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RCH_Student_Rehab_ClinicV2 HTML

HTML icon RCH_Student_Rehab_ClinicV2.html — HTML, 16 kB (17262 bytes)

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<html>

	<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>


<style type="text/css">
 .BoxBorder {
	position:absolute;
	border:1px solid #808080;
} 
</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('$%7Boscar_image_path%7D','');
				// page2
				var src2 = document.getElementById('BGImage2').href;
				document.getElementById('BGImage2').href = src2.replace('$%7Boscar_image_path%7D','');
			}
			setDocumentTitle('RCH Student Physiotherapy Clinic',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();
		}

		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 = 900;
}
}
</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>

<body onload="startUp();" onMouseDown="showButtons();">

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

<div id="page1" style="position:absolute; left:0px; top:0px; width:850px;">
	<img id="BGImage" SRC="${oscar_image_path}SROC_Pg1.png" width:850px">

<a name="BGImage2" id="BGImage2" class="DoNotPrint" style="position:absolute; left:680px; top:45px; font-family:Arial; font-size:15px;" href="${oscar_image_path}SROC_Pg2.png" target="_blank">More Info</a>

<!-- ----------------------------All textfields/checkboxes/textareas go here------ -->
<span style="position:absolute; left:250px; top:15px; font-family:san-serif; font-size:24px; font-weight:bold;">Royal Columbian Hospital</span>
<span style="position:absolute; left:250px; top:40px; font-family:san-serif; font-size:24px; font-weight:bold;">Student Rehabilitation Outpatient Clinic</span>
<span style="position:absolute; left:250px; top:65px; font-family:san-serif; font-size:24px; font-weight:normal;">330 East Columbia Street, Basement, Columbia Tower</span>
<span style="position:absolute; left:250px; top:90px; font-family:san-serif; font-size:24px; font-weight:normal;">New Westminster, BC, V3L 3W7</span>
<span style="position:absolute; left:250px; top:115px; font-family:san-serif; font-size:24px; font-weight:normal;">Tel: (604)-520-4672 &nbsp&nbsp&nbsp Fax: (604)-777-8383</span>

<span style="position:absolute; left:40px; top:160px; font-family:san-serif; font-size:30px; font-weight:bold;">Physiotherapy & Occupational Therapy Requisition</span>

<span style="position:absolute; left:40px; top:200px; width:600px; font-family:san-serif; font-size:24px; font-weight:normal; background:transparent;">Fax referral to above number.</span>
<span style="position:absolute; left:350px; top:200px; width:600px; font-family:san-serif; font-size:24px; font-weight:normal; background:transparent;">Select:</span>
<input name="PT" id="PT" type="text" style="position:absolute; left:430px; top:200px; width:24px; height:24px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:24px; 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:460px; top:200px; width:600px; font-family:san-serif; font-size:24px; font-weight:normal; background:transparent;">Physiotherapy</span>
<input name="OT" id="OT" type="text" style="position:absolute; left:625px; top:200px; width:24px; height:24px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:24px; 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:655px; top:200px; width:600px; font-family:san-serif; font-size:24px; font-weight:normal; background:transparent;">Occupational Therapy</span>

<span style="position:absolute; left:40px; top:245px; width:800px; font-family:san-serif; font-size:24px; font-weight:normal; background:transparent;">Please Note: &nbspAssessment and treatment will be performed <b>by a physiotherapy or occupational student</b>, under the supervision of a licensed therapist.</span>

<span style="position:absolute; left:40px; top:340px; font-family:san-serif; font-size:24px;"><b>Patient Info</b></span>
<span style="position:absolute; left:40px; top:370px; font-family:san-serif; font-size:24px;">Name:</span>

<input name="PatientName" id="PatientName" type="text" class="noborder" style="position:absolute; left:135px; top:370px; width:360px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=patient_name>

<span style="position:absolute; left:40px; top:400px; text-align:left; font-family:san-serif; font-size:24px;">Address:</span>
<input name="Address" type="text" class="noborder" style="position:absolute; left:135px; top:400px; width:765px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=addressLine>

<span style="position:absolute; left:40px; top:430px; text-align:left; font-family:san-serif; font-size:24px;">Telephone (home):</span>
<input name="phone1" type="text" class="noborder" style="position:absolute; left:235px; top:430px; width:180px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=phone>

<span style="position:absolute; left:450px; top:430px; text-align:left; font-family:san-serif; font-size:24px;">DOB (yyyy/mm/dd):</span>
<input name="DOB" type="text" class="noborder" style="position:absolute; left:670px; top:430px; width:230px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=dob>

<span style="position:absolute; left:40px; top:460px; text-align:left; font-family:san-serif; font-size:24px;">PHN:</span>
<input name="PHN" type="text" class="noborder" style="position:absolute; left:135px; top:460px; width:150px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=HIN>

<span style="position:absolute; left:40px; top:510px; text-align:left; font-family:san-serif; font-size:24px">Doctor:</span>
<input name="CurrentUser" type="text" class="noborder" style="position:absolute; left:135px; top:510px; width:400px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=current_user>

