Intake and Referral Form for Smoking Cessation
UofOHeartInstituteQuitSmoking.html
—
HTML,
49 kB (50890 bytes)
File contents
<html> <head> <title>U of O Heart Institute Quit Smoking</title> <link rel="stylesheet" type="text/css" href="${oscar_image_path}JSMPC.css" /> <script language="javascript" type="text/javascript"> /**************************** startup functions ****************************/ function startUp() { // shows the forms on development machine from notepad ++ - saves you from uploading to the server to input alignments var strLoc = window.location.href.toLowerCase(); if(strLoc.indexOf("https") == -1) { //page1 var src = document.getElementById('BGImage').src; document.getElementById('BGImage').src = src.replace('$%7Boscar_image_path%7D',''); // page2 var src2 = document.getElementById('BGImage2').src; document.getElementById('BGImage2').src = src2.replace('$%7Boscar_image_path%7D',''); } setDocumentTitle('U of O Heart Institute Quit Smoking',document.getElementById('patient_nameL').value); setDefaults(); } function setDocumentTitle(Title,PatientName) { // set document title document.title = Title + ' - ' + PatientName; } function setDefaults() { // check the newform flag to ensure this is the initial load of the form if (document.getElementById("newForm").value == 'True') { // set the gender // checkGender(); } } /**************************** submit and print functions ****************************/ function printSubmit() { printLetter(); submission(); releaseDirtyFlag(); } function printLetter(){ // hide the bottom buttons if (document.getElementById('BottomButtons').style.display == '') document.getElementById('BottomButtons').style.display = 'none'; // print the letter window.print(); } function submission() { setFlag(); setTimeout('document.FormName.submit()',1000); releaseDirtyFlag() } function setFlag() { // indicate that the form has been submitted if (document.getElementById("newForm").value == 'True') document.getElementById("newForm").value = 'False'; } function showButtons() { //show the bottom buttons if they are hidden if (document.getElementById('BottomButtons').style.display == 'none') document.getElementById('BottomButtons').style.display = ''; } /**************************** checkbox functions ****************************/ function changeValue(x) { if (document.getElementById(x).value == '') document.getElementById(x).value = 'X'; else document.getElementById(x).value = ''; } function displayKeyCode(evt,x) { var charCode = (evt.which) ? evt.which : event.keyCode // any key press except tab will constitute a value change to the checkbox if (charCode != 9) { changeValue(x); return false; } } </script> <!-------Script to optimize window on loading-----------> <script language="JavaScript"> top.window.moveTo(0,0); if (document.all) { top.window.resizeTo(screen.availWidth,screen.availHeight); } else if (document.layers||document.getElementById) { if (top.window.outerHeight<screen.availHeight||top.window.outerWidth<screen.availWidth){ top.window.outerHeight = screen.availHeight; top.window.outerWidth = 850; } } </script> <!----------End optimize window 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="startUp();" onMouseDown="showButtons();"> <form method="post" action="" name="FormName" id="FormName" > <div id="page1" style="position: relative; left: -8px; top: -16px; width:750px;" class="pagebreak"> <img id="BGImage" src="${oscar_image_path}QuitSmoking1.png" width="750"> <input name="PHN" id="PHN" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:510px; top:3px; width:222px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=hinc> <input name="PtLastName" id="PtLastName" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:514px; top:26px; width:216px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=patient_nameL> <input name="PtFirstName" id="PtFirstName" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:513px; top:46px; width:217px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=patient_nameF> <input name="StreetAddress" id="StreetAddress" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:501px; top:64px; width:230px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=address_street_number_and_name> <input name="City" id="City" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:480px; top:83px; width:123px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=city> <input name="PostalCode" id="PostalCode" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:669px; top:84px; width:62px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=postal> <input name="Phone" id="Phone" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:475px; top:102px; width:127px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=phone> <input name="DOB" id="DOB" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:672px; top:103px; width:70px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=dobc> <input name="Physician" id="Physician" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:505px; top:121px; width:228px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=doctor> <input name="FirstVisit" id="FirstVisit" type="text" style="position:absolute; background-color:lightyellow; left:7px; top:160px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Annual" id="Annual" type="text" style="position:absolute; background-color:lightyellow; left:88px; top:160px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Other" id="Other" type="text" style="position:absolute; background-color:lightyellow; left:273px; top:160px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Date" id="Date" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:435px; top:160px; width:300px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=today> <input