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Prenatal Ultrasound With Calculator

Checks for Metformin prescription as well linked to ImagingFHA092b.png

HTML icon PrenatalRadiology.html — HTML, 47 kB (48720 bytes)

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<html>
<head>
<title>Imaging Requisition - Hospital</title>

<script language="JavaScript1.2">
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	background-color: lightyellow;
	width: 200px;
	visibility: hidden;
	z-index: 100;
	font-size: 10;
}

</style>


<script type="text/javascript" language="javascript">
function date(){
       var digital = new Date();
       var days = digital.getDate();
       var months = (digital.getMonth()*1 +1)*30.4;
       var years = (digital.getFullYear())*365;
       var dToday = days+months+years;

	var myString2= document.getElementById("eGFRDate").value; 
        if (myString2> "0"){ 
	var mySplitResult2 = myString2.split("-");
	var aeGFR= mySplitResult2[0]*365;
	var beGFR= mySplitResult2[1]*30.4;
	var feGFR= mySplitResult2[2];
        var geGFR= feGFR.split(" ");
        var ceGFR= geGFR[0];
        var deGFR= (aeGFR*1)+(beGFR*1)+(ceGFR*1);
        var eeGFR= dToday - deGFR;
    }
         if ((eeGFR < 31)&&(eeGFR >= 0)){
                document.getElementById("eGFRDate2").style.background='#9AFF9A';
		document.getElementById('eGFRDate2').value = (Math.round(eeGFR));
         }
         if (eeGFR > 30){
                document.getElementById("eGFRDate2").style.background='#C6B5DE';
		document.getElementById('eGFRDate2').value = (Math.round(eeGFR));
         }

         if (document.getElementById ("eGFR").value == "> 120") {
                document.getElementById("eGFR2").style.background='#9AFF9A';
         }
         if (document.getElementById ("eGFR").value >59) {
                document.getElementById("eGFR2").style.background='#9AFF9A';
         }
         if ((document.getElementById ("eGFR").value <60)&& (document.getElementById ("eGFR").value >0)) {
                document.getElementById("eGFR2").style.background='#FF0000';
         }
}
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<script language="javascript" type="text/javascript">
function onLoad(){
      if (document.getElementById("counter").value ==''){
       (document.getElementById("counter").value = 1);
       date();
       checkIt();
       CheckCopyTo();
       date();
      }  

}
</script>

<!-- Script to check for change in default payer -->
<script language="javascript">
function checkIt(){
	if (BillToWSBC.checked==false && BillToICBC.checked==false && BillToPatient.checked==false && BillToOther.checked==false)
		{
		BillToMSP.checked = true;
	}
}
</script>

<script language="javascript" type="text/javascript">
function CheckCopyTo(){
      if (document.getElementById("PhysicianName").value != document.getElementById("PatientMD").value){
       (document.getElementById("CopyTo").value = document.getElementById("PatientMD").value);
    }

}
</script>


<script language="javascript" type="text/javascript">
 function start(){

	//Check to see if DM

	 if ((document.getElementById('DMT').value == '')){
	 document.MedicalImagingForm.DiabeticNo.checked = true;
       }
	 if ((document.getElementById('DMT').value == 'No')||(document.getElementById('DMT').value == 'Yes')||(document.getElementById('DMT').value == 'NotApplicable')){
	 document.MedicalImagingForm.DiabeticYes.checked = true;
       }
        if (document.getElementById("A1C").value >6.2){
          document.MedicalImagingForm.DiabeticYes.checked = true;
        }



var Drug = /METFORMIN/;
var string1 = document.getElementById("Meds").value;
var match = string1.search(Drug);

if(match != -1)
	  document.MedicalImagingForm.MetforminYes.checked = true;
else
	  document.MedicalImagingForm.MetforminNo.checked = true;

var Drug2 = /WARFARIN/;
var string2 = document.getElementById("Meds").value;
var match = string2.search(Drug2);

if(match != -1)
	  document.MedicalImagingForm.AnticoagulantYes.checked = true;
else
	  document.MedicalImagingForm.AnticogulantNo.checked = true;



