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PrenatalSerology.html

HTML icon PrenatalSerology.html — HTML, 14 kB (15249 bytes)

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<html>
<head>
<title> Prenatal Serology </title>

<!-- ---Script to maximize window on loading-- (put this inbetween <header></header>)------>
<script language="JavaScript">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,screen.availHeight);
}
else if (document.layers||document.getElementById) {
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top.window.outerHeight = screen.availHeight;
top.window.outerWidth = screen.availWidth;
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}
//-->
</script>
<!----------End maximizing window script------------------------------------------------------->

<!-- CSS Script that removes textarea and textbox borders when printing ---(put this inbetween <header></header>)----------------->
<style type="text/css" media="print">
.DoNotPrint {
	display: none;
}

.noborder {
	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;
	border : 0px;
}
</style>
<!-- ----------------------------------------------------------------------------------------- -->

</head>

<body width="750px">
<div style="position: absolute; left: 12px; top: 16px;">
    <IMG SRC="${oscar_image_path}Serology.png" width ="700">
</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="SerologyForm"
>
<!-- ----------------------------All textfields/checkboxes/textareas go here...------ -->


<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>


<!-----Patient Info---------->
<div style="position: absolute; left: 160px; top: 144px;"> 
	<input class="noborder" name="MSP/PHN#" oscardb=HIN style="width: 200px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 23px; top: 181px;"> 
	<input class="noborder" name="Patient surname" oscarDB=patient_nameL style="width: 150px; font-family: Arial; font-size: 12px;"  type="text">
</div>
<div style="position: absolute; left: 196px; top: 181px;"> 
	<input class="noborder" name="Patient first name" oscarDB=patient_nameF style="width: 175px; font-family: Arial; font-size: 12px;" type="text">
</div>	
<div style="position: absolute; left:23px; top: 209px;"> 
	<input class="noborder" name="Date of birth" oscardb=dob style="width: 150px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left:279px; top: 209px;"> 
	<input class="noborder" name="Patient sex" oscardb=sex style="width: 63px; font-family: Arial; font-size: 12px; text-align: center;"  type="text">
</div>
<div style="position: absolute; left: 23px; top: 241px;"> 
	<input name="Patient_1_Line_Address" type="text" class="noborder" style="width: 340px; font-family: Arial; font-size: 10px;" oscardb=addressLine >
</div>

