sites/default/referral_template.html

   1 <!DOCTYPE html>
   2 <html>
   3 <head>
   4   <meta http-equiv="content-type" content="text/html; charset=UTF-8">
   5   <title>{label_webpage_title}</title>
   6   <style type="text/css">
   7     body, td {
   8       font-family: sans-serif;
   9       font-weight: normal;
  10       font-size: 9pt;
  11       background-color: #fff;
  12     }
  13     .borderdiv {
  14       width: 524pt;
  15       height: 668pt;
  16       padding: 0;
  17       border-style: solid;
  18       border-width: 1px;
  19       border-color: #000000;
  20     }
  21     .paddingdiv {
  22       padding: 10pt;
  23     }
  24     .bigtable{
  25       padding: 0px;
  26       border-spacing: 0;
  27       border-collapse: collapse;
  28     }
  29     .bigtable, .linetable {
  30       width: 504pt;
  31     }
  32     .linetable {
  33       margin: 11pt 0 0 0;
  34       padding: 0px;
  35       border-spacing: 0;
  36       border-collapse: collapse;
  37     }
  38     .mainhead {
  39       font-weight: bold;
  40       font-size: 14pt;
  41       text-align: left;
  42     }
  43     .subhead {
  44       font-weight: bold;
  45       font-size: 8pt;
  46     }
  47     .under {
  48       border-style: solid;
  49       border-width: 0 0 1px 0;
  50       border-color: #999999;
  51     }
  52     .ftitletable {
  53       width: 100%;
  54       margin: 0 0 0 0;
  55     }
  56     .ftitlecell1 {
  57       width: 33%;
  58       vertical-align: top;
  59       text-align: left;
  60       font-size: 14pt;
  61       font-weight: bold;
  62     }
  63     .ftitlecell2 {
  64       width: 33%;
  65       vertical-align: top;
  66       text-align: right;
  67       font-size: 9pt;
  68     }
  69     .ftitlecellm {
  70       width: 34%;
  71       vertical-align: top;
  72       text-align: center;
  73       font-size: 14pt;
  74       font-weight: bold;
  75     }
  76     hr {
  77       border: 0;
  78       height: 6pt;
  79       color: #999999;
  80       background-color: #999999;
  81       margin: 12pt 0 12pt 0;
  82     }
  83     .tdLabelContainer {
  84       text-align: right;
  85       width: 10%;
  86       vertical-align: top;
  87       white-space: nowrap;
  88     }
  89     .mainhead {
  90       vertical-align: top;
  91     }
  92   </style>
  93 </head>
  94
  95 <body>
  96
  97 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
  98 <div class='borderdiv'><div class='paddingdiv'>
  99
 100  <table class="bigtable">
 101   <tr>
 102    <td class='mainhead' style="vertical-align:top">
 103     {header1}
 104     <span class='subhead'>{label_subhead_clinic}</span>
 105    </td>
 106    <td style="text-align:right;width:10%;white-space:nowrap">
 107     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 108      <!--
 109      <tr>
 110       <td style="white-space:nowrap">{label_clinic_id}</td>
 111       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 112      </tr>
 113      -->
 114      <tr>
 115       <td style="white-space:nowrap">{label_client_id}</td>
 116       <td style="white-space:nowrap">{pt_pubpid}&nbsp;</td>
 117      </tr>
 118      <!--
 119      <tr>
 120       <td style="white-space:nowrap">{label_control_no}</td>
 121       <td style="white-space:nowrap">{ref_id}</td>
 122      </tr>
 123      -->
 124      <tr>
 125       <td style="white-space:nowrap">{label_date}</td>
 126       <td style="white-space:nowrap;min-width:54pt">{ref_refer_date}&nbsp;</td>
 127      </tr>
 128     </table>
 129    </td>
 130   </tr>
 131  </table>
 132
 133  <br />&nbsp;<br />{label_history_summary}:
 134
 135  <table cellspacing='0' cellpadding='0' class='linetable'>
 136   <tr>
 137    <td width='1%' nowrap>{label_bp} &nbsp;</td>
 138    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 139    <td width='1%' nowrap>&nbsp; {label_ht} &nbsp;</td>
 140    <td class='under'>{v_height}&nbsp;</td>
 141    <td width='1%' nowrap>&nbsp; {label_wt} &nbsp;</td>
 142    <td class='under'>{v_weight}&nbsp;</td>
 143   </tr>
 144  </table>
 145
 146  <table class='linetable'>
 147   <tr>
 148    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 149    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 150    <td style="width:1%;white-space:nowrap">&nbsp; {label_age} &nbsp;</td>
 151    <td class='under'>{pt_age}&nbsp;</td>