}
</script>

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 * Website: http://www.datejs.com/ or http://www.coolite.com/datejs/
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try{r=(px[i].call(this,s));}catch(e){r=null;}
if(r){return r;}}
throw new $P.Exception(s);};},each:function(){var px=arguments;return function(s){var rx=[],r=null;for(var i=0;i<px.length;i++){if(px[i]==null){continue;}
try{r=(px[i].call(this,s));}catch(e){throw new $P.Exception(s);}
rx.push(r[0]);s=r[1];}
return[rx,s];};},all:function(){var px=arguments,_=_;return _.each(_.optional(px));},sequence:function(px,d,c){d=d||_.rtoken(/^\s*/);c=c||null;if(px.length==1){return px[0];}
return function(s){var r=null,q=null;var rx=[];for(var i=0;i<px.length;i++){try{r=px[i].call(this,s);}catch(e){break;}
rx.push(r[0]);try{q=d.call(this,r[1]);}catch(ex){q=null;break;}
s=q[1];}
if(!r){throw new $P.Exception(s);}
if(q){throw new $P.Exception(q[1]);}
if(c){try{r=c.call(this,r[1]);}catch(ey){throw new $P.Exception(r[1]);}}
return[rx,(r?r[1]:s)];};},between:function(d1,p,d2){d2=d2||d1;var _fn=_.each(_.ignore(d1),p,_.ignore(d2));return function(s){var rx=_fn.call(this,s);return[[rx[0][0],r[0][2]],rx[1]];};},list:function(p,d,c){d=d||_.rtoken(/^\s*/);c=c||null;return(p instanceof Array?_.each(_.product(p.slice(0,-1),_.ignore(d)),p.slice(-1),_.ignore(c)):_.each(_.many(_.each(p,_.ignore(d))),px,_.ignore(c)));},set:function(px,d,c){d=d||_.rtoken(/^\s*/);c=c||null;return function(s){var r=null,p=null,q=null,rx=null,best=[[],s],last=false;for(var i=0;i<px.length;i++){q=null;p=null;r=null;last=(px.length==1);try{r=px[i].call(this,s);}catch(e){continue;}
rx=[[r[0]],r[1]];if(r[1].length>0&&!last){try{q=d.call(this,r[1]);}catch(ex){last=true;}}else{last=true;}
if(!last&&q[1].length===0){last=true;}
if(!last){var qx=[];for(var j=0;j<px.length;j++){if(i!=j){qx.push(px[j]);}}
p=_.set(qx,d).call(this,q[1]);if(p[0].length>0){rx[0]=rx[0].concat(p[0]);rx[1]=p[1];}}
if(rx[1].length<best[1].length){best=rx;}
if(best[1].length===0){break;}}
if(best[0].length===0){return best;}
if(c){try{q=c.call(this,best[1]);}catch(ey){throw new $P.Exception(best[1]);}
best[1]=q[1];}
return best;};},forward:function(gr,fname){return function(s){return gr[fname].call(this,s);};},replace:function(rule,repl){return function(s){var r=rule.call(this,s);return[repl,r[1]];};},process:function(rule,fn){return function(s){var r=rule.call(this,s);return[fn.call(this,r[0]),r[1]];};},min:function(min,rule){return function(s){var rx=rule.call(this,s);if(rx[0].length<min){throw new $P.Exception(s);}
return rx;};}};var _generator=function(op){return function(){var args=null,rx=[];if(arguments.length>1){args=Array.prototype.slice.call(arguments);}else if(arguments[0]instanceof Array){args=arguments[0];}
if(args){for(var i=0,px=args.shift();i<px.length;i++){args.unshift(px[i]);rx.push(op.apply(null,args));args.shift();return rx;}}else{return op.apply(null,arguments);}};};var gx="optional not ignore cache".split(/\s/);for(var i=0;i<gx.length;i++){_[gx[i]]=_generator(_[gx[i]]);}
var _vector=function(op){return function(){if(arguments[0]instanceof Array){return op.apply(null,arguments[0]);}else{return op.apply(null,arguments);}};};var vx="each any all".split(/\s/);for(var j=0;j<vx.length;j++){_[vx[j]]=_vector(_[vx[j]]);}}());(function(){var flattenAndCompact=function(ax){var rx=[];for(var i=0;i<ax.length;i++){if(ax[i]instanceof Array){rx=rx.concat(flattenAndCompact(ax[i]));}else{if(ax[i]){rx.push(ax[i]);}}}