name="Use7Days" id="Use7Days" type="text" style="position:absolute; background-color:lightyellow; left:305px; top:256px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Use6Months" id="Use6Months" type="text" style="position:absolute; background-color:lightyellow; left:305px; top:270px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NonSmoker" id="NonSmoker" type="text" style="position:absolute; background-color:lightyellow; left:305px; top:284px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AdviseYes" id="AdviseYes" type="text" style="position:absolute; background-color:lightyellow; left:165px; top:401px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AdviseNo" id="AdviseNo" type="text" style="position:absolute; background-color:lightyellow; left:165px; top:414px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AdviseNA" id="AdviseNA" type="text" style="position:absolute; background-color:lightyellow; left:165px; top:428px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ReadyReferYes" id="ReadyReferYes" type="text" style="position:absolute; background-color:lightyellow; left:664px; top:451px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ReadyReferNo" id="ReadyReferNo" type="text" style="position:absolute; background-color:lightyellow; left:664px; top:465px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NotReadyReferYes" id="NotReadyReferYes" type="text" style="position:absolute; background-color:lightyellow; left:664px; top:513px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NotReadyReferNo" id="NotReadyReferNo" type="text" style="position:absolute; background-color:lightyellow; left:664px; top:528px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="PhoneSame" id="PhoneSame" type="text" style="position:absolute; background-color:lightyellow; left:350px; top:539px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AlternatePhone" id="AlternatePhone" type="text" class="noborder" style="position:absolute; background-color:lightyellow; left:260px; top:559px; width:178px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=phone2> <input name="7to9" id="7to9" type="text" style="position:absolute; background-color:lightyellow; left:262px; top:606px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="9to12" id="9to12" type="text" style="position:absolute; background-color:lightyellow; left:262px; top:620px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="1to5" id="1to5" type="text" style="position:absolute; background-color:lightyellow; left:262px; top:634px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="6to9" id="6to9" type="text" style="position:absolute; background-color:lightyellow; left:262px; top:647px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> </div> <div id="page2" style="position: relative;"> <img id="BGImage2" src="${oscar_image_path}QuitSmoking2.png" width="750px"> <input name="PHN2" id="PHN2" type="text" class="noborder" style="position:absolute; left:506px; top:3px; width:221px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=hinc> <input name="PtLastname2" id="PtLastname2" type="text" class="noborder" style="position:absolute; left:511px; top:26px; width:216px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=patient_nameL> <input name="PtFirstname2" id="PtFirstname2" type="text" class="noborder" style="position:absolute; left:510px; top:45px; width:216px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=patient_nameF> <input name="StreetAddress2" id="StreetAddress2" type="text" class="noborder" style="position:absolute; left:497px; top:64px; width:225px; height:16px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=address_street_number_and_name> <input name="City2" id="City2" type="text" class="noborder" style="position:absolute; left:477px; top:83px; width:120px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=city> <input name="PostalCode2" id="PostalCode2" type="text" class="noborder" style="position:absolute; left:664px; top:83px; width:60px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=postal> <input name="Phone2" id="Phone2" type="text" class="noborder" style="position:absolute; left:471px; top:102px; width:126px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=phone> <input name="DOB2" id="DOB2" type="text" class="noborder" style="position:absolute; left:668px; top:102px; width:70px; height:15px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=dobc> <input name="Physician2" id="Physician2" type="text" class="noborder" style="position:absolute; left:502px; top:121px; width:224px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=doctor> <input name="English" id="English" type="text" style="position:absolute; background-color:lightyellow; left:124px; top:159px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="French" id="French" type="text" style="position:absolute; background-color:lightyellow; left:191px; top:159px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherLanguage" id="OtherLanguage" type="text" style="position:absolute; background-color:lightyellow; left:255px; top:159px; width:16px; height:16px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherLanguageText" id="OtherLanguageText" type="text" class="noborder" style="position:absolute; left:360px; top:159px; width:375px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value=""> <input name="ZybanPreg" id="ZybanPreg" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:268px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanSeizure" id="ZybanSeizure" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:282px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanCurrent" id="ZybanCurrent" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:295px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanPrevious" id="ZybanPrevious" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:309px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanEatingDisorder" id="ZybanEatingDisorder" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:323px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanAlcohol" id="ZybanAlcohol" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:336px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanDrug1" id="ZybanDrug1" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:350px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanCipro" id="ZybanCipro" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:377px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanDiabetes" id="ZybanDiabetes" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:390px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanLiverImpared" id="ZybanLiverImpared" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