<div style="position: absolute; left:24px; top:297px;">
    <input name="SubmitterReferenceNumber" class="noborder" style="width: 150; font-family: Arial; font-size: 12px" type="text">
</div>
<div style="position: absolute; left:190px; top:297px;">
    <input name="CollectionFacilityCode" class="noborder" style="width: 175; font-family: Arial; font-size: 12px" type="text">
</div>
<div style="position: absolute; left:24px; top:326px;">
    <input name="CollectionDateTime" class="noborder" style="width: 340; font-family: Arial; font-size: 12px" type="text">
</div>
<!----------Physician Info----------->
<div style="position: absolute; left: 385px; top: 148px;"> 
	<input class="noborder" name="Current Provider Doctor" oscardb=provider_name style="width: 300px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 385px; top: 182px;"> 
	<input class="noborder" name="Locum" style="width: 300px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left:470px; top:206px;">
    <textarea name="Clinic address" class="noborder" style="height:53; width: 230; font-family: Arial; font-size: 12px" oscarDB=clinic_address ></textarea>
</div>
<div style="position: absolute; left: 390px; top: 275px;"> 
	<input class="noborder" name="CC1" style="width: 310px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<div style="position: absolute; left: 390px; top: 295px;"> 
	<input class="noborder" name="CC2" style="width: 310px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<div style="position: absolute; left: 390px; top: 315px;"> 
	<input class="noborder" name="CC3" style="width: 310px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<!--------Clinical Info-------------------->
<div style="position: absolute; left: 18px; top: 371px;">
        <input name="Asymptomatic" type="checkbox">
</div>
<div style="position: absolute; left: 18px; top:388px;">
        <input name="Headache" type="checkbox">
</div>
<div style="position: absolute; left: 18px; top:405px;">
        <input name="Rash" type="checkbox">
</div>
<div style="position: absolute; left: 18px; top:422px;">
        <input name="Fever" type="checkbox">
</div>
<div style="position: absolute; left: 155px; top: 371px;">
        <input name="GISx" type="checkbox">
</div>
<div style="position: absolute; left: 155px; top:388px;">
        <input name="RespSx" type="checkbox">
</div>
<div style="position: absolute; left: 155px; top:405px;">
        <input name="STDContact" type="checkbox">
</div>
<div style="position: absolute; left: 240px; top:405px;">
        <input name="STDSx" type="checkbox">
</div>
<div style="position: absolute; left: 155px; top:422px;">
        <input name="OtherClinicalInfo" type="checkbox">
</div>
<div style="position: absolute; left: 250px; top: 422px;"> 
	<input class="noborder" name="OtherClinicalText" style="width: 120px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<!--------Reason For Test------------->
<div style="position: absolute; left: 375px; top: 375px;">
        <input name="ReasonTherapeuticMonitoring" type="checkbox">
</div>
<div style="position: absolute; left: 375px; top:393px;">
        <input name="ReasonImmigration" type="checkbox">
</div>
<div style="position: absolute; left: 375px; top:409px;">
        <input name="ReasonPrenatal" type="checkbox" checked>
</div>
<div style="position: absolute; left: 375px; top:427px;">
        <input name="ReasonFollow-up" type="checkbox">
</div>
<div style="position: absolute; left: 513px; top: 359px;">
        <input name="ReasonNeedlestick" type="checkbox">
</div>
<div style="position: absolute; left: 513px; top:375px;">
        <input name="ReasonAcute" type="checkbox">
</div>
<div style="position: absolute; left: 513px; top:393px;">
        <input name="ReasonConvalescent" type="checkbox">
</div>
<div style="position: absolute; left: 513px; top:409px;">
        <input name="ReasonOutbreak" type="checkbox">
</div>
<div style="position: absolute; left: 513px; top:427px;">
        <input name="ReasonOther" type="checkbox">
</div>
<div style="position: absolute; left: 606px; top: 427px;"> 
	<input class="noborder" name="OtherClinicalText" style="width: 90px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<div style="position: absolute; left: 20px; top: 462px;"> 
	<input class="noborder" name="RecentTravelDateLocation" style="width: 155px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 190px; top: 462px;"> 
	<input class="noborder" name="SymptomOnsetDate" style="width: 180px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 380px; top: 462px;"> 
	<input class="noborder" name="ClinicalHistory" style="width: 320px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>