return rx;};Date.Grammar={};Date.Translator={hour:function(s){return function(){this.hour=Number(s);};},minute:function(s){return function(){this.minute=Number(s);};},second:function(s){return function(){this.second=Number(s);};},meridian:function(s){return function(){this.meridian=s.slice(0,1).toLowerCase();};},timezone:function(s){return function(){var n=s.replace(/[^\d\+\-]/g,"");if(n.length){this.timezoneOffset=Number(n);}else{this.timezone=s.toLowerCase();}};},day:function(x){var s=x[0];return function(){this.day=Number(s.match(/\d+/)[0]);};},month:function(s){return function(){this.month=((s.length==3)?Date.getMonthNumberFromName(s):(Number(s)-1));};},year:function(s){return function(){var n=Number(s);this.year=((s.length>2)?n:(n+(((n+2000)<Date.CultureInfo.twoDigitYearMax)?2000:1900)));};},rday:function(s){return function(){switch(s){case"yesterday":this.days=-1;break;case"tomorrow":this.days=1;break;case"today":this.days=0;break;case"now":this.days=0;this.now=true;break;}};},finishExact:function(x){x=(x instanceof Array)?x:[x];var now=new Date();this.year=now.getFullYear();this.month=now.getMonth();this.day=1;this.hour=0;this.minute=0;this.second=0;for(var i=0;i<x.length;i++){if(x[i]){x[i].call(this);}}
this.hour=(this.meridian=="p"&&this.hour<13)?this.hour+12:this.hour;if(this.day>Date.getDaysInMonth(this.year,this.month)){throw new RangeError(this.day+" is not a valid value for days.");}
var r=new Date(this.year,this.month,this.day,this.hour,this.minute,this.second);if(this.timezone){r.set({timezone:this.timezone});}else if(this.timezoneOffset){r.set({timezoneOffset:this.timezoneOffset});}
return r;},finish:function(x){x=(x instanceof Array)?flattenAndCompact(x):[x];if(x.length===0){return null;}
for(var i=0;i<x.length;i++){if(typeof x[i]=="function"){x[i].call(this);}}
if(this.now){return new Date();}
var today=Date.today();var method=null;var expression=!!(this.days!=null||this.orient||this.operator);if(expression){var gap,mod,orient;orient=((this.orient=="past"||this.operator=="subtract")?-1:1);if(this.weekday){this.unit="day";gap=(Date.getDayNumberFromName(this.weekday)-today.getDay());mod=7;this.days=gap?((gap+(orient*mod))%mod):(orient*mod);}
if(this.month){this.unit="month";gap=(this.month-today.getMonth());mod=12;this.months=gap?((gap+(orient*mod))%mod):(orient*mod);this.month=null;}
if(!this.unit){this.unit="day";}
if(this[this.unit+"s"]==null||this.operator!=null){if(!this.value){this.value=1;}
if(this.unit=="week"){this.unit="day";this.value=this.value*7;}
this[this.unit+"s"]=this.value*orient;}
return today.add(this);}else{if(this.meridian&&this.hour){this.hour=(this.hour<13&&this.meridian=="p")?this.hour+12:this.hour;}
if(this.weekday&&!this.day){this.day=(today.addDays((Date.getDayNumberFromName(this.weekday)-today.getDay()))).getDate();}
if(this.month&&!this.day){this.day=1;}
return today.set(this);}}};var _=Date.Parsing.Operators,g=Date.Grammar,t=Date.Translator,_fn;g.datePartDelimiter=_.rtoken(/^([\s\-\.\,\/\x27]+)/);g.timePartDelimiter=_.stoken(":");g.whiteSpace=_.rtoken(/^\s*/);g.generalDelimiter=_.rtoken(/^(([\s\,]|at|on)+)/);var _C={};g.ctoken=function(keys){var fn=_C[keys];if(!fn){var c=Date.CultureInfo.regexPatterns;var kx=keys.split(/\s+/),px=[];for(var i=0;i<kx.length;i++){px.push(_.replace(_.rtoken(c[kx[i]]),kx[i]));}
fn=_C[keys]=_.any.apply(null,px);}
