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Aviation Medical Page 1 HTML

HTML icon AvMed1.html — HTML, 21 kB (21932 bytes)

File contents

<html>
<head>
<title></title>
<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 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>

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

<!-- 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 = 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>

</head>

<body onload="checkGender();">
<img id='BGImage' src="${oscar_image_path}AvMed1.png" style="position: absolute; left: 0px; top: 0px; width:750px">
<form method="post" action="" name="FormName" id="FormName" >

<input name="CatDesired" id="CatDesired" type="text" class="noborder" style="position:absolute; left:149px; top:83px; width:69px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="CatHeld" id="CatHeld" type="text" class="noborder" style="position:absolute; left:283px; top:83px; width:69px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="LicenceNumber" id="LicenceNumber" type="text" class="noborder" style="position:absolute; left:357px; top:83px; width:106px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="HomeTel" id="HomeTel" type="text" class="noborder" style="position:absolute; left:523px; top:83px; width:88px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="WorkTel" id="WorkTel" type="text" class="noborder" style="position:absolute; left:627px; top:83px; width:100px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FirstName" id="FirstName" type="text" class="noborder" style="position:absolute; left:77px; top:102px; width:148px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=patient_nameF>


<input name="LastName" id="LastName" type="text" class="noborder" style="position:absolute; left:283px; top:102px; width:180px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=patient_nameL>


<input name="FormerLastName" id="FormerLastName" type="text" class="noborder" style="position:absolute; left:535px; top:102px; width:194px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="StreetAddress" id="StreetAddress" type="text" class="noborder" style="position:absolute; left:139px; top:128px; width:175px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=address_street_number_and_name>


<input name="City" id="City" type="text" class="noborder" style="position:absolute; left:317px; top:133px; width:114px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=city>


<input name="Province" id="Province" type="text" class="noborder" style="position:absolute; left:433px; top:133px; width:30px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=province>


<input name="Country" id="Country" type="text" class="noborder" style="position:absolute; left:466px; top:134px; width:132px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="PostCode" id="PostCode" type="text" class="noborder" style="position:absolute; left:604px; top:134px; width:125px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="AddressChangeYes" id="AddressChangeYes" type="checkbox" style="position:absolute; left:24px; top:164px; ">


<input name="AddressChangeNo" id="AddressChangeNo" type="checkbox" style="position:absolute; left:83px; top:163px; ">


<input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; left:184px; top:158px; width:90px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=dobc2>


<input name="BirthPlace" id="BirthPlace" type="text" class="noborder" style="position:absolute; left:275px; top:159px; width:116px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Male" id="Male" type="checkbox" style="position:absolute; left:393px; top:150px; ">


<input name="Citizenship" id="Citizenship" type="text" class="noborder" style="position:absolute; left:467px; top:160px; width:129px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Education" id="Education" type="text" class="noborder" style="position:absolute; left:600px; top:159px; width:129px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Occupation" id="Occupation" type="text" class="noborder" style="position:absolute; left:19px; top:188px; width:164px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Employer" id="Employer" type="text" class="noborder" style="position:absolute; left:186px; top:188px; width:205px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FlightTime90" id="FlightTime90" type="text" class="noborder" style="position:absolute; left:496px; top:189px; width:68px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FlightTime12" id="FlightTime12" type="text" class="noborder" style="position:absolute; left:584px; top:189px; width:68px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FlightTimeTotal" id="FlightTimeTotal" type="text" class="noborder" style="position:absolute; left:659px; top:188px; width:70px; height:17px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="AccidentYes" id="AccidentYes" type="checkbox" style="position:absolute; left:24px; top:218px; ">


<input name="AccidntNo" id="AccidntNo" type="checkbox" style="position:absolute; left:83px; top:218px; ">


<input name="AccidentDate" id="AccidentDate" type="text" class="noborder" style="position:absolute; left:215px; top:215px; width:113px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:white;" value="">


<input name="AccidentPlace" id="AccidentPlace" type="text" class="noborder" style="position:absolute; left:329px; top:215px; width:247px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="AircraftReg" id="AircraftReg" type="text" class="noborder" style="position:absolute; left:581px; top:215px; width:148px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<textarea name="PhysicianVisits" id="PhysicianVisits" class="noborder" style="position:absolute; left:21px; top:255px; width:307px; height:67px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="RenewalRefusedYes" id="RenewalRefusedYes" type="checkbox" style="position:absolute; left:483px; top:242px; ">


<input name="RenewalRefuseNo" id="RenewalRefuseNo" type="checkbox" style="position:absolute; left:533px; top:243px; ">


<input name="AudiogramDate" id="AudiogramDate" type="text" class="noborder" style="position:absolute; left:576px; top:243px; width:153px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="InjuryYes" id="InjuryYes" type="checkbox" style="position:absolute; left:484px; top:272px; ">


<input name="InjuryNo" id="InjuryNo" type="checkbox" style="position:absolute; left:533px; top:272px; ">


