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VIHA Cystology Histology Specimen

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<html>

<head>
<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>
 
 
 

<script language="javascript">
function formPrint(){
			window.print();
} 
</script>




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<script language="javascript">
//keypress events trigger dirty flag
var needToConfirm = false;
document.onkeyup=setDirtyFlag;
function setDirtyFlag(){
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}
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>

<!-- ------------------------------------------------------------------ -->

<!-- Pre-checking Gender script -->
<script type="text/javascript" language="javascript">
function checkGender(){
	if (document.getElementById('PatientGender').value == 'M'){
		document.getElementById('Male').checked = true;
	}else if (document.getElementById('PatientGender').value == 'F'){
		document.getElementById('Female').checked = true;
	}
}
</script>


</head>

<body width="750px" onLoad="checkGender();">
<div style="position: absolute; width:750px; height:971px; left: 12; top: 16; z-index:'-1'"><IMG SRC="${oscar_image_path}histologycytologyviha.GIF"></div><!---->

<form method="POST" action="">
<!-- ----------------------------All textfields/checkboxes/textareas go here...------ -->

<div style="position: absolute; left:66px; top:183px;"> 
	<input type="text" class="noborder" name="PHN" style="width: 219px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=HINc>
</div>
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	<input type="text" class="noborder" name="DOB" style="width: 129px; font-family: Arial; font-size: 11px;" tabindex="1"oscarDB=DOBc>
</div>
<div style="position: absolute; left:424px; top:188px;"> 
	<input type="text" class="noborder" name="physicianname" style="width: 223px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=current_user>
</div>
<div style="position: absolute; left:43px; top:216px;"> 
	<input type="text" class="noborder" name="surname" style="width: 190px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=patient_nameL>
</div>
<div style="position: absolute; left:236px; top:216px;"> 
	<input type="text" class="noborder" name="firstname" style="width: 182px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=patient_nameF>
</div>
<div style="position: absolute; left:96px; top:293px;"> 
	<input type="text" class="noborder" name="telephonenumber" style="width: 206px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=phone>
</div>
<div style="position: absolute; left:311px; top:299px;"> 
	<input type="text" class="noborder" name="VIHAMRN" style="width: 111px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=ohip_no>
</div>
<div style="position: absolute; left:41px; top:326px;"> 
	<input type="text" class="noborder" name="dateofprocedure" style="width: 187px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>
<div style="position: absolute; left:238px; top:326px;"> 
	<input type="text" class="noborder" name="timeofprocedure" style="width: 185px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>
<div style="position: absolute; left:41px; top:358px;"> 
	<input type="text" class="noborder" name="FNAbookingpathologist" style="width: 381px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>

<div style="position: absolute; left:38px; top:406px;"> 
	<textarea class="noborder" name="relevanthistory" style="height: 74px; width: 605px; font-family: Arial; font-size: 12px;" tabindex="1"></textarea>
</div>

<div style="position: absolute; left:151px; top:480px;">
        <input type="checkbox" name="previousmalignancyno">
</div>
<div style="position: absolute; left:195px; top:480px;">
        <input type="checkbox" name="previousmalignancyyes">
</div>

<div style="position: absolute; left:296px; top:481px;"> 
	<input type="text" class="noborder" name="specifypreviousmalignanvy" style="width: 344px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>

<div style="position: absolute; left:151px; top:497px;">
        <input type="checkbox" name="previouscytologyno">
</div>
<div style="position: absolute; left:195px; top:497px;">
        <input type="checkbox" name="previouscytologyyes">
</div>

<div style="position: absolute; left:296px; top:501px;"> 
	<input type="text" class="noborder" name="specifypreviouscytology" style="width: 344px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>

<div style="position: absolute; left:151px; top:516px;">
        <input type="checkbox" name="previoushistologyno">
</div>
<div style="position: absolute; left:195px; top:516px;">
        <input type="checkbox" name="previoushistologyyes">
</div>


<div style="position: absolute; left:296px; top:519px;"> 
	<input type="text" class="noborder" name="specifyprevioushistology" style="width: 344px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>