:403px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ZybanCNSTumor" id="ZybanCNSTumor" type="text" style="position:absolute; background-color:lightyellow; left:164px; top:417px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixPregnant" id="ChampixPregnant" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:268px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixUnder18" id="ChampixUnder18" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:282px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixRenalCimetidine" id="ChampixRenalCimetidine" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:295px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixNRT" id="ChampixNRT" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:309px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixRxn" id="ChampixRxn" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:323px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixRenalFail" id="ChampixRenalFail" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:336px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ChampixNV" id="ChampixNV" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:350px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Machinery" id="Machinery" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:376px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NRTDentures" id="NRTDentures" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:417px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NRTAllergy" id="NRTAllergy" type="text" style="position:absolute; background-color:lightyellow; left:459px; top:430px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Anxiety" id="Anxiety" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:468px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Depression" id="Depression" type="text" style="position:absolute; background-color:lightyellow; left:229px; top:468px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Substance" id="Substance" type="text" style="position:absolute; background-color:lightyellow; left:312px; top:468px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HxOther" id="HxOther" type="text" style="position:absolute; background-color:lightyellow; left:487px; top:468px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="OtherHxText" id="OtherHxText" type="text" class="noborder" style="position:absolute; left:585px; top:468px; width:143px; height:13px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value=""> <input name="CurrentRxY" id="CurrentRxY" type="text" style="position:absolute; background-color:lightyellow; left:658px; top:453px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="CurrentRxN" id="CurrentRxN" type="text" style="position:absolute; background-color:lightyellow; left:697px; top:453px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <!--------- <a name="HandoutLink1" class="DoNotPrint" style="position: absolute; left: 318px; top: 230px;" href=../dms/ManageDocument.do?method=display&doc_no=29925 target="_blank" >Your Quit Smoking Plan</a> -----> <input name="HandoutYes" id="HandoutYes" type="text" style="position:absolute; background-color:lightyellow; left:645px; top:233px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HandoutNo" id="HandoutNo" type="text" style="position:absolute; background-color:lightyellow; left:681px; top:233px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="NRT" id="NRT" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:493px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Patch7" id="Patch7" type="text" style="position:absolute; background-color:lightyellow; left:248px; top:536px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Patch14" id="Patch14" type="text" style="position:absolute; background-color:lightyellow; left:340px; top:536px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Patch21" id="Patch21" type="text" style="position:absolute; background-color:lightyellow; left:435px; top:536px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Patch28mg" id="Patch28mg" type="text" style="position:absolute; background-color:lightyellow; left:526px; top:536px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Patch42" id="Patch42" type="text" style="position:absolute; background-color:lightyellow; left:623px; top:536px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatch14" id="HigherPatch14" type="text" style="position:absolute; background-color:lightyellow; left:248px; top:572px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatch" id="HigherPatch" type="text" style="position:absolute; background-color:lightyellow; left:340px; top:572px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatch28" id="HigherPatch28" type="text" style="position:absolute; background-color:lightyellow; left:435px; top:572px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatch35" id="HigherPatch35" type="text" style="position:absolute; background-color:lightyellow; left:526px; top:572px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatch_" id="HigherPatch_" type="text" style="position:absolute; background-color:lightyellow; left:623px; top:572px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="HigherPatchText" id="HigherPatchText" type="text" class="noborder" style="position:absolute; left:643px; top:567px; width:78px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value=""> <input