2PageForm.html
2PageForm.html
—
HTML,
18Kb
File contents
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN">
<HTML>
<HEAD>
<link rel="stylesheet" type="text/css" title="print2" href="${oscar_image_path}print2.css" />
<link rel="stylesheet" type="text/css" title="print1" href="${oscar_image_path}print1.css" />
<script language="JavaScript">
<!--
top.window.moveTo(0,0);
if (document.all) {
top.window.resizeTo(screen.availWidth,800);
}
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 = 800;
}
}
//-->
</script>
<style type="text/css" media="print">
td.subjectline {
display:none;
}
input.noborder {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
input.small {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 8pt;
text-transform: uppercase;
}
input.large {
border : 0px;
background: transparent;
font-family: monospace;
font-size: 16pt;
text-transform: uppercase;
}
input.spaced {
border : 0px;
background: transparent;
letter-spacing:14px;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
textarea.noborder {
scrollbar-3dlight-color: transparent;
scrollbar-3dlight-color: transparent;
scrollbar-arrow-color: transparent;
scrollbar-base-color: transparent;
scrollbar-darkshadow-color: transparent;
scrollbar-face-color: transparent;
scrollbar-highlight-color: transparent;
scrollbar-shadow-color: transparent;
scrollbar-track-color: transparent;
background: transparent;
//scrollbar : none;
border : 0px;
font-family: monospace;
font-size: 12pt;
text-transform: uppercase;
}
</style>
<style type="text/css">
.style1 {
font-family: arial, sans-serif;
font-size: 10px;
font-weight: normal;
}
</style>
<SCRIPT LANGUAGE="JavaScript">
function FormSetup() {
changeStyle('print1')
}
function changeStyle(css_title) {
var i, link_tag ;
for (i = 0, link_tag = document.getElementsByTagName("link") ; i < link_tag.length ; i++ ) {
if ((link_tag[i].rel.indexOf( "stylesheet" ) != -1) && link_tag[i].title) {
link_tag[i].disabled = true ;
if (link_tag[i].title == css_title) {
link_tag[i].disabled = false ;
}
}
}
}
function pagePrint(title) {
changeStyle(title);
window.print();
}
function checkGender(){
if (document.getElementById('PatientGender').value == 'M'){
document.getElementById('Male').checked = true;
}else if (document.getElementById('PatientGender').value == 'F'){
document.getElementById('Female').checked = true;
}
}
</SCRIPT>
</HEAD>
<body Onload="FormSetup(); checkGender();">
<form method="post" action="" name="twoPageForm">
<div id="page1" style="position: absolute; left: 0px; top: 0px;" >
<img src="${oscar_image_path}output1.png" width="750">
</div >
<div id="page2" style="position: absolute; left: 0px; top: 0px;" >
<img src="${oscar_image_path}output2.png" width="750">
</div >
<div id="page1">
<input name="PageOneItem1" id="PageOneItem1" type="text" class="noborder" style="position:absolute; left:9px; top:136px; width:365px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameL>
<input name="PageOneItem2" id="PageOneItem2" type="text" class="noborder" style="position:absolute; left:9px; top:173px; width:364px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameF>
<input name="PageOneItem3" id="PageOneItem3" type="text" class="noborder" style="position:absolute; left:9px; top:200px; width:158px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=HIN>
<input name="PageOneItem5" id="PageOneItem5" type="text" class="noborder" style="position:absolute; left:180px; top:200px; width:140px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=DOB>
<input name="PageOneItem4" id="PageOneItem4" type="text" class="noborder" style="position:absolute; left:380px; top:163px; width:365px; height:27px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=addressLine>
<textarea name="PageOneItem6" id="PageOneItem6" class="noborder" style="position:absolute; left:9px; top:263px; width:727px; height:142px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=Medical_History></textarea>
<input name="PageOneItem7" id="PageOneItem7" type="checkbox" style="position:absolute; left:278px; top:414px; " checked>
<input name="PageOneItem8" id="PageOneItem8" type="checkbox" style="position:absolute; left:278px; top:449px; ">
<input name="PageOneItem9" id="PageOneItem9" type="checkbox" style="position:absolute; left:555px; top:420px; ">
<input name="PageOneItem10" id="PageOneItem10" type="checkbox" style="position:absolute; left:637px; top:420px; ">
<input name="PageOneItem11" id="PageOneItem11" type="checkbox" style="position:absolute; left:556px; top:447px; ">
<input name="PageOneItem12" id="PageOneItem12" type="checkbox" style="position:absolute; left:637px; top:450px; ">
<textarea name="PageOneItem13" id="PageOneItem13" class="noborder" style="position:absolute; left:8px; top:532px; width:724px; height:179px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=Medical_History></textarea>