return fn;};g.ctoken2=function(key){return _.rtoken(Date.CultureInfo.regexPatterns[key]);};g.h=_.cache(_.process(_.rtoken(/^(0[0-9]|1[0-2]|[1-9])/),t.hour));g.hh=_.cache(_.process(_.rtoken(/^(0[0-9]|1[0-2])/),t.hour));g.H=_.cache(_.process(_.rtoken(/^([0-1][0-9]|2[0-3]|[0-9])/),t.hour));g.HH=_.cache(_.process(_.rtoken(/^([0-1][0-9]|2[0-3])/),t.hour));g.m=_.cache(_.process(_.rtoken(/^([0-5][0-9]|[0-9])/),t.minute));g.mm=_.cache(_.process(_.rtoken(/^[0-5][0-9]/),t.minute));g.s=_.cache(_.process(_.rtoken(/^([0-5][0-9]|[0-9])/),t.second));g.ss=_.cache(_.process(_.rtoken(/^[0-5][0-9]/),t.second));g.hms=_.cache(_.sequence([g.H,g.mm,g.ss],g.timePartDelimiter));g.t=_.cache(_.process(g.ctoken2("shortMeridian"),t.meridian));g.tt=_.cache(_.process(g.ctoken2("longMeridian"),t.meridian));g.z=_.cache(_.process(_.rtoken(/^(\+|\-)?\s*\d\d\d\d?/),t.timezone));g.zz=_.cache(_.process(_.rtoken(/^(\+|\-)\s*\d\d\d\d/),t.timezone));g.zzz=_.cache(_.process(g.ctoken2("timezone"),t.timezone));g.timeSuffix=_.each(_.ignore(g.whiteSpace),_.set([g.tt,g.zzz]));g.time=_.each(_.optional(_.ignore(_.stoken("T"))),g.hms,g.timeSuffix);g.d=_.cache(_.process(_.each(_.rtoken(/^([0-2]\d|3[0-1]|\d)/),_.optional(g.ctoken2("ordinalSuffix"))),t.day));g.dd=_.cache(_.process(_.each(_.rtoken(/^([0-2]\d|3[0-1])/),_.optional(g.ctoken2("ordinalSuffix"))),t.day));g.ddd=g.dddd=_.cache(_.process(g.ctoken("sun mon tue wed thu fri sat"),function(s){return function(){this.weekday=s;};}));g.M=_.cache(_.process(_.rtoken(/^(1[0-2]|0\d|\d)/),t.month));g.MM=_.cache(_.process(_.rtoken(/^(1[0-2]|0\d)/),t.month));g.MMM=g.MMMM=_.cache(_.process(g.ctoken("jan feb mar apr may jun jul aug sep oct nov dec"),t.month));g.y=_.cache(_.process(_.rtoken(/^(\d\d?)/),t.year));g.yy=_.cache(_.process(_.rtoken(/^(\d\d)/),t.year));g.yyy=_.cache(_.process(_.rtoken(/^(\d\d?\d?\d?)/),t.year));g.yyyy=_.cache(_.process(_.rtoken(/^(\d\d\d\d)/),t.year));_fn=function(){return _.each(_.any.apply(null,arguments),_.not(g.ctoken2("timeContext")));};g.day=_fn(g.d,g.dd);g.month=_fn(g.M,g.MMM);g.year=_fn(g.yyyy,g.yy);g.orientation=_.process(g.ctoken("past future"),function(s){return function(){this.orient=s;};});g.operator=_.process(g.ctoken("add subtract"),function(s){return function(){this.operator=s;};});g.rday=_.process(g.ctoken("yesterday tomorrow today now"),t.rday);g.unit=_.process(g.ctoken("minute hour day week month year"),function(s){return function(){this.unit=s;};});g.value=_.process(_.rtoken(/^\d\d?(st|nd|rd|th)?/),function(s){return function(){this.value=s.replace(/\D/g,"");};});g.expression=_.set([g.rday,g.operator,g.value,g.unit,g.orientation,g.ddd,g.MMM]);_fn=function(){return _.set(arguments,g.datePartDelimiter);};g.mdy=_fn(g.ddd,g.month,g.day,g.year);g.ymd=_fn(g.ddd,g.year,g.month,g.day);g.dmy=_fn(g.ddd,g.day,g.month,g.year);g.date=function(s){return((g[Date.CultureInfo.dateElementOrder]||g.mdy).call(this,s));};g.format=_.process(_.many(_.any(_.process(_.rtoken(/^(dd?d?d?|MM?M?M?|yy?y?y?|hh?|HH?|mm?|ss?|tt?|zz?z?)/),function(fmt){if(g[fmt]){return g[fmt];}else{throw Date.Parsing.Exception(fmt);}}),_.process(_.rtoken(/^[^dMyhHmstz]+/),function(s){return _.ignore(_.stoken(s));}))),function(rules){return _.process(_.each.apply(null,rules),t.finishExact);});var _F={};var _get=function(f){return _F[f]=(_F[f]||g.format(f)[0]);};g.formats=function(fx){if(fx instanceof Array){var rx=[];for(var i=0;i<fx.length;i++){rx.push(_get(fx[i]));}
return _.any.apply(null,rx);}else{return _get(fx);}};g._formats=g.formats(["yyyy-MM-ddTHH:mm:ss","ddd, MMM dd, yyyy H:mm:ss tt","ddd MMM d yyyy HH:mm:ss zzz","d"]);g._start=_.process(_.set([g.date,g.time,g.expression],g.generalDelimiter,g.whiteSpace),t.finish);g.start=function(s){try{var r=g._formats.call({},s);if(r[1].length===0){return r;}}catch(e){}
return g._start.call({},s);};}());Date._parse=Date.parse;Date.parse=function(s){var r=null;if(!s){return null;}
try{r=Date.Grammar.start.call({},s);}catch(e){return null;}
return((r[1].length===0)?r[0]:null);};Date.getParseFunction=function(fx){var fn=Date.Grammar.formats(fx);return function(s){var r=null;try{r=fn.call({},s);}catch(e){return null;}
return((r[1].length===0)?r[0]:null);};};Date.parseExact=function(s,fx){return Date.getParseFunction(fx)(s);};