name="Inhaler1a1" id="Inhaler1a1" type="text" style="position:absolute; background-color:lightyellow; left:248px; top:619px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Inhaler2" id="Inhaler2" type="text" style="position:absolute; background-color:lightyellow; left:340px; top:619px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Inhaler3" id="Inhaler3" type="text" style="position:absolute; background-color:lightyellow; left:435px; top:619px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Inhaler4" id="Inhaler4" type="text" style="position:absolute; background-color:lightyellow; left:526px; top:619px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Inhaler5" id="Inhaler5" type="text" style="position:absolute; background-color:lightyellow; left:623px; top:619px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Gum1" id="Gum1" type="text" style="position:absolute; background-color:lightyellow; left:248px; top:632px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Gum2" id="Gum2" type="text" style="position:absolute; background-color:lightyellow; left:340px; top:632px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Gum3" id="Gum3" type="text" style="position:absolute; background-color:lightyellow; left:435px; top:632px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Gum4" id="Gum4" type="text" style="position:absolute; background-color:lightyellow; left:526px; top:632px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Gum5" id="Gum5" type="text" style="position:absolute; background-color:lightyellow; left:623px; top:632px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Lozenge1" id="Lozenge1" type="text" style="position:absolute; background-color:lightyellow; left:248px; top:646px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Lozenge2" id="Lozenge2" type="text" style="position:absolute; background-color:lightyellow; left:340px; top:646px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Lozenge3" id="Lozenge3" type="text" style="position:absolute; background-color:lightyellow; left:435px; top:646px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Lozenge4" id="Lozenge4" type="text" style="position:absolute; background-color:lightyellow; left:526px; top:646px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Lozenge5" id="Lozenge5" type="text" style="position:absolute; background-color:lightyellow; left:623px; top:646px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SelectChampix" id="SelectChampix" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:669px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SelectZyban" id="SelectZyban" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:695px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SelectNone" id="SelectNone" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:723px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="QuitDate" id="QuitDate" type="text" class="noborder" style="position:absolute; left:403px; top:742px; width:93px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value=""> <input name="QuitDateYes" id="QuitDateYes" type="text" style="position:absolute; background-color:lightyellow; left:645px; top:756px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="QuitDateNo" id="QuitDateNo" type="text" style="position:absolute; background-color:lightyellow; left:683px; top:756px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="FUArrangedYes" id="FUArrangedYes" type="text" style="position:absolute; background-color:lightyellow; left:645px; top:789px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="FUArrangedNo" id="FUArrangedNo" type="text" style="position:absolute; background-color:lightyellow; left:681px; top:789px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="SamePhone2" id="SamePhone2" type="text" style="position:absolute; background-color:lightyellow; left:251px; top:808px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AlternatePhone2" id="AlternatePhone2" type="text" class="noborder" style="position:absolute; left:417px; top:799px; width:212px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=phone2> <input name="7to9_2" id="7to9_2" type="text" style="position:absolute; background-color:lightyellow; left:286px; top:823px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="9to12_2" id="9to12_2" type="text" style="position:absolute; background-color:lightyellow; left:338px; top:823px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="1to5_2" id="1to5_2" type="text" style="position:absolute; background-color:lightyellow; left:413px; top:823px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="6to9_2" id="6to9_2" type="text" style="position:absolute; background-color:lightyellow; left:466px; top:823px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ReviewMood" id="ReviewMood" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:846px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ReviewMed" id="ReviewMed" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:860px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="AdvisePrepare" id="AdvisePrepare" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:873px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="DiscussRoutines" id="DiscussRoutines" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:887px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="RemindCaffeine" id="RemindCaffeine" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:900px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="ReviewFU" id="ReviewFU" type="text" style="position:absolute; background-color:lightyellow; left:168px; top:913px; width:12px; height:12px; border: 1px solid #000000; font-weight: bold; text-align: center;" onkeypress="javascript:return displayKeyCode(event,this.id);" onmousedown="changeValue(this.id);" onkeypress="javascript:return displayKeyCode(event,this.id);"> <input name="Counsellor" id="Counsellor" type="text" class="noborder" style="position:absolute; left:407px; top:932px; width:178px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=current_user> <input name="Date2" id="Date2" type="text" class="noborder" style="position:absolute; left:618px; top:931px; width:110px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" oscarDB=today> <input name="SmartCardVIN" id="SmartCardVIN" type="text" class="noborder" style="position:absolute; left:407px; top:954px; width:320px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; text-decoration:underline; background-color:white;" value=""> </div> <div class="DoNotPrint" id="BottomButtons"> <table> <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="javascript:submission();"> <input value="Reset" name="ResetButton" id="ResetButton" type="reset"> <input value="Print" name="PrintButton" id="PrintButton" type="button" onclick="printLetter()"> <input value="Print & Submit" name="PrintSubmitButton" id="PrintSubmitButton" type="button" onclick="printSubmit()"> </td></tr></table> </div> </form> </body> </html>
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