


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<input name="FlexSigNA" id="FlexSigNA" type="checkbox" style="position:absolute; left:701px; top:438px; ">


<input name="FastLipidProfUTD" id="FastLipidProfUTD" type="checkbox" style="position:absolute; left:458px; top:472px; ">


<input name="FastLipidProfOrdered" id="FastLipidProfOrdered" type="checkbox" style="position:absolute; left:525px; top:472px; ">


<textarea name="FastLipidResults" id="FastLipidResults" class="noborder" style="position:absolute; left:548px; top:465px; width:147px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:transparent;" ></textarea>


<input name="FastLipidNA" id="FastLipidNA" type="checkbox" style="position:absolute; left:701px; top:472px; ">


<input name="FBSUTD" id="FBSUTD" type="checkbox" style="position:absolute; left:458px; top:507px; ">


<input name="FBSOrdered" id="FBSOrdered" type="checkbox" style="position:absolute; left:525px; top:507px; ">


<textarea name="FBSResults" id="FBSResults" class="noborder" style="position:absolute; left:548px; top:500px; width:145px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" ></textarea>


<input name="FBSNA" id="FBSNA" type="checkbox" style="position:absolute; left:701px; top:507px; ">


<input name="InfluenzaUTD" id="InfluenzaUTD" type="checkbox" style="position:absolute; left:129px; top:602px; ">


<input name="InfluenzaGiven" id="InfluenzaGiven" type="checkbox" style="position:absolute; left:168px; top:602px; ">


<input name="TDUTD" id="TDUTD" type="checkbox" style="position:absolute; left:129px; top:632px; ">


<input name="TDGiven" id="TDGiven" type="checkbox" style="position:absolute; left:168px; top:632px; ">


<input name="PneumoUTD" id="PneumoUTD" type="checkbox" style="position:absolute; left:129px; top:661px; ">


<input name="PneumoGiven" id="PneumoGiven" type="checkbox" style="position:absolute; left:168px; top:661px; ">


<textarea name="Rx" id="Rx" class="noborder" style="position:absolute; left:236px; top:582px; width:500px; height:55px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;"  oscarDB=druglist_line></textarea>


<textarea name="OTCHerbal" id="OTCHerbal" class="noborder" style="position:absolute; left:236px; top:650px; width:500px; height:52px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" ></textarea>


<input name="PhysAct" id="PhysAct" type="checkbox" style="position:absolute; left:133px; top:761px; ">


<input name="PhysActSupport" id="PhysActSupport" type="text" class="noborder" style="position:absolute; left:152px; top:759px; width:235px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" value="">


<input name="Diet" id="Diet" type="checkbox" style="position:absolute; left:133px; top:785px; ">


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<input name="WeightLoss" id="WeightLoss" type="checkbox" style="position:absolute; left:133px; top:810px; ">


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<input name="SmokingCessation" id="SmokingCessation" type="checkbox" style="position:absolute; left:133px; top:835px; ">


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<input name="ASAProphylaxisDiscussed" id="ASAProphylaxisDiscussed" type="checkbox" style="position:absolute; left:159px; top:857px; ">


<input name="ASAProphylaxisTake" id="ASAProphylaxisTake" type="checkbox" style="position:absolute; left:228px; top:875px; ">


<input name="ASAProphylaxisDecline" id="ASAProphylaxisDecline" type="checkbox" style="position:absolute; left:292px; top:875px; ">


<textarea name="Comments" id="Comments" class="noborder" style="position:absolute; left:391px; top:758px; width:346px; height:142px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:14px; text-align:left; background-color:white;" ></textarea>




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