<input name="ECGDate" id="ECGDate" type="text" class="noborder" style="position:absolute; left:577px; top:272px; width:152px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="LastAMEDate" id="LastAMEDate" type="text" class="noborder" style="position:absolute; left:452px; top:303px; width:115px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="AMEPlace" id="AMEPlace" type="text" class="noborder" style="position:absolute; left:578px; top:302px; width:151px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="Recreation" id="Recreation" type="checkbox" style="position:absolute; left:25px; top:334px; ">


<input name="Business" id="Business" type="checkbox" style="position:absolute; left:141px; top:334px; ">


<input name="Career" id="Career" type="checkbox" style="position:absolute; left:245px; top:332px; ">


<input name="English" id="English" type="checkbox" style="position:absolute; left:398px; top:332px; ">


<input name="French" id="French" type="checkbox" style="position:absolute; left:484px; top:333px; ">


<input name="FHMentalYes" id="FHMentalYes" type="checkbox" style="position:absolute; left:221px; top:376px; ">


<input name="FHMentalNo" id="FHMentalNo" type="checkbox" style="position:absolute; left:248px; top:376px; ">


<input name="FHCVSYes" id="FHCVSYes" type="checkbox" style="position:absolute; left:221px; top:394px; ">


<input name="FHCVSNo" id="FHCVSNo" type="checkbox" style="position:absolute; left:249px; top:395px; ">


<input name="FHDMYes" id="FHDMYes" type="checkbox" style="position:absolute; left:223px; top:414px; ">


<input name="FHDMNo" id="FHDMNo" type="checkbox" style="position:absolute; left:249px; top:415px; ">


<input name="FHOther" id="FHOther" type="text" class="noborder" style="position:absolute; left:21px; top:433px; width:194px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" value="">


<input name="FHOtherYes" id="FHOtherYes" type="checkbox" style="position:absolute; left:222px; top:432px; ">


<input name="FHOtherNo" id="FHOtherNo" type="checkbox" style="position:absolute; left:250px; top:432px; ">


<input name="RiskFactorFH" id="RiskFactorFH" type="checkbox" style="position:absolute; left:609px; top:398px; ">


<input name="RiskFactorSmoking" id="RiskFactorSmoking" type="checkbox" style="position:absolute; left:704px; top:398px; ">


<input name="RiskFactorHT" id="RiskFactorHT" type="checkbox" style="position:absolute; left:610px; top:417px; ">


<input name="RiskFactorDM" id="RiskFactorDM" type="checkbox" style="position:absolute; left:704px; top:415px; ">


<input name="RiskFactorObesity" id="RiskFactorObesity" type="checkbox" style="position:absolute; left:611px; top:435px; ">


<input name="RiskFactorLipids" id="RiskFactorLipids" type="checkbox" style="position:absolute; left:705px; top:434px; ">


<input name="HeadInjYes" id="HeadInjYes" type="checkbox" style="position:absolute; left:321px; top:490px; ">


<input name="HeadInjNo" id="HeadInjNo" type="checkbox" style="position:absolute; left:349px; top:490px; ">


<input name="HeadacheYes" id="HeadacheYes" type="checkbox" style="position:absolute; left:322px; top:504px; ">


<input name="HeadacheNo" id="HeadacheNo" type="checkbox" style="position:absolute; left:349px; top:505px; ">


<input name="EpilepsyYes" id="EpilepsyYes" type="checkbox" style="position:absolute; left:322px; top:519px; ">


<input name="EpilepsyNo" id="EpilepsyNo" type="checkbox" style="position:absolute; left:350px; top:519px; ">


<input name="PsychYes" id="PsychYes" type="checkbox" style="position:absolute; left:323px; top:533px; ">


<input name="PsychNo" id="PsychNo" type="checkbox" style="position:absolute; left:350px; top:533px; ">


<input name="EarYes" id="EarYes" type="checkbox" style="position:absolute; left:323px; top:548px; ">


<input name="EarNo" id="EarNo" type="checkbox" style="position:absolute; left:350px; top:548px; ">


<input name="AllergyYes" id="AllergyYes" type="checkbox" style="position:absolute; left:323px; top:562px; ">


<input name="AllergyNo" id="AllergyNo" type="checkbox" style="position:absolute; left:351px; top:562px; ">


<input name="PulmonaryYes" id="PulmonaryYes" type="checkbox" style="position:absolute; left:324px; top:576px; ">


<input name="PulmonaryNo" id="PulmonaryNo" type="checkbox" style="position:absolute; left:351px; top:576px; ">


<input name="CVSYes" id="CVSYes" type="checkbox" style="position:absolute; left:325px; top:592px; ">


<input name="CVSNo" id="CVSNo" type="checkbox" style="position:absolute; left:352px; top:591px; ">


<input name="GIYes" id="GIYes" type="checkbox" style="position:absolute; left:677px; top:490px; ">


