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BC-referral to St. Paul's Hospital Healthy Heart Program html file

HTML icon HealthyHeartProvidence2014.html — HTML, 19 kB (20380 bytes)

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<html>
<head>

<!------Created Feb 12, 2014 by Herb Chang, modified from form created by Chris Sedergreen--->
<!----- Do not use apostrophes - they do not allow for proper eForm zip inside Oscar.  Instead, use: &#8217; --->

<link rel="stylesheet" type="text/css" media="print" href="${oscar_image_path}JSMPC.css" />
	
<style type="text/css" media="print">
 .DoNotPrint {
	 display:none;
 }
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	 border:0px;
	 background:transparent;
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	 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 background
				var src = document.getElementById('BGImage').src;				
				document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D','');				
			}
			setDocumentTitle('HealthyHeartProvidence',document.getElementById('PatientName').value);
			setDefaults();			
		}
		
		function setDocumentTitle(Title,PatientName)
		{
			// set document title
			document.title = Title + ' - ' + PatientName;					
		}
		
		function setDefaults()
		{	            
			// check the newform flag to ensure this is the initial load of the form
			if (document.getElementById("newForm").value == 'True')
			{
				//document.getElementById("").value = 'X';	
			}   
		}

		/****************************
			submit and print functions 
		****************************/
		function printSubmit()
		{
			printLetter();
			releaseDirtyFlag();			
			submission();
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		function printLetter(){
			// hide the bottom buttons
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				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 = '';
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		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);
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		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 = 900;
		}
		}
</script>
<!----------End optimize window script---------->

<!-- scripts to confirm closing of window if have not saved yet -->
<script language="javascript">
		//keypress events trigger dirty flag
		var needToConfirm = false;
		document.onkeyup=setDirtyFlag;
function setDirtyFlag()
		{
		needToConfirm = true;
		}
function releaseDirtyFlag()
		{
		needToConfirm = false; //Call this function if does not requires an alert.
		//this could be called when save button is clicked
		}
		window.onbeforeunload = confirmExit;
function confirmExit()
		{
		if (needToConfirm)
		{
		return "You have attempted to leave this page. If you have made any changes to the fields without clicking the Save button, your changes will be lost. Are you sure you want to exit this page?";
		}
		}
</script>
</head>

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

<div id="page1" style="position:relative; left:0px; top:0px; width:850px;" class="pagebreak">

<img id="BGImage" SRC="${oscar_image_path}HHProvidence2008.png" width="850">

<!-- ----------------------------All textfields/checkboxes/textareas go here...---------------- -->

<input name="patient_nameL" id="patient_nameL" type="text" class="noborder" style="position:absolute; left:164px; top:200px; width:200px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameL>
<input name="patient_nameF" id="patient_nameF" type="text" class="noborder" style="position:absolute; left:464px; top:200px; width:160px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=patient_nameF>
<input name="patient_Initial" id="patient_Initial" type="text" class="noborder" style="position:absolute; left:680px; top:200px; width:26px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  value="">

<input name="addressline" id="addressline" type="text" class="noborder" style="position:absolute; left:154px; top:224px; width:660px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=address_street_number_and_name>
<input name="city" id="city" type="text" class="noborder" style="position:absolute; left:144px; top:248px; width:200px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=city>
<input name="province" id="province" type="text" class="noborder" style="position:absolute; left:462px; top:248px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=province>
<input name="postal" id="postal" type="text" class="noborder" style="position:absolute; left:726px; top:248px; width:80px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=postal>

<input name="phone" id="phone" type="text" class="noborder" style="position:absolute; left:202px; top:273px; width:140px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=phone>
<input name="phone2" id="phone2" type="text" class="noborder" style="position:absolute; left:440px; top:273px; width:140px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=phone2>

<span style="position:absolute; left:600px; top:278px; font-family:Arial; font-style:bold; font-size:12px;">(Cell):</span>
<input name="phone3" id="phone3" type="text" class="noborder" style="position:absolute; left:642px; top:273px; width:158px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=cell>

<input name="phn" id="phn" type="text" class="noborder" style="position:absolute; left:126px; top:298px; width:200px; height:20px; font-family:sans-serif;  font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=hinc>
<input name="dob" id="dob" type="text" class="noborder" style="position:absolute; left:500px; top:298px; width:120px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=dobc>
<input name="sex" id="sex" type="text" class="noborder" style="position:absolute; left:680px; top:298px; width:100px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=sex>

