adding ubuntu cvs development package scripts with other pieces
[openemr.git] / custom / referral_template.html
blob630f749364dcc60e75bd14e31bcd4703ceb5a856
1 <html>
2 <head>
4 <style>
5 body, td {
6 font-family: sans-serif;
7 font-weight: normal;
8 font-size: 9pt;
10 .borderdiv {
11 width: 524pt;
12 height: 668pt;
13 padding: 0;
14 border-style: solid;
15 border-width: 1px;
16 border-color: #000000;
18 .paddingdiv {
19 padding: 10pt;
21 .bigtable, .linetable {
22 width: 504pt;
24 .linetable {
25 margin: 11pt 0 0 0;
27 .mainhead {
28 font-weight: bold;
29 font-size: 14pt;
30 text-align: center;
32 .under {
33 border-style: solid;
34 border-width: 0 0 1px 0;
35 border-color: #999999;
38 .ftitletable {
39 width: 100%;
40 margin: 0 0 0 0;
42 .ftitlecell1 {
43 vertical-align: top;
44 text-align: left;
45 font-size: 14pt;
46 font-weight: bold;
48 .ftitlecell2 {
49 vertical-align: top;
50 text-align: right;
51 font-size: 9pt;
52 padding-right: 10pt;
54 </style>
56 <title>{label_webpage_title}</title>
57 </head>
59 <body bgcolor='#ffffff'>
61 <!-- The double div resolves a difference between Firefox and IE in treatment of padding. -->
62 <div class='borderdiv'><div class='paddingdiv'>
64 <table cellspacing='0' cellpadding='0' class='bigtable'>
65 <tr>
66 <td class='mainhead' valign='top'>{header1}</td>
67 <td align='right' width='10%' valign='top' nowrap>
68 <table border='1' cellpadding='2' cellspacing='0'>
69 <tr>
70 <td nowrap>{label_clinic_id}</td>
71 <td style='width:60pt' nowrap>{fac_facility_npi}</td>
72 </tr>
73 <tr>
74 <td nowrap>{label_clinic_id}</td>
75 <td nowrap>{ref_pid}</td>
76 </tr>
77 <tr>
78 <td nowrap>{label_control_no}</td>
79 <td nowrap>{ref_id}</td>
80 </tr>
81 <tr>
82 <td nowrap>{label_date}</td>
83 <td nowrap>{ref_refer_date}</td>
84 </tr>
85 </table>
86 </td>
87 </tr>
88 </table>
90 <table cellspacing='0' cellpadding='0' class='linetable'>
91 <tr>
92 <td width='1%' nowrap>{label_name} &nbsp;</td>
93 <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
94 <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
95 <td class='under'>{pt_age}&nbsp;</td>
96 <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
97 <td class='under'>{pt_sex}&nbsp;</td>
98 </tr>
99 </table>
101 <table cellspacing='0' cellpadding='0' class='linetable'>
102 <tr>
103 <td width='1%' nowrap>{label_address} &nbsp;</td>
104 <td class='under'>{pt_street}, {pt_city} {pt_state}&nbsp;</td>
105 <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
106 <td class='under'>{pt_postal_code}&nbsp;</td>
107 <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
108 <td class='under'>{pt_phone_home}&nbsp;</td>
109 </tr>
110 </table>
112 <table cellspacing='0' cellpadding='0' class='linetable'>
113 <tr>
114 <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
115 <td class='under'>{ref_body}&nbsp;</td>
116 </tr>
117 </table>
119 <table cellspacing='0' cellpadding='0' class='linetable'>
120 <tr>
121 <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
122 <td class='under'>{ref_refer_diag}&nbsp;</td>
123 </tr>
124 </table>
126 <table cellspacing='0' cellpadding='0' class='linetable'>
127 <tr>
128 <td width='1%' nowrap>{label_ref_class} &nbsp;</td>