</script>
<script type="text/javascript">
function orderUS(){
	var EDD = Date.parse(document.getElementById('EDD').value);
	var GA1 = parseInt(document.getElementById('GA1').value);
	var GA2 = parseInt(document.getElementById('GA2').value);
	var GA3 = parseInt(document.getElementById('GA3').value);

	if (GA1){
		var EDD1 = EDD.clone();
		var USDate1 = EDD1.addWeeks(-40).addWeeks(GA1).toString('MMM dd, yyyy');
		var Text1 = "  For week " + GA1 + " ultrasound around " + USDate1 + ".";
		document.getElementById('RelevantHistory').value += Text1;
	}
	if (GA2){
		var EDD2 = EDD.clone();
		var USDate2 = EDD2.addWeeks(-40).addWeeks(GA2).toString('MMM dd, yyyy');
		var Text2 = "  For week " + GA2 + " ultrasound around " + USDate2 + ".";
		document.getElementById('RelevantHistory').value += Text2;
	}
	if (GA3){
		var EDD3 = EDD.clone();
		var USDate3 = EDD3.addWeeks(-40).addWeeks(GA3).toString('MMM dd, yyyy');
		var Text3 = "  For week " + GA3 + " ultrasound around " + USDate3 + ".";
		document.getElementById('RelevantHistory').value += Text3;
	}
}
</script>


</head>
<body width="750px" onload="onLoad();start();">
<div style="position: absolute; left: 12px; top: 16px;">
     <IMG SRC="${oscar_image_path}ImagingFHA092b.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 method="post" action="" name="MedicalImagingForm">

