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PrenatalGDMScreen.html

HTML icon PrenatalGDMScreen.html — HTML, 20 kB (20610 bytes)

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<html>
<head>
<title>Lab Requisition - Prenatal GDM Screening</title>
<!-------Script to maximize window on loading----------->
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</script>
<!----------End maximizing window scipt---------->
<!-- CSS Script that removes textarea and textbox borders when printing -->
<style type="text/css" media="print">
.DoNotPrint{
    display:none;
}
.noborder {
	scrollbar-3dlight-color: transparent;
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	background: transparent;
	overflow: hidden;
	border : 0px;
}
</style>
<!-- ------------------------------------------------------------------ -->
</head>

<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
	<img src="${oscar_image_path}LabReq.png" width="750">
</div>
<!-- You can remove ${oscar_image_path} as you develop the form, but make sure you put it back before uploading to OSCAR otherwise the image wouldn't show.
<!-- Also note: the image filename IS CASE SENSITIVE INCLUDING THE EXTENSION. It may work otherwise in Windows, but not in OSCAR because it's based on a Linux platform -->

<form name="LabReqForm" method="POST" action="">

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

<!-- -------------Bill to:------ -->
<div style="position: absolute; left: 58px; top: 58px;">
	<input name="BillToMSP" type="checkbox" tabindex="1" class="noborder">
</div>
<div style="position: absolute; left: 102px; top: 58px;">
	<input name="BillToICBC" type="checkbox" tabindex="2" class="noborder">
</div>
<div style="position: absolute; left: 150px; top: 58px;">
	<input name="BillToWCB" type="checkbox" tabindex="3" class="noborder">
</div>
<div style="position: absolute; left: 196px; top: 58px;">
	<input name="BillToPatient" type="checkbox" tabindex="4" class="noborder">
</div>
<div style="position: absolute; left: 250px; top: 58px;">
	<input name="BillToOther" type="checkbox" tabindex="5" class="noborder">
</div>
<div style="position: absolute; left: 298px; top: 58px;"> 
	<input name="BillToOtherText" class="noborder"  style="width: 210px; font-family: Arial; font-size: 12px;" tabindex="6" type="text">
</div>
<div style="position: absolute; left: 58px; top: 80px;"> 
	<input name="PHN" class="noborder"  oscardb=HIN style="width: 180px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="7" type="text">
</div>
<div style="position: absolute; left: 314px; top: 80px;"> 
	<input name="IDNumber" class="noborder"  style="width: 180px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="8" type="text">
</div>

<!-- -------------Name------ -->
<div style="position: absolute; left:21px; top:113px;"> 
	<input name="Surname" type="text" class="noborder"  oscarDB=patient_nameL style="width: 190px; font-family: Arial; font-size: 12px;" tabindex="9">
</div>
<div style="position: absolute; left:254px; top:113px;"> 
	<input name="FirstName" type="text" class="noborder"  oscarDB=patient_nameF style="width: 124px; font-family: Arial; font-size: 12px;" tabindex="10">
</div>
<div style="position: absolute; left:421px; top:113px;"> 
	<input name="Initials" type="text" class="noborder"  style="width: 63px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="11">
</div>
<!-- -------------Demographics------ -->
<div style="position: absolute; left: 20px; top: 145px;"> 
	<input name="Address" class="noborder" oscardb=addressLine style="width: 490px; font-family: Arial; font-size: 12px;" tabindex="12" type="text">
</div>

<div style="position: absolute; left: 20px; top: 183px;"> 
	<input name="DOB" class="noborder"  oscardb=dob style="width: 110px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="13" type="text">
</div>

<div style="position: absolute; left: 54px; top: 216px;"> 
	<input name="gender" class="noborder" name="gender" oscardb=sex style="width: 63px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="14" type="text">
</div>
<div style="position: absolute; left: 163px; top: 183px;"> 
	<input name="PatientPhoneNumber" class="noborder"  oscardb=phone style="width: 180px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="15" type="text">
</div>

<div style="position: absolute; left: 163px; top: 216px;"> 
	<input name="ChartNumber" class="noborder"  style="width: 80px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="16" type="text">
</div>
<div style="position: absolute; left: 254px; top: 216px;"> 
	<input name="LTCRoomNumber" class="noborder"  style="width: 80px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="17" type="text">
</div>
<div style="position: absolute; left:20px; top:253px;">
	<textarea name="CurrentMedications" class="noborder" wrap="virtual" style="height: 60; width: 150; font-family: Arial; font-size: 10px" tabindex="18"></textarea>
</div>
<div style="position: absolute; left: 20px; top: 333px;"> 
	<input name="DateTimeLastDose" class="noborder"  style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="19" type="text">
</div>
<div style="position: absolute; left: 183px; top: 252px;">
<b>        <input name="PregnantYes" type="checkbox" checked tabindex="20" checked>
</b></div>
<div style="position: absolute; left: 183px; top: 271px;">
<b>        <input name="PregnantNo" type="checkbox" tabindex="21">
</b></div>

