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.
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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