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

<input type="hidden" name="PatientMD" id="PatientMD" oscarDB=doctor>
<input type="hidden" name="DMT" id="DMT"  oscarDB=m$DMME#value>
<input type="hidden" name="A1C" id="A1C"  oscarDB=m$A1C#value>
<input type="hidden" name="Meds" id="Meds"  oscarDB=druglist_generic>
<input type="hidden" name="counter" id="counter">

<div style="position: absolute; left: 500px; top: 0px;"> 
<input name="ClinicName" type="text" class="noborder" style="width: 200px; font-family: Arial; 

font-size:12px;font-weight: bold; text-align: center;" oscardb=clinic_name >
</div>

<!-- top left -->
<div style="position: absolute; left: 40px; top: 97px;"> 
	<input name="HospitalSite" class="noborder" style="width: 49px; font-family: Arial; font-size:12px; text-align: center;" type="text" value=CGH>
</div>
<div style="position: absolute; left:120px; top: 97px;"> 
	<input name="ApptDate" class="noborder" style="width: 100px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left:240px; top: 97px;"> 
	<input name="ApptTime" class="noborder" style="width: 75px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 215px; top: 188px;"> 
	<input name="Language" class="noborder"  value=English style="width: 55px; font-

family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 24px; top: 157px;">
        <input name="NotWillingAlternateHospital" type="checkbox">
</div>
<div style="position: absolute; left: 24px; top: 187px;">
        <input name="InterpreterNeeded" type="checkbox" >
</div>

<!-- top right label -->

<div style="position: absolute; left: 680px; top: 37px;"> 
	<input name="PatientSex" type="text" class="noborder" style="width: 73px; font-family: 

Arial; font-size: 12px; text-align: center;" oscardb=sex >
</div>
<div style="position: absolute; left: 348px; top: 35px;"> 
	<input name="PatientSurname,FirstName" type="text" class="noborder" style="width: 

300px; font-family: Arial; font-size: 12px;" oscarDB=patient_name >
</div>
<div style="position: absolute; left: 348px; top: 67px;"> 
	<input name="Patient_1_Line_Address" type="text" class="noborder" style="width: 

390px; font-family: Arial; font-size: 12px;" oscardb=addressLine >
</div>
<div style="position: absolute; left: 598px; top: 100px;"> 
	<input name="PatientHomePhone" type="text" class="noborder" style="width: 140px; 

font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone>
</div>
<div style="position: absolute; left: 348px; top: 133px;"> 
	<input name="DateOfBirth" type="text" class="noborder" style="width: 210px; font-

family: Arial; font-size: 12px; text-align: center;" oscardb=dob >
</div>
<div style="position: absolute; left: 598px; top: 132px;"> 
	<input name="PatientWorkPhone" class="noborder" type="text" style="width: 140px; 

font-family: Arial; font-size: 12px; text-align: center;" oscardb=phone2>
</div>
<div style="position: absolute; left: 348px; top: 166px;"> 
	<input name="MSP/PHN#" type="text" class="noborder" style="width: 210px; font-family: 

Arial; font-size: 12px; text-align: center;" oscardb=HIN>
</div>
<div style="position: absolute; left: 598px; top: 166px;"> 
	<input name="Claim#" type="text" class="noborder" style="width: 140px; font-family: 

Arial; font-size: 12px; text-align: center;">
</div>
<!-- Bill to: -->
<div style="position: absolute; left: 338px; top: 190px;">
	<input name="BillToMSP" id="BillToMSP" type="checkbox" tabindex="1" class="noborder">
</div>
<div style="position: absolute; left: 395px; top: 190px;">
	<input name="BillToWSBC" id="BillToWSBC" type="checkbox" tabindex="3" class="noborder">
</div>
<div style="position: absolute; left: 450px; top: 190px;">
	<input name="BillToICBC" id="BillToICBC" type="checkbox" tabindex="2" class="noborder">
</div>