<div style="position: absolute; left:38px; top:563px;"> 
	<textarea class="noborder" name="exactsiteofspecimen" style="height: 56px; width: 603px; font-family: Arial; font-size: 12px;" tabindex="1"></textarea>
</div>

<div style="position: absolute; left:425px; top:216px;"> 
	<input type="text" class="noborder" name="physiciannumber" style="width: 219px; font-family: Arial; font-size: 12px;" tabindex="1" oscarDB=current_user_ohip_no>
</div>
<div style="position: absolute; left:424px; top:242px;"> 
	<input type="text" class="noborder" name="clinicnumber" style="width: 116px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=clinic_phone>
</div>
<div style="position: absolute; left:543px; top:242px;"> 
	<input type="text" class="noborder" name="faxnumberclinic" style="width: 103px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=clinic_fax>
</div>
<div style="position: absolute; left:469px; top:265px;"> 
	<input type="text" class="noborder" name="copiesto" style="width: 173px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>
<div style="position: absolute; left:469px; top:293px;"> 
	<input type="text" class="noborder" name="copiestotwo" style="width: 173px; font-family: Arial; font-size: 12px;" tabindex="1">
</div>






<div style="position: absolute; left:40px; top:244px;"> 
	<textarea class="noborder" name="patientaddress" style="height: 41px; width: 268px; font-family: Arial; font-size: 12px;" tabindex="1"oscarDB=address></textarea>
</div>




<div style="position:absolute; left:334px; top: 242px;">
	<input name="Male" id="Male" type="checkbox" class="noborder">
</div>
<div style="position:absolute; left:376px; top: 242px;">
	<input name="Female" id="Female" type="checkbox" class="noborder">
</div>
<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex >



<div style="position: absolute; left:43px; top:160px;">
        <input type="checkbox" name="MSP">
</div>
<div style="position: absolute; left:86px; top:160px;">
        <input type="checkbox" name="WCB">
</div>
<div style="position: absolute; left:132px; top:160px;">
        <input type="checkbox" name="ICBC">
</div>
<div style="position: absolute; left:180px; top:160px;">
        <input type="checkbox" name="patient">
</div>
<div style="position: absolute; left:233px; top:160px;">
        <input type="checkbox" name="otherbillableto">
</div>
<div style="position: absolute; left:416px; top:160px;">
        <input type="checkbox" name="outofprovince">
</div>
<div style="position: absolute; left:503px; top:160px;">
        <input type="checkbox" name="nonresidentofcanada">
</div>



<div style="position: absolute; left:33px; top:656px;">
        <input type="checkbox" name="biospy">
</div>
<div style="position: absolute; left:92px; top:656px;">
        <input type="checkbox" name="exicisional">
</div>
<div style="position: absolute; left:160px; top:656px;">
        <input type="checkbox" name="needlecore">
</div>
<div style="position: absolute; left:233px; top:656px;">
        <input type="checkbox" name="punch">
</div>
<div style="position: absolute; left:290px; top:656px;">
        <input type="checkbox" name="shave">
</div>
<div style="position: absolute; left:348px; top:656px;">
        <input type="checkbox" name="othertypeofspecimenbiopsy">
</div>
<div style="position: absolute; left:33px; top:675px;">
        <input type="checkbox" name="cytology">
</div>
<div style="position: absolute; left:92px; top:675px;">
        <input type="checkbox" name="FNA">
</div>
<div style="position: absolute; left:160px; top:675px;">
        <input type="checkbox" name="fluid">
</div>
<div style="position: absolute; left:234px; top:675px;">
        <input type="checkbox" name="sputum">
</div>
<div style="position: absolute; left:291px; top:675px;">
        <input type="checkbox" name="urine">
</div>
<div style="position: absolute; left:348px; top:675px;">
        <input type="checkbox" name="othercytology">
</div>

  

   <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:967px; left:73px;"> 
    <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 and Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onClick="formPrint();releaseDirtyFlag();setTimeout('SubmitButton.click()',1000);"> 
	 </td></tr></table>
 </div>
</form>
</body>

</html>

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