<!-----------Collection Detail-------------->

<div style="position: absolute; left: 235px; top: 244px;">
	<input name="Fasting" type="checkbox" tabindex="22" class="noborder">
</div>
<div style="position: absolute; left: 240px; top: 265px;"> 
	<input name="FastingTime" class="noborder"  style="width: 25px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="23" type="text">
</div>
<div style="position: absolute; left: 364px; top: 183px;"> 
	<input name="CollectionDateTime" class="noborder"  style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="24" type="text">
</div>
<div style="position: absolute; left: 364px; top: 216px;"> 
	<input name="Phlebotomist" class="noborder"  style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="25" type="text">
</div>
<div style="position: absolute; left: 364px; top: 255px;"> 
	<input name="TelephoneRequisitionReceivedBy" class="noborder"  style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="26" type="text">
</div>
<div style="position: absolute; left: 195px; top: 316px;"> 
	<input name="DiagnosisAndIndications" class="noborder"  style="width: 550px; font-family: Arial; font-size: 12px;" tabindex="27" type="text" value="Pregnancy">
</div>
<!------------Ordering Physcian(s) info--------------->
<div style="position: absolute; left: 527px; top: 80px;"> 
	<input name="PhysicanName" class="noborder"  oscardb=doctor style="width: 220px; font-family: Arial; font-size: 12px; font-weight: bold; text-align: left;" tabindex="28" type="text">
</div>
<div style="position: absolute; left:527px; top:96px;">
    <textarea name="Clinic label" class="noborder" style="height: 70; width: 220; font-family: Arial; font-size: 10px; font-weight: bold;" oscarDB=clinic_label tabindex="29"></textarea>
</div>
<div style="position: absolute; left: 527px; top: 183px;"> 
	<input name="STATContact" class="noborder"  style="width: 210px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="30" type="text">
</div>
<div style="position: absolute; left: 527px; top: 218px;"> 
	<input name="CopyTo" class="noborder"  style="width: 168px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="31" type="text">
</div>

<div style="position: absolute; left: 590px; top: 250px;"> 
	<input name="LocumName" class="noborder"  style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="32" type="text">
</div>

<div style="position: absolute; left: 590px; top: 270px;"> 
	<input name="LocumMSP" class="noborder"  style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="33" type="text">
</div>

<!-----------Hematology-------------------->
<div style="position: absolute; left: 13px; top: 378px;">
	<input name="WBC" type="checkbox" tabindex="34" class="noborder">
</b></div>
<div style="position: absolute; left: 13px; top: 393px;">
	<input name="Hemoglobin" type="checkbox" tabindex="35" class="noborder">
</div>
<div style="position: absolute; left: 95px; top: 392px;">
	<input name="HemoglobinOnly" type="checkbox" tabindex="36" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 410px;">
	<input name="HematologyProfile" type="checkbox" checked tabindex="37" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 448px;">
	<input name="PTINR" type="checkbox" tabindex="38" class="noborder">
</div>
<div style="position: absolute; left: 176px; top: 448px;">
	<input name="WarfarinYes" type="checkbox" tabindex="39" class="noborder">
</div>
<div style="position: absolute; left: 210px; top: 448px;">
	<input name="WarfarinNo" type="checkbox" tabindex="40" class="noborder">
</div>
<div style="position: absolute; left: 176px; top: 467px;">
	<input name="MechanicalValveYes" type="checkbox" tabindex="41" class="noborder">
</div>
<div style="position: absolute; left: 210px; top: 467px;">
	<input name="MechanicalValveNo" type="checkbox" tabindex="42" class="noborder">
</div>