<!----------Tests Requested---------------->
<!-----HIV-NonPrenatal--------->
<div style="position: absolute; left: 125px; top: 554px;">
        <input name="HIVNominal" type="checkbox">
</div>
<div style="position: absolute; left: 125px; top:578px;">
        <input name="HIVNonNominal" type="checkbox">
</div>
<!-----Syphilis-NonPrenatal---->
<div style="position: absolute; left: 308px; top: 509px;">
        <input name="SyphilisScreen" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:535px;">
        <input name="SyphylisConfirmatory" type="checkbox">
</div>
<div style="position: absolute; left: 190px; top: 573px;"> 
	<textarea class="noborder" name="SyphilisHistoryText" style="width: 175px;height: 40; font-family: Arial; font-size: 12px; text-align: center;"></textarea>
</div>
<!-----Prenatal--------->
<div style="position: absolute; left: 446px; top: 510px;">
        <input name="PnHIVNominal" type="checkbox" checked>
</div>
<div style="position: absolute; left: 628px; top:510px;">
        <input name="PnHIVNonNominal" type="checkbox">
</div>
<div style="position: absolute; left: 446px; top: 535px;">
        <input name="PnHBsAg" type="checkbox" checked>
</div>
<div style="position: absolute; left: 628px; top: 535px;">
        <input name="PnSyphilisScreen" type="checkbox" checked>
</div>
<div style="position: absolute; left: 446px; top: 564px;">
        <input name="PnRubellaIgG" type="checkbox" checked>
</div>
<div style="position: absolute; left: 628px; top: 564px;">
        <input name="PnOther" type="checkbox">
</div>
<div style="position: absolute; left: 550px; top: 576px;"> 
	<input class="noborder" name="PnOtherText" style="width: 120px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 408px; top: 595px;"> 
	<input class="noborder" name="PnEDC" style="width: 90px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<div style="position: absolute; left: 605px; top: 595px;"> 
	<input class="noborder" name="PnHospitalOfDelivery" style="width: 90px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<!-----Hepatitis--------->
<div style="position: absolute; left: 125px; top: 647px;">
        <input name="ChronicHepUndefined" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:647px;">
        <input name="AcuteHepUndefined" type="checkbox">
</div>
<div style="position: absolute; left: 125px; top: 709px;">
        <input name="AntiHepATotal" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:709px;">
        <input name="AntiHepAIgM" type="checkbox">
</div>
<div style="position: absolute; left: 125px; top: 733px;">
        <input name="Anti-HBs" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:733px;">
        <input name="HBsAg" type="checkbox">
</div>
<div style="position: absolute; left: 125px; top: 773px;">
        <input name="Anti-HBcTotal" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:773px;">
        <input name="Anti-HBc-IgM" type="checkbox">
</div>
<div style="position: absolute; left: 125px; top: 810px;">
        <input name="HBeAg" type="checkbox">
</div>
<div style="position: absolute; left: 308px; top:810px;">
        <input name="Anti-HCV" type="checkbox">
</div>
<!----------Other Serology---------->
<div style="position: absolute; left: 448px; top: 648px;">
        <input name="MeaslesIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top:648px;">
        <input name="MeaslesIgM" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 679px;">
        <input name="MumpsIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 679px;">
        <input name="MumpsIgM" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 706px;">
        <input name="B19IgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 706px;">
        <input name="B19IgM" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 730px;">
        <input name="RubellaIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 730px;">
        <input name="RubellaIgM" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 755px;">
        <input name="EBVIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 755px;">
        <input name="EBVIgG" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 782px;">
        <input name="CMVIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 782px;">
        <input name="CMVIgM" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 807px;">
        <input name="VZIgG" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 807px;">
        <input name="HTLV-I/III" type="checkbox">
</div>
<div style="position: absolute; left: 448px; top: 834px;">
        <input name="Hpylori" type="checkbox">
</div>
<div style="position: absolute; left: 623px; top: 834px;">
        <input name="Mycoplasma" type="checkbox">
</div>
<!--------Others------------>
<div style="position: absolute; left: 115px; top: 860px;"> 
	<input class="noborder" name="OtherTests" style="width: 575px; font-family: Arial; font-size: 12px; text-align: center;" type="text">
</div>
<!-- --------------------------------------------------------------------- -->

<!-- The submit/print/reset buttons ------------------------------------------------------------->
<div class="DoNotPrint" style="position: absolute; top: 1000px; left: 41px;">
<table>
	<tr>
		<td>
			Subject: <input name="subject" size="40" type="text">
			<input value="Submit" name="B1" type="submit">
			<input value="Reset" name="B2" type="reset">
			<input value="Print" onclick="window.print()" type="button">
                        <input value="Print and Submit" name="PrintSubmitButton" type="button" onClick="window.print(); document.SerologyForm.submit()">
		</td>
	</tr>
</table>
</div>
</form>
<!-- ------End of submit/print/reset buttons----------------------------------------------------->


</body></html>

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