<span style="position:absolute; left:560px; top:510px; text-align:left; font-family:san-serif; font-size:24px">Phone:</span>
<input name="ClinicPhone" type="text" class="noborder" style="position:absolute; left:640px; top:510px; width:200px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=clinic_phone>

<span style="position:absolute; left:40px; top:540px; text-align:left; font-family:san-serif; font-size:24px">Fax:</span>
<input name="ClinicFax" type="text" class="noborder" style="position:absolute; left:135px; top:540px; width:200px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=clinic_fax>

<span style="position:absolute; left:40px; top:590px; width:220px; font-family:san-serif; font-size:24px; background-color:transparent;">Operative Procedure / Date:</span>
<textarea name="Operation" style="position:absolute; left:290px; top:590px; width:610px; height:60px; font-family:san-serif; font-size:24px;"></textarea>

<span style="position:absolute; left:40px; top:660px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">Problem / Reason For Referral (please be as specific as possible):</span>
<textarea name="Reason" style="position:absolute; left:40px; top:690px; width:860px; height:60px; font-family:san-serif; font-size:24px;"></textarea>

<span style="position:absolute; left:40px; top:770px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">Contraindications:</span>
<input name="Contraindications" type="text" class="noborder" style="position:absolute; left:250px; top:770px; width:650px; font-family:san-serif; font-size:24px; background-color:transparent;" value="">

<span style="position:absolute; left:40px; top:810px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">Weight Bearing:</span>
<span style="position:absolute; left:250px; top:810px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">None:</span>
<input name="None" id="None" type="text" style="position:absolute; left:320px; top:810px; width:24px; height:24px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:24px; 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:450px; top:810px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">% of Full:</span>
<input name="PercentFull" type="text" class="noborder" style="position:absolute; left:560px; top:810px; width:50px; font-family:san-serif; font-size:24px; text-align:center; background-color:transparent;" value="">
<span style="position:absolute; left:710px; top:810px; text-align:left; font-family:san-serif; font-size:24px; background-color:transparent;">Full:</span>
<input name="Full" id="Full" type="text" style="position:absolute; left:770px; top:810px; width:24px; height:24px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:24px; 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:40px; top:860px; font-family:san-serif; font-size:24px; background-color:transparent;">Briefly describe patient's recent rehab activities & improvements (if appplicable):</span>
<textarea name="RehabDone" style="position:absolute; left:40px; top:890px; width:860px; height:60px; font-family:san-serif; font-size:24px;"></textarea>

<span style="position:absolute; left:40px; top:960px; font-family:san-serif; font-size:24px;"><b>Treatment Requested:</b></span>
<span style="position:absolute; left:290px; top:960px; font-family:san-serif; font-size:24px;">Or PT/OT student to assess and treat as appropriate:</span>
<input name="PT_OT_Student" id="PT_OT_Student" type="text" style="position:absolute; left:800px; top:960px; width:24px; height:24px; border:1px solid #000000; font-weight:bold; text-align:center; font-size:24px; background-color:transparent;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);">
<textarea name="TreatmentReq" style="position:absolute; left:40px; top:990px; width:860px; height:60px; font-family:san-serif; font-size:24px;"></textarea>


<span style="position:absolute; left:40px; top:1070px; font-family:san-serif; font-size:24px;"><b>Referring Physician/Health Care Worker:</b></span>
<input name="CurrentUser2" type="text" class="noborder" style="position:absolute; left:490px; top:1070px; width:410px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=current_user>

<span style="position:absolute; left:40px; top:1100px; text-align:left; font-family:san-serif; font-size:24px">Phone:</span>
<input name="ClinicPhone2" type="text" class="noborder" style="position:absolute; left:120px; top:1100px; width:200px; font-family:san-serif; font-size:24px; background-color:transparent;" oscardb=clinic_phone>


<span style="position:absolute; left:40px; top:1130px; font-family:san-serif; font-size:24px;">Date:</span>
<input name="today" type="text" class="noborder" style="position:absolute; left:120px; top:1130px; width:230px; font-family:san-serif;; font-size:24px; text-align:left; background-color:transparent;" oscardb=today>


<span style="position:absolute; left:490px; top:1110px; width:180px; font-family:san-serif; font-size:16px;">For Office Use Only Date Ref. Rec'd:</span>

<!-- --------------- Overdose Risk Text Box------ -->
<span class="BoxBorder" style="left:480px; top:1100px; width:420px;"></span>
<span class="BoxBorder" style="left:480px; top:1160px; width:420px;"></span>
<hr class="BoxBorder" style="left:480px; top:1094px; height:60px;"></hr>
<hr class="BoxBorder" style="left:900px; top:1094px; height:60px;"></hr>



<!-- --------------------------------------------- -->
</div>

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" id="BottomButtons" style="position:absolute; left:40px; top:1200px;">
		<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();document.FormName.submit()">
		<input value="Reset" name="ResetButton" id="ResetButton" type="reset"> 
		<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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