129 <td class='under'>{ref_refer_risk_level}&nbsp;</td>
130 </tr>
131 </table>
133 <table cellspacing='0' cellpadding='0' class='linetable'>
134 <tr>
135 <td width='1%' nowrap>{label_dr_name_sig} &nbsp;</td>
136 <td class='under'>{ref_refer_from}&nbsp;</td>
137 </tr>
138 </table>
140 <table cellspacing='0' cellpadding='0' class='linetable'>
141 <tr>
142 <td width='1%' nowrap>{label_refer_to} &nbsp;</td>
143 <td class='under'>{ref_refer_to} / {to_organization}&nbsp;</td>
144 </tr>
145 </table>
147 <hr style='border:0;height:6pt;color:#999999;background-color:#999999;margin:12pt 0 12pt 0;' />
149 <table cellspacing='0' cellpadding='0' class='bigtable'>
150 <tr>
151 <td class='mainhead' valign='top'>{header1}</td>
152 <td align='right' width='10%' nowrap>
153 <table border='1' cellpadding='2' cellspacing='0'>
154 <tr>
155 <td nowrap>{label_clinic_id}</td>
156 <td style='width:60pt' nowrap>{fac_facility_npi}</td>
157 </tr>
158 <tr>
159 <td nowrap>{label_clinic_id}</td>
160 <td nowrap>{ref_pid}</td>
161 </tr>
162 <tr>
163 <td nowrap>{label_control_no}</td>
164 <td nowrap>{ref_id}</td>
165 </tr>
166 <tr>
167 <td nowrap>{label_date}</td>
168 <td nowrap>{ref_refer_date}</td>
169 </tr>
170 </table>
171 </td>
172 </tr>
173 </table>
175 <table cellspacing='0' cellpadding='0' class='linetable'>
176 <tr>
177 <td width='1%' nowrap>{label_name} &nbsp;</td>
178 <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
179 <td width='1%' nowrap>&nbsp; Age &nbsp;</td>
180 <td class='under'>{pt_age}&nbsp;</td>
181 <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
182 <td class='under'>{pt_sex}&nbsp;</td>
183 </tr>
184 </table>
186 <table cellspacing='0' cellpadding='0' class='linetable'>
187 <tr>
188 <td width='1%' nowrap>{label_clinic} &nbsp;</td>
189 <td class='under'>{to_organization}&nbsp;</td>
190 </tr>
191 </table>
193 <table cellspacing='0' cellpadding='0' class='linetable'>
194 <tr>
195 <td width='1%' nowrap>{label_address} &nbsp;</td>
196 <td class='under'>{to_street}, {to_city} {to_state}&nbsp;</td>
197 <td width='1%' nowrap>&nbsp; {label_postal} &nbsp;</td>
198 <td class='under'>{to_zip}&nbsp;</td>
199 <td width='1%' nowrap>&nbsp; {label_phone} &nbsp;</td>
200 <td class='under'>{to_phone}&nbsp;</td>
201 </tr>
202 </table>
204 <table cellspacing='0' cellpadding='0' class='linetable'>
205 <tr>
206 <td width='1%' nowrap>{label_ref_reason} &nbsp;</td>
207 <td class='under'>{ref_body}&nbsp;</td>
208 </tr>
209 </table>
211 <br />&nbsp;<br />{label_history_summary}:
213 <table cellspacing='0' cellpadding='0' class='linetable'>
214 <tr>
215 <td width='1%' nowrap>{label_bp} &nbsp;</td>
216 <td class='under'>{v_bps}/{v_bpd}&nbsp;</td>
217 <td width='1%' nowrap>&nbsp; {label_ht} &nbsp;</td>
218 <td class='under'>{v_height}&nbsp;</td>
219 <td width='1%' nowrap>&nbsp; {label_wt} &nbsp;</td>
220 <td class='under'>{v_weight}&nbsp;</td>
221 </tr>
222 </table>
226 <table cellspacing='0' cellpadding='0' class='linetable'>
227 <tr>
228 <td width='1%' nowrap>{label_ref_name_sig} &nbsp;</td>
229 <td class='under'>{ref_refer_from}&nbsp;</td>
230 </tr>
231 </table>
233 <table cellspacing='0' cellpadding='0' class='linetable'>
234 <tr>
235 <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