<input name="GINo" id="GINo" type="checkbox" style="position:absolute; left:705px; top:490px; ">


<input name="MsKYes" id="MsKYes" type="checkbox" style="position:absolute; left:678px; top:505px; ">


<input name="MsKNo" id="MsKNo" type="checkbox" style="position:absolute; left:706px; top:505px; ">


<input name="MenstrualYes" id="MenstrualYes" type="checkbox" style="position:absolute; left:679px; top:519px; ">


<input name="MenstrualNo" id="MenstrualNo" type="checkbox" style="position:absolute; left:707px; top:519px; ">


<input name="DrugsAlcoholYes" id="DrugsAlcoholYes" type="checkbox" style="position:absolute; left:678px; top:533px; ">


<input name="DrugsAlcoholNo" id="DrugsAlcoholNo" type="checkbox" style="position:absolute; left:707px; top:533px; ">


<input name="OtherConditionsYes" id="OtherConditionsYes" type="checkbox" style="position:absolute; left:680px; top:548px; ">


<input name="OtherConditionsNo" id="OtherConditionsNo" type="checkbox" style="position:absolute; left:707px; top:548px; ">


<input name="MedicationsYes" id="MedicationsYes" type="checkbox" style="position:absolute; left:679px; top:562px; ">


<input name="MedicationsNo" id="MedicationsNo" type="checkbox" style="position:absolute; left:706px; top:562px; ">


<input name="SmokesYes" id="SmokesYes" type="checkbox" style="position:absolute; left:679px; top:578px; ">


<input name="SmokesNo" id="SmokesNo" type="checkbox" style="position:absolute; left:707px; top:578px; ">


<input name="AlcoholYes" id="AlcoholYes" type="checkbox" style="position:absolute; left:679px; top:591px; ">


<input name="AlcoholNo" id="AlcoholNo" type="checkbox" style="position:absolute; left:706px; top:592px; ">


<input name="AlcoholWeekly" id="AlcoholWeekly" type="text" class="noborder" style="position:absolute; left:506px; top:594px; width:168px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:white;" value="">


<textarea name="Elaborate" id="Elaborate" class="noborder" style="position:absolute; left:20px; top:632px; width:706px; height:65px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="Today1" id="Today1" type="text" class="noborder" style="position:absolute; left:32px; top:781px; width:140px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=today>


<input name="Fit" id="Fit" type="checkbox" style="position:absolute; left:101px; top:852px; ">


<input name="Deferred" id="Deferred" type="checkbox" style="position:absolute; left:142px; top:853px; ">


<input name="Cat1" id="Cat1" type="checkbox" style="position:absolute; left:101px; top:871px; ">


<input name="Cat2" id="Cat2" type="checkbox" style="position:absolute; left:141px; top:871px; ">


<input name="Cat3" id="Cat3" type="checkbox" style="position:absolute; left:182px; top:872px; ">


<input name="Cat4" id="Cat4" type="checkbox" style="position:absolute; left:223px; top:872px; ">


<input name="RenewalYes" id="RenewalYes" type="checkbox" style="position:absolute; left:503px; top:853px; ">


<input name="RenewalNo" id="RenewalNo" type="checkbox" style="position:absolute; left:529px; top:853px; ">


<input name="FurtherExamYes" id="FurtherExamYes" type="checkbox" style="position:absolute; left:503px; top:867px; ">


<input name="FurtherExamNo" id="FurtherExamNo" type="checkbox" style="position:absolute; left:530px; top:867px; ">


<input name="ReportYes" id="ReportYes" type="checkbox" style="position:absolute; left:503px; top:881px; ">


<input name="ReportNo" id="ReportNo" type="checkbox" style="position:absolute; left:530px; top:881px; ">


<input name="LastBoxYes" id="LastBoxYes" type="checkbox" style="position:absolute; left:503px; top:894px; ">


<input name="LastBoxNo" id="LastBoxNo" type="checkbox" style="position:absolute; left:531px; top:894px; ">


<input name="Today2" id="Today2" type="text" class="noborder" style="position:absolute; left:37px; top:924px; width:107px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:white;"  oscarDB=today>


<textarea name="Remarks" id="Remarks" class="noborder" style="position:absolute; left:72px; top:890px; width:197px; height:32px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="MDPhone" id="MDPhone" type="text" class="noborder" style="position:absolute; left:156px; top:924px; width:115px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;"  oscarDB=doctor_work_phone>


<textarea name="Details" id="Details" class="noborder" style="position:absolute; left:279px; top:375px; width:255px; height:74px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:center; background-color:transparent;" ></textarea>


<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="checkbox" class="noborder" style="position:absolute; left: -2px; top: -4px">
<input name="Female" id="Female" type="checkbox" class="noborder" style="position:absolute; left: 394px; top: 164px">



 <div class="DoNotPrint" id="BottomButtons" style="position: absolute; top:980px; left:0px;">
	 <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 & 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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