You can not select more than 25 topics
Topics must start with a letter or number, can include dashes ('-') and can be up to 35 characters long.
464 lines
13 KiB
464 lines
13 KiB
<!DOCTYPE html> |
|
<html> |
|
<head> |
|
<meta http-equiv="content-type" content="text/html; charset=UTF-8"> |
|
<title>{label_webpage_title}</title> |
|
<style> |
|
body, td { |
|
font-family: sans-serif; |
|
font-weight: normal; |
|
font-size: 9pt; |
|
background-color: #fff; |
|
} |
|
.borderdiv { |
|
width: 524pt; |
|
height: 668pt; |
|
padding: 0; |
|
border-style: solid; |
|
border-width: 1px; |
|
border-color: #000000; |
|
} |
|
.paddingdiv { |
|
padding: 10pt; |
|
} |
|
.bigtable{ |
|
padding: 0px; |
|
border-spacing: 0; |
|
border-collapse: collapse; |
|
} |
|
.bigtable, .linetable { |
|
width: 504pt; |
|
} |
|
.linetable { |
|
margin: 11pt 0 0 0; |
|
padding: 0px; |
|
border-spacing: 0; |
|
border-collapse: collapse; |
|
} |
|
.mainhead { |
|
font-weight: bold; |
|
font-size: 14pt; |
|
text-align: left; |
|
} |
|
.subhead { |
|
font-weight: bold; |
|
font-size: 8pt; |
|
} |
|
.under { |
|
border-style: solid; |
|
border-width: 0 0 1px 0; |
|
border-color: #999999; |
|
} |
|
.ftitletable { |
|
width: 100%; |
|
margin: 0 0 0 0; |
|
} |
|
.ftitlecell1 { |
|
width: 33%; |
|
vertical-align: top; |
|
text-align: left; |
|
font-size: 14pt; |
|
font-weight: bold; |
|
} |
|
.ftitlecell2 { |
|
width: 33%; |
|
vertical-align: top; |
|
text-align: right; |
|
font-size: 9pt; |
|
} |
|
.ftitlecellm { |
|
width: 34%; |
|
vertical-align: top; |
|
text-align: center; |
|
font-size: 14pt; |
|
font-weight: bold; |
|
} |
|
hr { |
|
border: 0; |
|
height: 6pt; |
|
color: #999999; |
|
background-color: #999999; |
|
margin: 12pt 0 12pt 0; |
|
} |
|
.tdLabelContainer { |
|
text-align: right; |
|
width: 10%; |
|
vertical-align: top; |
|
white-space: nowrap; |
|
} |
|
.mainhead { |
|
vertical-align: top; |
|
} |
|
</style> |
|
</head> |
|
|
|
<body> |
|
|
|
<!-- The double div resolves a difference between Firefox and IE in treatment of padding. --> |
|
<div class='borderdiv'><div class='paddingdiv'> |
|
|
|
<table class="bigtable"> |
|
<tr> |
|
<td class='mainhead' style="vertical-align:top"> |
|
{header1} |
|
<span class='subhead'>{label_subhead_clinic}</span> |
|
</td> |
|
<td style="text-align:right;width:10%;white-space:nowrap"> |
|
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse"> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_clinic_id}</td> |
|
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_client_id}</td> |
|
<td style="white-space:nowrap">{pt_pubpid} </td> |
|
</tr> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_control_no}</td> |
|
<td style="white-space:nowrap">{ref_id}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_date}</td> |
|
<td style="white-space:nowrap;min-width:54pt">{ref_refer_date} </td> |
|
</tr> |
|
</table> |
|
</td> |
|
</tr> |
|
</table> |
|
|
|
<br /> <br />{label_history_summary}: |
|
|
|
<table cellspacing='0' cellpadding='0' class='linetable'> |
|
<tr> |
|
<td width='1%' nowrap>{label_bp} </td> |
|
<td class='under'>{v_bps}/{v_bpd} </td> |
|
<td width='1%' nowrap> {label_ht} </td> |
|
<td class='under'>{v_height} </td> |
|
<td width='1%' nowrap> {label_wt} </td> |
|
<td class='under'>{v_weight} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_name} </td> |
|
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_age} </td> |
|
<td class='under'>{pt_age} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_gender} </td> |
|
<td class='under'>{pt_sex} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ins_name} </td> |
|
<td class='under'>{insurance_provider_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_plan_name} </td> |
|
<td class='under'>{insurance_plan_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_policy} </td> |
|
<td class='under'>{insurance_policy_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_group} </td> |
|
<td class='under'>{insurance_group_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_date} </td> |
|
<td class='under'>{insurance_date}</td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_address} </td> |
|
<td class='under'>{pt_street}, {pt_city} {pt_state} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_postal} </td> |
|
<td class='under'>{pt_postal_code} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_phone} </td> |
|
<td class='under'>{pt_phone_home} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ref_reason} </td> |
|
<td class='under'>{ref_body} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_diagnosis} </td> |
|
<td class='under'>{ref_refer_diag} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ref_class} </td> |
|
<td class='under'>{ref_refer_risk_level} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_dr_name_sig} </td> |
|
<td class='under'>{ref_refer_from} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_refer_to} </td> |
|
<td class='under'>{ref_refer_to} / {to_organization} </td> |
|
</tr> |
|
</table> |
|
|
|
<hr /> |
|
|
|
<table class="bigtable"> |
|
<tr> |
|
<td class='mainhead'> |
|
{header1} |
|
<span class='subhead'>{label_subhead_patient}</span> |
|
</td> |
|
<td style="text-align:right;vertical-align:top;width:10%;white-space:nowrap"> |
|
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse"> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_clinic_id}</td> |
|
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_client_id}</td> |
|
<td style="white-space:nowrap">{pt_pubpid} </td> |
|