<textarea name="PageOneItem14" id="PageOneItem14" class="noborder" style="position:absolute; left:10px; top:732px; width:729px; height:156px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=Other_Medications_History></textarea>
<input name="PatientGender" id="PatientGender" type="hidden" oscarDB=sex>
<input name="Male" id="Male" type="checkbox" class="noborder" style="position:absolute; left: 315px; top: 205px">
<input name="Female" id="Female" type="checkbox" class="noborder" style="position:absolute; left: 348px; top: 205px">
</div>
<div id="page2" >
<input name="PageTwoItem1" id="PageTwoItem1" type="text" class="noborder" style="position:absolute; left:10px; top:12px; width:288px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameL>
<input name="PageTwoItem2" id="PageTwoItem2" type="text" class="noborder" style="position:absolute; left:311px; top:12px; width:227px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=patient_nameF>
<input name="PageTwoItem3" id="PageTwoItem3" type="text" class="noborder" style="position:absolute; left:548px; top:12px; width:196px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:transparent;" oscarDB=HIN>
<input name="PageTwoItem4" id="PageTwoItem4" type="text" class="noborder" style="position:absolute; left:10px; top:61px; width:162px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem5" id="PageTwoItem5" type="text" class="noborder" style="position:absolute; left:183px; top:61px; width:278px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem6" id="PageTwoItem6" type="text" class="noborder" style="position:absolute; left:470px; top:61px; width:275px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem7" id="PageTwoItem7" type="text" class="noborder" style="position:absolute; left:10px; top:112px; width:161px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem8" id="PageTwoItem8" type="text" class="noborder" style="position:absolute; left:183px; top:112px; width:277px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem9" id="PageTwoItem9" type="text" class="noborder" style="position:absolute; left:470px; top:112px; width:275px; height:24px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem10" id="PageTwoItem10" type="text" class="noborder" style="position:absolute; left:10px; top:161px; width:162px; height:21px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem11" id="PageTwoItem11" type="text" class="noborder" style="position:absolute; left:183px; top:163px; width:277px; height:19px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem12" id="PageTwoItem12" type="text" class="noborder" style="position:absolute; left:472px; top:163px; width:269px; height:20px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem13" id="PageTwoItem13" type="text" class="noborder" style="position:absolute; left:10px; top:210px; width:158px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem14" id="PageTwoItem14" type="text" class="noborder" style="position:absolute; left:183px; top:211px; width:278px; height:22px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem15" id="PageTwoItem15" type="text" class="noborder" style="position:absolute; left:472px; top:213px; width:269px; height:23px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem16" id="PageTwoItem16" type="text" class="noborder" style="position:absolute; left:13px; top:256px; width:285px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem17" id="PageTwoItem17" type="text" class="noborder" style="position:absolute; left:308px; top:258px; width:309px; height:14px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem18" id="PageTwoItem18" type="checkbox" style="position:absolute; left:2px; top:298px; ">
<input name="PageTwoItem19" id="PageTwoItem19" type="checkbox" style="position:absolute; left:2px; top:313px; ">
<input name="PageTwoItem20" id="PageTwoItem20" type="checkbox" style="position:absolute; left:146px; top:298px; ">
<input name="PageTwoItem21" id="PageTwoItem21" type="checkbox" style="position:absolute; left:146px; top:313px; ">
<input name="PageTwoItem22" id="PageTwoItem22" type="checkbox" style="position:absolute; left:146px; top:328px; ">
<input name="PageTwoItem23" id="PageTwoItem23" type="checkbox" style="position:absolute; left:306px; top:313px; ">
<input name="PageTwoItem24" id="PageTwoItem24" type="checkbox" style="position:absolute; left:306px; top:331px; ">
<input name="PageTwoItem25" id="PageTwoItem25" type="checkbox" style="position:absolute; left:375px; top:325px; ">
<input name="PageTwoItem26" id="PageTwoItem26" type="checkbox" style="position:absolute; left:532px; top:313px; ">
<input name="PageTwoItem27" id="PageTwoItem27" type="checkbox" style="position:absolute; left:532px; top:331px; ">
<input name="PageTwoItem28" id="PageTwoItem28" type="checkbox" style="position:absolute; left:594px; top:331px; ">
<textarea name="PageTwoItem29" id="PageTwoItem29" class="noborder" style="position:absolute; left:8px; top:368px; width:724px; height:90px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=recent_rx></textarea>