236 <td class='under'>{ref_refer_to}&nbsp;</td>
237 </tr>
238 </table>
240 </div></div>
241 <br clear='all' /><!-- kludge to fix bizarre Firefox problem with page breaks -->
242 <p style='page-break-after: always' />
243 <div class='borderdiv'><div class='paddingdiv'>
245 <table cellspacing='0' cellpadding='0' class='bigtable'>
246 <tr>
247 <td class='mainhead' valign='top'>{header2}</td>
248 <td align='right' width='10%' nowrap>
249 <table border='1' cellpadding='2' cellspacing='0'>
250 <tr>
251 <td nowrap>{label_clinic_id}</td>
252 <td style='width:60pt' nowrap>{fac_facility_npi}</td>
253 </tr>
254 <tr>
255 <td nowrap>{label_clinic_id}</td>
256 <td nowrap>{ref_pid}</td>
257 </tr>
258 <tr>
259 <td nowrap>{label_control_no}</td>
260 <td nowrap>{ref_id}</td>
261 </tr>
262 <tr>
263 <td nowrap>{label_date}</td>
264 <td nowrap>{ref_reply_date}&nbsp;</td>
265 </tr>
266 </table>
267 </td>
268 </tr>
269 </table>
271 <table cellspacing='0' cellpadding='0' class='linetable'>
272 <tr>
273 <td width='1%' nowrap>{label_name} &nbsp;</td>
274 <td class='under'>{pt_title} {pt_fname} {pt_mname} {pt_lname}&nbsp;</td>
275 <td width='1%' nowrap>&nbsp; {label_age} &nbsp;</td>
276 <td class='under'>{pt_age}&nbsp;</td>
277 <td width='1%' nowrap>&nbsp; {label_gender} &nbsp;</td>
278 <td class='under'>{pt_sex}&nbsp;</td>
279 </tr>
280 </table>
282 <table cellspacing='0' cellpadding='0' class='linetable'>
283 <tr>
284 <td width='1%' nowrap>{label_clinic} &nbsp;</td>
285 <td class='under'>{to_organization}&nbsp;</td>
286 </tr>
287 </table>
289 <table cellspacing='0' cellpadding='0' class='linetable'>
290 <tr>
291 <td width='1%' nowrap>{label_diagnosis} &nbsp;</td>
292 <td class='under'>{ref_reply_init_diag}&nbsp;</td>
293 </tr>
294 </table>
296 <table cellspacing='0' cellpadding='0' class='linetable'>
297 <tr>
298 <td width='1%' nowrap>{label_findings} &nbsp;</td>
299 <td class='under'>{ref_reply_findings}&nbsp;</td>
300 </tr>
301 </table>
303 <table cellspacing='0' cellpadding='0' class='linetable'>
304 <tr>
305 <td width='1%' nowrap>{label_final_diagnosis} &nbsp;</td>
306 <td class='under'>{ref_reply_final_diag}&nbsp;</td>
307 </tr>
308 </table>
310 <table cellspacing='0' cellpadding='0' class='linetable'>
311 <tr>
312 <td width='1%' nowrap>{label_services_provided} &nbsp;</td>
313 <td class='under'>{ref_reply_services}&nbsp;</td>
314 </tr>
315 </table>
317 <table cellspacing='0' cellpadding='0' class='linetable'>
318 <tr>
319 <td width='1%' nowrap>{label_recommendations} &nbsp;</td>
320 <td class='under'>{ref_reply_recommend}&nbsp;</td>
321 </tr>
322 </table>
324 <table cellspacing='0' cellpadding='0' class='linetable'>
325 <tr>
326 <td width='1%' nowrap>{label_scripts_and_referrals} &nbsp;</td>
327 <td class='under'>{ref_reply_rx_refer}&nbsp;</td>
328 </tr>
329 </table>
331 <table cellspacing='0' cellpadding='0' class='linetable'>
332 <tr>
333 <td width='1%' nowrap>{label_special_name_sig} &nbsp;</td>
334 <td class='under'>{ref_refer_to}&nbsp;</td>
335 </tr>
336 </table>
338 </div></div>
340 <!-- This should really be in the onload handler but that seems to be unreliable and can crash Firefox 3. -->
341 <script language='JavaScript'>
342 window.print();
343 </script>
345 </body>
346 </html>