<input name="Chol" id="Chol" type="text" style="position:absolute; left:86px; top:350px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Obesity" id="Obesity" type="text" style="position:absolute; left:86px; top:370px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="Diabetes" id="Diabetes" type="text" style="position:absolute; left:86px; top:390px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="IFG" id="IFG" type="text" style="position:absolute; left:86px; top:410px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="Smoker" id="Smoker" type="text" style="position:absolute; left:376px; top:350px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" 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:376px; top:370px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PxInactive" id="PxInactive" type="text" style="position:absolute; left:376px; top:390px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PsychoSocial" id="PsychoSocial" type="text" style="position:absolute; left:376px; top:410px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="FamHxVasc" id="FamHxVasc" type="text" style="position:absolute; left:376px; top:430px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="CAD" id="CAD" type="text" style="position:absolute; left:594px; top:350px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="CVD" id="CVD" type="text" style="position:absolute; left:594px; top:370px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="PVD" id="PVD" type="text" style="position:absolute; left:594px; top:390px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<input name="OtherRisk" id="OtherRisk" type="text" style="position:absolute; left:594px; top:410px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<textarea name="RefReason" id="RefReason" class="noborder" style="position:absolute; left:84px; top:483px; width:742px; height:41px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>
<textarea name="Medication" id="Medication" class="noborder" style="position:absolute; left:84px; top:540px; width:742px; height:30px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" > </textarea>

<textarea name="CardiacTest" id="CardiacTest" class="noborder" style="position:absolute; left:84px; top:644px; width:742px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" > </textarea>

<span style="position:absolute; left:86px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">TChol:</span>
<input name="TCHL" id="TCHL" type="text" class="noborder" style="position:absolute; left:124px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$TCHL#value>

<span style="position:absolute; left:205px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">TG:</span>
<input name="TG" id="TG" type="text" class="noborder" style="position:absolute; left:229px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$TG#value>

<span style="position:absolute; left:315px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">HDL:</span>
<input name="HDL" id="HDL" type="text" class="noborder" style="position:absolute; left:345px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$HDL#value>

<span style="position:absolute; left:425px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">LDL:</span>
<input name="LDL" id="LDL" type="text" class="noborder" style="position:absolute; left:455px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$LDL#value>

<span style="position:absolute; left:535px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">TC/HDL:</span>
<input name="TCHD" id="TCHD" type="text" class="noborder" style="position:absolute; left:586px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$TCHD#value>

<span style="position:absolute; left:670px; top:612px; font-family:Arial; font-style:bold; font-size:12px;">FBS:</span>
<input name="FBS" id="FBS" type="text" class="noborder" style="position:absolute; left:705px; top:607px; width:68px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;"  oscarDB=m$FBS#value>

<input name="Prevention" id="Prevention" type="text" style="position:absolute; left:88px; top:696px; width:20px; height:20px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:14px; background-color:white;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">

<input name="doctor" id="doctor" type="text" class="noborder" style="position:absolute; left:230px; top:1006px; width:322px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=current_user>
<input name="doctor_ohip_no" id="doctor_ohip_no" type="text" class="noborder" style="position:absolute; left:552px; top:1006px; width:156px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=current_user_ohip_no>

<input name="clinic_addressLineFull" id="clinic_addressLineFull" type="text" class="noborder" style="position:absolute; left:230px; top:1026px; width:594px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_addressLineFull>
<span style="position:absolute; left:230px; top:1046px; font-family:Arial; font-style:bold; font-size:12px;">Phone:</span>
<input name="clinic_phone" id="clinic_phone" type="text" class="noborder" style="position:absolute; left:270px; top:1046px; width:204px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_phone>
<span style="position:absolute; left:530px; top:1046px; font-family:Arial; font-style:bold; font-size:12px;">Fax:</span>
<input name="clinic_fax" id="clinic_fax" type="text" class="noborder" style="position:absolute; left:556px; top:1046px; width:200px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;"  oscarDB=clinic_fax>

</div>

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons">
<table>
	<tr><td>
		<input type="hidden" id="newForm" name="newForm" value="True" />				
Subject:<input name="subject" size="40" type="text"> 
		<input value="Submit" name="SubmitButton" id="SubmitButton" type="button" onclick="releaseDirtyFlag();submission()">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset" onClick="history.go(0)"> 
		<input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> 			
		<input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="printSubmit()">
	</td></tr>
</table>
</div>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->

</form></body></html>

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