 152    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 153    <td class='under'>{pt_sex}&nbsp;</td>
 154   </tr>
 155  </table>
 156
 157  <table class='linetable'>
 158   <tr>
 159    <td style="width:1%;white-space:nowrap">{label_address} &nbsp;</td>
 160    <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
 161    <td style="width:1%;white-space:nowrap">&nbsp; {label_postal} &nbsp;</td>
 162    <td class='under'>{pt_postal_code}&nbsp;</td>
 163    <td style="width:1%;white-space:nowrap">&nbsp; {label_phone} &nbsp;</td>
 164    <td class='under'>{pt_phone_home}&nbsp;</td>
 165   </tr>
 166  </table>
 167
 168  <table class='linetable'>
 169   <tr>
 170    <td style="width:1%;white-space:nowrap">{label_ref_reason} &nbsp;</td>
 171    <td class='under'>{ref_body}&nbsp;</td>
 172   </tr>
 173  </table>
 174
 175  <table class='linetable'>
 176   <tr>
 177    <td style="width:1%;white-space:nowrap">{label_diagnosis} &nbsp;</td>
 178    <td class='under'>{ref_refer_diag}&nbsp;</td>
 179   </tr>
 180  </table>
 181
 182  <table class='linetable'>
 183   <tr>
 184    <td style="width:1%;white-space:nowrap">{label_ref_class} &nbsp;</td>
 185    <td class='under'>{ref_refer_risk_level}&nbsp;</td>
 186   </tr>
 187  </table>
 188
 189  <table class='linetable'>
 190   <tr>
 191    <td style="width:1%;white-space:nowrap">{label_dr_name_sig} &nbsp;</td>
 192    <td class='under'>{ref_refer_from}&nbsp;</td>
 193   </tr>
 194  </table>
 195
 196  <table class='linetable'>
 197   <tr>
 198    <td style="width:1%;white-space:nowrap">{label_refer_to} &nbsp;</td>
 199    <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
 200   </tr>
 201  </table>
 202
 203  <hr />
 204
 205  <table class="bigtable">
 206   <tr>
 207    <td class='mainhead'>
 208     {header1}
 209     <span class='subhead'>{label_subhead_patient}</span>
 210    </td>
 211    <td style="text-align:right;vertical-align:top;width:10%;white-space:nowrap">
 212     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 213      <!--
 214      <tr>
 215       <td style="white-space:nowrap">{label_clinic_id}</td>
 216       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 217      </tr>
 218      -->
 219      <tr>
 220       <td style="white-space:nowrap">{label_client_id}</td>
 221       <td style="white-space:nowrap">{pt_pubpid}&nbsp;</td>
 222      </tr>
 223      <!--
 224      <tr>
 225       <td style="white-space:nowrap">{label_control_no}</td>
 226       <td style="white-space:nowrap">{ref_id}</td>
 227      </tr>
 228      -->
 229      <tr>
 230       <td style="white-space:nowrap">{label_date}</td>
 231       <td style="white-space:nowrap;min-width:54pt">{ref_refer_date}&nbsp;</td>
 232      </tr>
 233     </table>
 234    </td>
 235   </tr>
 236  </table>
 237
 238  <table class='linetable'>
 239   <tr>
 240    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 241    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 242    <td style="width:1%;white-space:nowrap">&nbsp; Age &nbsp;</td>
 243    <td class='under'>{pt_age}&nbsp;</td>
 244    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 245    <td class='under'>{pt_sex}&nbsp;</td>
 246   </tr>
 247  </table>
 248
 249  <table class='linetable'>
 250   <tr>
 251    <td style="width:1%;white-space:nowrap">{label_clinic} &nbsp;</td>
 252    <td class='under'>{to_organization}&nbsp;</td>
 253   </tr>
 254  </table>
 255
 256  <table class='linetable'>
 257   <tr>
 258    <td style="width:1%;white-space:nowrap">{label_address} &nbsp;</td>
 259    <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
 260    <td style="width:1%;white-space:nowrap">&nbsp; {label_postal} &nbsp;</td>
 261    <td class='under'>{to_zip}&nbsp;</td>
 262    <td style="width:1%;white-space:nowrap">&nbsp; {label_phone} &nbsp;</td>
 263    <td class='under'>{to_phone}&nbsp;</td>
 264   </tr>
 265  </table>
 266
 267  <table class='linetable'>
 268   <tr>
 269    <td style="width:1%;white-space:nowrap">{label_ref_reason} &nbsp;</td>
 270    <td class='under'>{ref_body}&nbsp;</td>
 271   </tr>
 272  </table>
 273
 274  <br />&nbsp;<br />{label_history_summary}:
 275
 276  <table class='linetable'>
 277   <tr>
 278    <td style="width:1%;white-space:nowrap">{label_bp} &nbsp;</td>
 279    <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
 280    <td style="width:1%;white-space:nowrap">&nbsp; {label_ht} &nbsp;</td>
 281    <td class='under'>{v_height}&nbsp;</td>