<input name="PageTwoItem30" id="PageTwoItem30" type="checkbox" style="position:absolute; left:2px; top:478px; ">
<input name="PageTwoItem31" id="PageTwoItem31" type="checkbox" style="position:absolute; left:79px; top:478px; ">
<input name="PageTwoItem32" id="PageTwoItem32" type="checkbox" style="position:absolute; left:2px; top:499px; ">
<input name="PageTwoItem33" id="PageTwoItem33" type="checkbox" style="position:absolute; left:2px; top:513px; ">
<input name="PageTwoItem34" id="PageTwoItem34" type="checkbox" style="position:absolute; left:167px; top:499px; ">
<input name="PageTwoItem35" id="PageTwoItem35" type="checkbox" style="position:absolute; left:166px; top:513px; ">
<input name="PageTwoItem36" id="PageTwoItem36" type="text" class="noborder" style="position:absolute; left:353px; top:496px; width:188px; height:29px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<input name="PageTwoItem37" id="PageTwoItem37" type="text" class="noborder" style="position:absolute; left:555px; top:495px; width:176px; height:31px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" value="">
<textarea name="PageTwoItem38" id="PageTwoItem38" class="noborder" style="position:absolute; left:10px; top:561px; width:725px; height:74px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>
<textarea name="PageTwoItem39" id="PageTwoItem39" class="noborder" style="position:absolute; left:15px; top:683px; width:720px; height:76px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>
<textarea name="PageTwoItem40" id="PageTwoItem40" class="noborder" style="position:absolute; left:17px; top:777px; width:717px; height:51px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" ></textarea>
<input name="PageTwoItem41" id="PageTwoItem41" type="checkbox" style="position:absolute; left:4px; top:862px; ">
<input name="PageTwoItem42" id="PageTwoItem42" type="checkbox" style="position:absolute; left:4px; top:880px; ">
<input name="PageTwoItem43" id="PageTwoItem43" type="checkbox" style="position:absolute; left:417px; top:880px; ">
<input name="PageTwoItem44" id="PageTwoItem44" type="checkbox" style="position:absolute; left:493px; top:880px; ">
<input name="PageTwoItem45" id="PageTwoItem45" type="checkbox" style="position:absolute; left:558px; top:880px; ">
<input name="PageTwoItem46" id="PageTwoItem46" type="checkbox" style="position:absolute; left:659px; top:880px; ">
<input name="PageTwoItem47" id="PageTwoItem47" type="text" class="noborder" style="position:absolute; left:79px; top:874px; width:321px; height:27px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=doctor>
<input name="PageTwoItem48" id="PageTwoItem48" type="text" class="noborder" style="position:absolute; left:14px; top:919px; width:385px; height:18px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=provider_name>
<input name="PageTwoItem49" id="PageTwoItem49" type="text" class="noborder" style="position:absolute; left:106px; top:944px; width:297px; height:46px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=clinic_name>
<input name="PageTwoItem50" id="PageTwoItem50" type="checkbox" style="position:absolute; left:332px; top:1014px; ">
<input name="PageTwoItem51" id="PageTwoItem51" type="checkbox" style="position:absolute; left:409px; top:1014px; ">
<input name="PageTwoItem52" id="PageTwoItem52" type="checkbox" style="position:absolute; left:508px; top:1014px; ">
<input name="PageTwoItem53" id="PageTwoItem53" type="text" class="noborder" style="position:absolute; left:587px; top:1007px; width:156px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=today>
<input name="PageTwoItem54" id="PageTwoItem54" type="text" class="noborder" style="position:absolute; left:424px; top:919px; width:311px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=clinic_phone>
<input name="PageTwoItem55" id="PageTwoItem55" type="text" class="noborder" style="position:absolute; left:424px; top:970px; width:300px; height:25px; font-family:sans-serif; font-style:normal; font-weight:normal; font-size:12px; text-align:left; background-color:white;" oscarDB=clinic_addressLineFull>
</div>
<div class="DoNotPrint" style="position: absolute; top: 10px; left: 10px;">
<table>
<tr>
<td class="subjectline">
<input type="button" value="View Page 1" onclick="javascript:changeStyle('print1')" class="button">
<input type="button" value="View Page 2" onclick="javascript:changeStyle('print2')" class="button">
<input type="button" value="Print Page 1" onclick="javascript:pagePrint('print1')" class="button">
<input type="button" value="Print Page 2" onclick="javascript:pagePrint('print2')" class="button">
Description: <input name="subject" size="10" type="text">
<input value="Save" name="SubmitButton" type="submit">
<input value="Reset" name="ResetButton" type="reset">
</td>
</tr>
</table>
</div>
</form>
</BODY>
</HTML>
