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Doctor's note

Provided by Eileen Cochien - This is a stand alone html eform for a doctors note. It has multiple choices including surgery, illness, illness in the family, can return to work etc. It uses the calendar feature to pick dates.

HTML icon dr_note_plainv2.html — HTML, 9 kB (9324 bytes)

File contents

<!-- Compiled by Dr. Eileen Cochien May 2015 -->
<html>
	<head>
<style type="text/css" media="print">
	body {
			font-family: 'Arial', serif;
			font-size: 14px;
			line-height: 26px;
		}
		.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;
		}
		.fancyheader {
			font-family: 'Arial', serif;
			font-size: 20px;
		}
    </style>
	

<!--OSCAR building functions-->  
<!-- main calendar program -->
<script type="text/javascript" src="../share/calendar/calendar.js"></script>
<!-- language for the calendar -->
<script type="text/javascript"	src="../share/calendar/lang/calendar-en.js"></script>
<!-- the following script defines the Calendar.setup helper function -->
<script type="text/javascript" src="../share/calendar/calendar-setup.js"></script>
<!-- calendar stylesheet -->
<link rel="stylesheet" type="text/css" media="all" href="../share/calendar/calendar.css" title="win2k-cold-1" />



<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?";
		 }
	}

//submit and print functions 
        function printSubmit(){
            printLetter();
            releaseDirtyFlag();
            submission();
        }

        function printLetter(){
            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';
        }

</script>
<!--end of OSCAR building functions-->  


	<!-- Xbox styling -->
	<style type="text/css">
		.box1 {
			position: relative;
			border: 1px solid #000000;
			cursor: pointer;
			font-weight: bold;
			text-align: center;
			background: white;
			font-size: 14px;
			width:16px;
			height:16px;
		}
		
	</style>
	<!-- XBox styling -->
	
	<!-- XBox code -->
	<script language="javascript" type="text/javascript" src="https://code.jquery.com/jquery-1.9.1.min.js"></script>
	<script language="javascript" type="text/javascript">
	    $( document ).ready(function() {
		    $('.XBox').prop("readonly","true");
            $('.XBox').mousedown(function(evt) {
            	changeValue(evt.target);
            });
			$('.XBox').keydown(function(evt) {
				displayKeyCode(evt);
			});	
        });
		function changeValue(element) {
        	if (element.val == undefined) {
        		element = $(element); // Convert to jquery element
        	}

            if (element.val() == '') {
            	element.val('X');
            } else {
            	element.val('');
            }
        }
        function displayKeyCode(evt) {
            var charCode = evt.which || evt.keyCode;
            // any key press except tab will constitute a value change to the checkbox
            if (charCode != 9){
                changeValue(evt.target);
                return false;
            }
        }	
	</script>
	<!-- XBox code -->


<title>Doctor's Note</title>

</head>

	<body>
	<form method="post" action="" name="FormName" id="FormName" autocomplete="on">
		<div style="text-align: center;  width: 700px;">
		<input name="ClinicName" class="fancyheader" type="text" style="border: medium none white; text-align: center; width:700px;" oscardb=clinic_name><br>
		<input name="ClinicAddress" type="text" style="border: medium none white; text-align: center; width:700px;" oscardb=clinic_addressLineFull><br>
		<span>Tel&#58; &nbsp; <input name="Tel" type="text" style="border: medium none white; text-align: left;" oscardb=clinic_phone> &nbsp; &nbsp; Fax&#58;  &nbsp; <input name="Fax" type="text" style="border: medium none white; text-align: left;" oscardb=clinic_fax></span>
		</div>
		
		<div style="text-align: left; width: 700px;">
			<br>
			<p>Date: <input name="todaydate" class="noborder" oscarDB=today style="border: medium none white; text-align: left;" type="text"></p>

			<text>This letter is to certify that </text><input name="patient_name" class="noborder" oscarDB=first_last_name style="border: medium none white; text-align: left;" type="text"><br>
			
			<input type="text" class="Xbox box1" name="seen"> &nbsp; was seen in my office today for medical problems<br>
			<input type="text" class="Xbox box1" name="assessed"> &nbsp; was assessed today and was found to be unfit to work due to medical problem(s)<br>
			<input type="text" class="Xbox box1" name="unfit"> &nbsp; is unfit for gym or sports due to medical problems<br>
			<input type="text" class="Xbox box1" name="absent"> &nbsp; is absent due to illness in the family<br>
			<input type="text" class="Xbox box1" name="return"  > &nbsp; may return to work<br>
			<input type="text" class="Xbox box1" name="restrictions"> &nbsp; may return to suitable work with the following restrictions:<br>
			<textarea rows="4" cols="75" style="font-family:sans-serif; font-style:normal; font-weight:normal;"></textarea><br>
			From <img src="../images/cal.gif" id="User_date_cal_frm" class="DoNotPrint" ><input type="text" id="fromDate" name="fromDate" style="width: 80px; text-align: left;"/>
			To <img src="../images/cal.gif" id="User_date_cal_to" class="DoNotPrint" ><input type="text" id="toDate" name="toDate" style="width: 80px; text-align: left;"/> (dd-mm-yyyy) <br><br>
			
			Additional comments:<br>
			<textarea rows="10" cols="75" style="font-family:sans-serif; font-style:normal; font-weight:normal;"></textarea><br><br>
			
			Sincerely,<br>
			Dr. <input name="current_user" class="noborder" oscarDB=current_user type="text"><br><br>
			
		</div>
	</form>
<script type="text/javascript">
  Calendar.setup(
    {
      inputField  : "fromDate",         // ID of the input field
      ifFormat    : "%d-%m-%Y",     // the date format
      button      : "User_date_cal_frm" // ID of the calendar trigger
    }
  ); 
</script>

<script type="text/javascript">
  Calendar.setup(
    {
      inputField  : "toDate",         // ID of the input field
      ifFormat    : "%d-%m-%Y",     // the date format
      button      : "User_date_cal_to" // ID of the calendar trigger
    }
  ); 
</script>	
	
            <!-- The submit/print/reset buttons -->
                <table class="DoNotPrint" >
                    <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" id="PrintSubmitButton" type="button" onClick="printSubmit()">
                        </td>
                    </tr>
                </table>
                <!-- End of submit/print/reset buttons -->
	
<!-- Copy Left -->
<div class="DoNotPrint" id="CopyLeft" style="font-family:sans-serif; font-size:12px">
	<p><br></p>	
	<a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US"><br><img alt="Creative Commons License" style="border-width:0;" src="http://i.creativecommons.org/l/by-sa/3.0/80x15.png" /></a><br><span xmlns:dct="http://purl.org/dc/terms/" property="dct:title">Doctors note </span> by <span xmlns:cc="http://creativecommons.org/ns#" property="cc:attributionName">Eileen Cochien</span> is licensed under a <a rel="license" href="http://creativecommons.org/licenses/by-sa/3.0/deed.en_US">Creative Commons Attribution-ShareAlike 3.0 Unported License</a>.<br>Permissions beyond the scope of this license may be available at <a xmlns:cc="http://creativecommons.org/ns#" href="http://www.oscarcanada.org/" rel="cc:morePermissions">http://www.oscarcanada.org/</a>.
</div>
</span>

	</body>
	
</html>

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