</tr> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_control_no}</td> |
|
<td style="white-space:nowrap">{ref_id}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_date}</td> |
|
<td style="white-space:nowrap;min-width:54pt">{ref_refer_date} </td> |
|
</tr> |
|
</table> |
|
</td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_name} </td> |
|
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td> |
|
<td style="width:1%;white-space:nowrap"> Age </td> |
|
<td class='under'>{pt_age} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_gender} </td> |
|
<td class='under'>{pt_sex} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ins_name} </td> |
|
<td class='under'>{insurance_provider_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_plan_name} </td> |
|
<td class='under'>{insurance_plan_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_policy} </td> |
|
<td class='under'>{insurance_policy_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_group} </td> |
|
<td class='under'>{insurance_group_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_date} </td> |
|
<td class='under'>{insurance_date}</td> |
|
</tr> |
|
</table> |
|
|
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_clinic} </td> |
|
<td class='under'>{to_organization} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_address} </td> |
|
<td class='under'>{to_street}, {to_city} {to_state} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_postal} </td> |
|
<td class='under'>{to_zip} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_phone} </td> |
|
<td class='under'>{to_phone} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ref_reason} </td> |
|
<td class='under'>{ref_body} </td> |
|
</tr> |
|
</table> |
|
|
|
<br /> <br />{label_history_summary}: |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_bp} </td> |
|
<td class='under'>{v_bps}/{v_bpd} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_ht} </td> |
|
<td class='under'>{v_height} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_wt} </td> |
|
<td class='under'>{v_weight} </td> |
|
</tr> |
|
</table> |
|
|
|
<p> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ref_name_sig} </td> |
|
<td class='under'>{ref_refer_from} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_special_name_sig} </td> |
|
<td class='under'>{ref_refer_to} </td> |
|
</tr> |
|
</table> |
|
|
|
</div></div> |
|
<br style="clear:both;" /><!-- kludge to fix bizarre Firefox problem with page breaks --> |
|
<p style='page-break-after: always'></p> |
|
<div class='borderdiv'><div class='paddingdiv'> |
|
|
|
<table class="bigtable"> |
|
<tr> |
|
<td class='mainhead'> |
|
{header2} |
|
<span class='subhead'>{label_subhead_referred}</span> |
|
</td> |
|
<td style="text-align:right;vertical-align:top;width:10%;white-space:nowrap"> |
|
<table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse"> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_clinic_id}</td> |
|
<td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_client_id}</td> |
|
<td style="white-space:nowrap">{pt_pubpid} </td> |
|
</tr> |
|
<!-- |
|
<tr> |
|
<td style="white-space:nowrap">{label_control_no}</td> |
|
<td style="white-space:nowrap">{ref_id}</td> |
|
</tr> |
|
--> |
|
<tr> |
|
<td style="white-space:nowrap">{label_date}</td> |
|
<td style="white-space:nowrap;min-width:54pt">{ref_reply_date} </td> |
|
</tr> |
|
</table> |
|
</td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_name} </td> |
|
<td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_age} </td> |
|
<td class='under'>{pt_age} </td> |
|
<td style="width:1%;white-space:nowrap"> {label_gender} </td> |
|
<td class='under'>{pt_sex} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_ins_name} </td> |
|
<td class='under'>{insurance_provider_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_plan_name} </td> |
|
<td class='under'>{insurance_plan_name} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_policy} </td> |
|
<td class='under'>{insurance_policy_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_group} </td> |
|
<td class='under'>{insurance_group_number} </td> |
|
<td style="width:1%;white-space:nowrap">{label_ins_date} </td> |
|
<td class='under'>{insurance_date}</td> |
|
</tr> |
|
</table> |
|
|
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_clinic} </td> |
|
<td class='under'>{to_organization} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_diagnosis} </td> |
|
<td class='under'>{ref_reply_init_diag} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_findings} </td> |
|
<td class='under'>{ref_reply_findings} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_final_diagnosis} </td> |
|
<td class='under'>{ref_reply_final_diag} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_services_provided} </td> |
|
<td class='under'>{ref_reply_services} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_recommendations} </td> |
|
<td class='under'>{ref_reply_recommend} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_scripts_and_referrals} </td> |
|
<td class='under'>{ref_reply_rx_refer} </td> |
|
</tr> |
|
</table> |
|
|
|
<table class='linetable'> |
|
<tr> |
|
<td style="width:1%;white-space:nowrap">{label_special_name_sig} </td> |
|
<td class='under'>{ref_refer_to} </td> |
|
</tr> |
|
</table> |
|
|
|
</div></div> |
|
|
|
<!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. --> |
|
<script> |
|
var win = top.printLogPrint ? top : opener.top; |
|
win.printLogPrint(window); |
|
</script> |
|
|
|
</body> |
|
</html>
|
|
|