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

<div style="position: absolute; left: 13px; top: 530px;">
	<input name="GlucoseFasting" type="checkbox"  tabindex="43" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 544px;">
	<input name="GTTGDMScreen" type="checkbox" checked tabindex="44" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 570px;">
	<input name="GTTGDMConfirmation" type="checkbox" tabindex="45" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 595px;">
	<input name="UrinePregnancyTest" type="checkbox" tabindex="46" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 614px;">
	<input name="TherapeuticDrugConcentration" type="checkbox" tabindex="47" class="noborder">
</div>
<div style="position: absolute; left: 35px; top: 646px;"> 
	<input name="TherapeuticDrugs" class="noborder"  style="width: 205px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="48" type="text">
</div>
<div style="position: absolute; left: 32px; top: 664px;">
	<input name="ToxicitSuspected" type="checkbox" tabindex="49" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 684px;">
	<input name="TSH" type="checkbox" tabindex="50" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 718px;">
	<input name="PSABillable" type="checkbox" tabindex="51" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 744px;">
	<input name="PSAPatientMustPay" type="checkbox" tabindex="52" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 765px;">
	<input name="Ferritin" type="checkbox" tabindex="53" class="noborder">
</div>
<div style="position: absolute; left: 74px; top: 765px;">
	<input name="IronAndTransferrinSaturation" type="checkbox" tabindex="54">
</div>
<div style="position: absolute; left: 13px; top: 852px;">
	<input name="TCBillable" type="checkbox" tabindex="55" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 866px;">
	<input name="HDLBillable" type="checkbox" tabindex="56" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 880px;">
	<input name="TGBillable" type="checkbox" tabindex="57" class="noborder">
</div>
<div style="position: absolute; left: 13px; top: 894px;">
	<input name="LDLBillable" type="checkbox" tabindex="58" class="noborder">
</div>
<div style="position: absolute; left: 144px; top: 852px;">
	<input name="TCPatientPay" type="checkbox" tabindex="59" class="noborder">
</div>
<div style="position: absolute; left: 144px; top: 866px;">
	<input name="HDLPatientPay" type="checkbox" tabindex="60" class="noborder">
</div>
<div style="position: absolute; left: 144px; top: 880px;">
	<input name="TGPatientPay" type="checkbox" tabindex="61" class="noborder">
</div>
<div style="position: absolute; left: 144px; top: 894px;">
	<input name="LDLPatientPay" type="checkbox" tabindex="62" class="noborder">
</div>

<!-----------Microbiology-------------------------->
<!-----------Non-genital-------->
<div style="position: absolute; left: 250px; top: 433px;">
	<input name="Nose" type="checkbox" tabindex="63" class="noborder">
</div>
<div style="position: absolute; left: 344px; top: 433px;">
	<input name="Stool" type="checkbox" tabindex="64" class="noborder">
</div>
<div style="position: absolute; left: 250px; top: 450px;">
	<input name="Sputum" type="checkbox" tabindex="65" class="noborder">
</div>
<div style="position: absolute; left: 344px; top: 450px;">
	<input name="Other" type="checkbox" tabindex="66" class="noborder">
</div>
<div style="position: absolute; left: 395px; top: 450px;" class="noborder"> 
	<input name="OtherSpecimen" type="text" class="noborder"  style="width: 95px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="67">
</div>
<div style="position: absolute; left: 250px; top: 468px;">
	<input name="Throat" type="checkbox" tabindex="69" class="noborder">
</div>
<div style="position: absolute; left: 350px; top: 484px;"> 
	<input name="AbxAllergies" type="text" class="noborder"  style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" tabindex=70">
</div>
<div style="position: absolute; left: 356px; top: 506px;">
	<input name="OnAbxYes" type="checkbox" tabindex="71" class="noborder">
</div>
<div style="position: absolute; left: 408px; top: 506px;">
	<input name="OnAbxNo" type="checkbox" tabindex="72" class="noborder">
</div>
<div style="position: absolute; left: 350px; top: 527px;"> 
	<input name="NameOfAbx" type="text" class="noborder"  style="width: 140px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="73">
</div>

