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Intake and Referral Form for Smoking Cessation

Used with Permission from the University of Ottawa Heart Institute Smoking Cessation Program. Link to patient handout is commented out. The document number in the patient handout link will need to be changed to reflect the individual number on the individual server. Patient handout will open in a new window.

HTML icon 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 
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		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;												
		}
		
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				document.getElementById('BottomButtons').style.display = 'none';
			// print the letter
			window.print();
		} 

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			setFlag();
			setTimeout('document.FormName.submit()',1000);
			releaseDirtyFlag()
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		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 
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		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;
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	<!-------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;
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}
</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>

Document Actions

 

Download button

DOWNLOAD OSCAR FOR TESTING

 

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DOWNLOAD SHARED E-FORMS


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FIND PLUG-INS AND TWEAKS
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Help button

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