 282    <td style="width:1%;white-space:nowrap">&nbsp; {label_wt} &nbsp;</td>
 283    <td class='under'>{v_weight}&nbsp;</td>
 284   </tr>
 285  </table>
 286
 287  <p>
 288
 289  <table class='linetable'>
 290   <tr>
 291    <td style="width:1%;white-space:nowrap">{label_ref_name_sig} &nbsp;</td>
 292    <td class='under'>{ref_refer_from}&nbsp;</td>
 293   </tr>
 294  </table>
 295
 296  <table class='linetable'>
 297   <tr>
 298    <td style="width:1%;white-space:nowrap">{label_special_name_sig} &nbsp;</td>
 299    <td class='under'>{ref_refer_to}&nbsp;</td>
 300   </tr>
 301  </table>
 302
 303 </div></div>
 304 <br style="clear:both;" /><!-- kludge to fix bizarre Firefox problem with page breaks -->
 305 <p style='page-break-after: always'></p>
 306 <div class='borderdiv'><div class='paddingdiv'>
 307
 308  <table class="bigtable">
 309   <tr>
 310    <td class='mainhead'>
 311     {header2}
 312     <span class='subhead'>{label_subhead_referred}</span>
 313    </td>
 314    <td style="text-align:right;vertical-align:top;width:10%;white-space:nowrap">
 315     <table border='1' style="padding:2px;border-spacing:0;border-collapse:collapse">
 316      <!--
 317      <tr>
 318       <td style="white-space:nowrap">{label_clinic_id}</td>
 319       <td style='width:60pt;white-space:nowrap'>{fac_facility_npi}</td>
 320      </tr>
 321      -->
 322      <tr>
 323       <td style="white-space:nowrap">{label_client_id}</td>
 324       <td style="white-space:nowrap">{pt_pubpid}&nbsp;</td>
 325      </tr>
 326      <!--
 327      <tr>
 328       <td style="white-space:nowrap">{label_control_no}</td>
 329       <td style="white-space:nowrap">{ref_id}</td>
 330      </tr>
 331      -->
 332      <tr>
 333       <td style="white-space:nowrap">{label_date}</td>
 334       <td style="white-space:nowrap;min-width:54pt">{ref_reply_date}&nbsp;</td>
 335      </tr>
 336     </table>
 337    </td>
 338   </tr>
 339  </table>
 340
 341  <table class='linetable'>
 342   <tr>
 343    <td style="width:1%;white-space:nowrap">{label_name} &nbsp;</td>
 344    <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
 345    <td style="width:1%;white-space:nowrap">&nbsp; {label_age} &nbsp;</td>
 346    <td class='under'>{pt_age}&nbsp;</td>
 347    <td style="width:1%;white-space:nowrap">&nbsp; {label_gender} &nbsp;</td>
 348    <td class='under'>{pt_sex}&nbsp;</td>
 349   </tr>
 350  </table>
 351
 352  <table class='linetable'>
 353   <tr>
 354    <td style="width:1%;white-space:nowrap">{label_clinic} &nbsp;</td>
 355    <td class='under'>{to_organization}&nbsp;</td>
 356   </tr>
 357  </table>
 358
 359  <table class='linetable'>
 360   <tr>
 361    <td style="width:1%;white-space:nowrap">{label_diagnosis} &nbsp;</td>
 362    <td class='under'>{ref_reply_init_diag}&nbsp;</td>
 363   </tr>
 364  </table>
 365
 366  <table class='linetable'>
 367   <tr>
 368    <td style="width:1%;white-space:nowrap">{label_findings} &nbsp;</td>
 369    <td class='under'>{ref_reply_findings}&nbsp;</td>
 370   </tr>
 371  </table>
 372
 373  <table class='linetable'>
 374   <tr>
 375    <td style="width:1%;white-space:nowrap">{label_final_diagnosis} &nbsp;</td>
 376    <td class='under'>{ref_reply_final_diag}&nbsp;</td>
 377   </tr>
 378  </table>
 379
 380  <table class='linetable'>
 381   <tr>
 382    <td style="width:1%;white-space:nowrap">{label_services_provided} &nbsp;</td>
 383    <td class='under'>{ref_reply_services}&nbsp;</td>
 384   </tr>
 385  </table>
 386
 387  <table class='linetable'>
 388   <tr>
 389    <td style="width:1%;white-space:nowrap">{label_recommendations} &nbsp;</td>
 390    <td class='under'>{ref_reply_recommend}&nbsp;</td>
 391   </tr>
 392  </table>
 393
 394  <table class='linetable'>
 395   <tr>
 396    <td style="width:1%;white-space:nowrap">{label_scripts_and_referrals} &nbsp;</td>
 397    <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
 398   </tr>
 399  </table>
 400
 401  <table class='linetable'>
 402   <tr>
 403    <td style="width:1%;white-space:nowrap">{label_special_name_sig} &nbsp;</td>
 404    <td class='under'>{ref_refer_to}&nbsp;</td>
 405   </tr>
 406  </table>
 407
 408 </div></div>
 409
 410 <!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
 411 <script type="text/javascript">
 412  var win = top.printLogPrint ? top : opener.top;
 413  win.printLogPrint(window);
 414 </script>
 415
 416 </body>
 417 </html>