<div style="position: absolute; left: 250px; top: 555px;">
	<input name="FungusCulture" type="checkbox" tabindex="74" class="noborder">
</div>
<div style="position: absolute; left: 348px; top: 555px;">
	<input name="FungusKOHPrep" type="checkbox" tabindex="75" class="noborder">
</div>
<div style="position: absolute; left: 295px; top: 575px;"> 
	<input name="FungusSpecimenSite" type="text" class="noborder" name="FungusSpecimenSite" style="width: 200px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="76">
</div>
<!-----------Genital-------->
<div style="position: absolute; left: 253px; top: 616px;">
	<input name="VaginitisInitial" type="checkbox" tabindex="77" class="noborder">
</div>
<div style="position: absolute; left: 253px; top: 632px;">
	<input name="VaginitisChronic" type="checkbox" tabindex="78" class="noborder">
</div>
<div style="position: absolute; left: 253px; top: 649px;">
	<input name="CervixGC" type="checkbox" tabindex="79" class="noborder">
</div>
<div style="position: absolute; left: 253px; top: 664px;">
	<input name="UrethraGCSmear" type="checkbox" tabindex="80" class="noborder">
</div>
<div style="position: absolute; left: 253px; top: 680px;">
	<input name="VaginoAnoRectalGBS" type="checkbox" tabindex="81"  class="noborder">
</div>
<div style="position: absolute; left: 253px; top: 695px;">
	<input name="Trichomonas" type="checkbox" tabindex="82" class="noborder">
</div>
<!-----------GC-------->
<div style="position: absolute; left: 253px; top: 730px;">
	<input name="Chlamydia" type="checkbox" tabindex="83" class="noborder">
</div>
<div style="position: absolute; left: 367px; top: 730px;">
	<input name="ChlamydiaGC" type="checkbox" tabindex="84" class="noborder">
</div>
<div style="position: absolute; left: 295px; top: 748px;"> 
	<input name="ChlamydiaGCSite" type="text" class="noborder" style="width: 200px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="85">
</div>
<!-----------Viral Hepatitis-------->
<div style="position: absolute; left: 248px; top: 814px;">
	<input name="AcuteHepatitis" type="checkbox" tabindex="86"  class="noborder">
</div>
<div style="position: absolute; left: 313px; top: 814px;">
	<input name="PreviousChronicHepatitis" type="checkbox" tabindex="87" class="noborder">
</div>
<div style="position: absolute; left: 412px; top: 814px;" >
	<input name="CarrierHepatitis" type="checkbox" tabindex="88" class="noborder">
</div>
<!-----------Stool O&P-------->
<div style="position: absolute; left: 248px; top: 860px;">
	<input name="OneStoolSpecimen" type="checkbox" tabindex="89" class="noborder">
</div>
<div style="position: absolute; left: 344px; top: 860px;">
	<input name="TwoStoolSpecimen" type="checkbox" tabindex="90"  class="noborder">
</div>

<!-----------Urinalysis/Urine Culture-------->
<div style="position: absolute; left: 508px; top: 383px;">
	<input name="UrineMacroscopic" type="checkbox" tabindex="91" class="noborder">
</div>
<div style="position: absolute; left: 629px; top: 383px;">
	<input name="UrineMicroscopic" type="checkbox" tabindex="92" class="noborder">
</div>
<div style="position: absolute; left: 508px; top: 400px;">
	<input name="UrineMacroscopicMicroscopicIfDipstickPositive" type="checkbox"  tabindex="93" class="noborder">
</div>
<div style="position: absolute; left: 508px; top: 416px;">
	<input name="UrineMacroscopicAndMicroscopic" type="checkbox" tabindex="94" class="noborder">
</div>
<div style="position: absolute; left: 508px; top: 431px;">
	<input name="UrineMacroscopicCultureIfPyuriaOrNitrate" type="checkbox"  tabindex="95" class="noborder">
</div>
<div style="position: absolute; left: 508px; top: 447px;">
	<input name="UrineCulture" type="checkbox"  tabindex="96" class="noborder">
</div>
<!-----------Special Tests-------->
<div style="position: absolute; left: 520px; top: 499px;">
	<input name="HIVNominal" type="checkbox" tabindex="97" class="noborder">
</div>
<div style="position: absolute; left: 520px; top: 516px;">
	<input name="HIVNonNominal" type="checkbox" tabindex="98" class="noborder">
</div>
<!-----------Additional test/instructions------------------>
<div style="position: absolute; left: 510px; top: 650px;"> 
	<textarea name="AdditionalTestInstructions" class="noborder" wrap="virtual" style="height: 230px; width: 245px; font-family: Arial; font-size: 12px;" tabindex="99"></textarea>
</div>
<!----------Signoff----------------------->
<div style="position: absolute; left: 260px; top: 903px; font-size:12px">
	<b>"Electronically signed"</b>
</div>
<div style="position: absolute; left: 518px; top: 903px;"> 
	<input name="LabreqDate" class="noborder" oscardb=today style="width: 200px; font-family: Arial; font-size: 12px; text-align: center;" tabindex="100" type="text">
</div>


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


<!-- The submit/print/reset buttons -->
<div class="DoNotPrint" style="position: absolute; top: 958px; left: 41px;">
<table>
	<tr>
		<td class="subjectline">
			Subject: <input name="subject" size="40" type="text">&nbsp;
			<input value="Submit" name="B1" type="submit">
			<input value="Reset" name="B2" type="reset">
			<input value="Print" onclick="javascript:window.print()" type="button">
                        <input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print(); document.LabReqForm.submit()">
		</td>
	</tr>
</table>
</div>
</form>
</body></html>

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