<div style="position: absolute; left: 513px; top: 190px;">
	<input name="BillToPatient" id="BillToPatient" type="checkbox" tabindex="4" class="noborder">
</div>
<div style="position: absolute; left: 588px; top: 190px;">
	<input name="BillToOther" id="BillToOther" type="checkbox" tabindex="5" class="noborder">
</div>
<div style="position: absolute; left: 655px; top: 190px;"> 
	<input class="noborder" name="BillToOtherText" style="width: 80px; font-family: Arial; 

font-size: 12px;" tabindex="6" type="text">
</div>





<!-- Modality -->
<div style="position: absolute; left: 67px; top: 243px;">
        <input name="Xray" type="checkbox">
</div>
<div style="position: absolute; left: 159px; top: 244px;">
        <input name="Ultrasound" type="checkbox" checked>
</div>
<div style="position: absolute; left: 310px; top: 244px;">
        <input name="CT" type="checkbox">
</div>
<div style="position: absolute; left: 384px; top: 244px;">
        <input name="SpecialProcedures" type="checkbox">
</div>


<div style="position: absolute; left: 192px; top: 270px;"> 
	<input name="ExamRequestedText" value= "Obstetrical ultrasound" class="noborder" style="width: 560px; font-family:Arial; font-size: 12px; text-align: center;font-weight:bold"  type="text">
</div>


<div style="position: absolute; left: 36px; top: 309px;"> 
	<textarea name="RelevantHistory" id="RelevantHistory" class="noborder"  style="height: 86px; width:342px; font-family: Arial; font-size: 12px;" ></textarea>
</div>


<div style="position: absolute; left: 401px; top: 309px;"> 
	<textarea name="RelevantHistoryText" id="RelevantHistoryText"  class="noborder"  style="height: 56px; width:342px; font-family: Arial; font-size: 12px;" >Pregnant</textarea>
</div>

<div style="position: absolute; left:390px; top:365px;"> 
	<textarea name="ProtocolTextbox" class="noborder"  style="height:30px; width:367px; font-family:Arial; font-weight: bold; font-size:12px;"></textarea>
</div>



<div style="position: absolute; left: 217px; top: 400px;">
        <input name="PregnantYes" type="checkbox" checked>
</div>
<div style="position: absolute; left: 273px; top: 400px;">
        <input name="PregnantNo" type="checkbox">
</div>

<div style="position: absolute; left: 411px; top: 400px;"> 
	<input name="LMP" class="noborder"  style="width: 230px; font-family: Arial; font-size: 12px; text-align: center;"  type="text" oscarDB=m$LMP#value>
</div>

<div style="position: absolute; left: 217px; top: 417px;">
        <input name="DiabeticYes" id="DiabeticYes" type="checkbox">
</div>
<div style="position: absolute; left: 273px; top: 417px;">
        <input name="DiabeticNo" id="DiabeticNo" type="checkbox">
</div>
<div style="position: absolute; left: 618px; top: 417px;">
        <input name="MetforminYes" type="checkbox">
</div>
<div style="position: absolute; left: 664px; top: 417px;">
        <input name="MetforminNo" type="checkbox">
</div>
<div style="position: absolute; left: 217px; top: 435px;">
        <input name="DialysisYes" type="checkbox">
</div>
<div style="position: absolute; left: 273px; top: 435px;">
        <input name="DialysisNo" type="checkbox" checked>
</div>
<div style="position: absolute; left: 479px; top: 435px;">
        <input name="AnticoagulantYes" type="checkbox">
</div>
<div style="position: absolute; left: 527px; top: 435px;">
        <input name="AnticogulantNo" type="checkbox">
</div>
<div style="position:absolute; left: 580px; top: 435px;">
	<input name="AnticoagulantText" type="text" class="noborder" style="width:165; font-

family: Arial; font-size:12px; text-align: center;">
</div>
<div style="position: absolute; left: 482px; top: 464px;">
        <input name="IsolationStandard" type="checkbox" checked>
</div>
<div style="position:absolute; left: 607px; top: 465px;">
	<input name="IsolationOtherText" type="text" class="noborder" style="width:145; font-family:Arial; font-size:12px; text-align: center;">
</div>

<div style="position: absolute; left: 118px; top: 465px;"> 
	<input name="Allergies" oscarDB=allergies_des class="noborder"  style="width: 300px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 240px; top: 515px;">        
         <input name="eGFR" id="eGFR" class="noborder"  style="width: 67px; height:20px; font-family: Arial; font-size:12px; text-align: center;"  type="text"oscarDB=m$EGFR#value>
</div>
<div style="position: absolute; left: 478px; top: 515px;"> 
	<input name="eGFRDate" id ="eGFRDate"class="noborder"  style="width: 70px; height:20px; font-family: Arial; font-size:12px; text-align: center;" type="text" oscarDB=m$EGFR#dateObserved>
</div>

<div style="position: absolute; left: 320px; top: 515px;" class="DoNotPrint">        
         <input name="eGFR2" id="eGFR2" class="noborder"  style="width: 20px; height:20px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 560px; top: 515px;" class="DoNotPrint"> 
	<input name="eGFRDate2" id ="eGFRDate2"class="noborder"  style="width: 30px; height:20px; font-family: Arial; font-size:12px; text-align: center;" type="text"  >Days since last test
</div>

<div style="position: absolute; left: 240px; top: 535px;"> 
	<input name="Creatinine" class="noborder"  style="width: 67px; height:20px; font-family: Arial; font-size:12px; text-align: center;"  type="text"oscarDB=m$SCR#value>
</div>
<div style="position: absolute; left: 478px; top: 535px;"> 
	<input name="CreatinineDate" class="noborder"  style="width: 70px; height:20px; font-family: Arial;font-size:12px; text-align: center;"  type="text" oscarDB=m$SCR#dateObserved> 
</div>
<div style="position: absolute; left: 286px; top: 555px;"> 
	<input name="HxContrastAllergy" class="noborder"  style="width: 445px; height:20px; font-family: Arial; font-size:12px; text-align: center;" type="text">
</div>

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

<div style="position: absolute; left: 98px; top: 595px;"> 
	<input name="PhysicianName" id="PhysicianName"  class="noborder" oscardb=current_user style="width: 245px; font-family:Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left:98px; top: 627px;"> 
	<input name="ClinicPhone" class="noborder" oscardb=clinic_phone style="width:200px; font-family:Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 192px; top: 661px;"> 
	<input  name="CopyTo" id="CopyTo" class="noborder" style="width: 200px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 98px; top: 661px;"> 
	<input  name="Mat" id="Mat" value = "CGH Maternity;" class="noborder" style="width: 95px; font-family: Arial; font-size:12px; text-align: center;"  type="text">
</div>

<div style="position: absolute; left: 658px; top: 603px;"> 
	<input name="Y/NDate" class="noborder" style="width: 90px; font-family:Arial; font-size: 12px; text-align: center;" Value = "No" type="text">
</div>
<div style="position: absolute; left: 469px; top: 623px;"> 
	<input name="LocationOfPreviousFilm" class="noborder" style="width: 114px; font-family:Arial; font-size:12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 658px; top: 623px;"> 
	<input name="DateOfPreviousFilm" class="noborder" style="width: 90px; font-family:Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 516px; top: 641px;">
        <input name="Attachedreports" type="checkbox">
</div>
<div style="position: absolute; left: 605px; top: 641px;">
        <input name="Attachedlabwork" type="checkbox">
</div>
<div style="position: absolute; left: 663px; top: 641px;">
        <input name="AttachedCD" type="checkbox">
</div>
<div style="position: absolute; left: 459px; top: 661px;"> 
	<input name="Notes" class="noborder" style="width: 280px; font-family:Arial; font-size:12px; text-align: center;"  type="text">
</div>
<div style="position: fixed; left: 770px; top: 100px; width: 200px; height: 300px; outline: black solid thin;" class="DoNotPrint">
Ultrasound for Week(s) #:<br>
<input type="text" name="GA1" id="GA1" style="width: 50px;" value = "18">
<input type="text" name="GA2" id="GA2" style="width: 50px;">
<input type="text" name="GA3" id="GA3" style="width: 50px;">
Calculate using EDD of:
<input type="text" name="EDD" id="EDD" oscarDB=m$EDD#value>
<input type="button" name="GAEnter" id="GAEnter" value="Enter" onclick="orderUS();">
</div>
<!-- --------------------------------------------------------------------- -->

<!-- The submit/print/reset buttons -->
<div class="DoNotPrint" style="position: absolute; top: 970px; left: 129px;">
     <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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