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HTMLFORM

tibwangchuk Nov 14th, 2016 79 Never
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  1. <htmlform >
  2.  
  3.     <!-- Autogenerated example form  (template from 01-Nov-2010 -->
  4.     <macros>
  5.         paperFormId = (Fill this in)
  6.         headerColor =#009d8e
  7.         fontOnHeaderColor = white
  8.     </macros>
  9.  
  10.     <style>
  11.         .section {
  12.             border: 1px solid $headerColor;
  13.             padding: 2px;
  14.             text-align: left;
  15.             margin-bottom: 1em;
  16.         }
  17.         .sectionHeader {
  18.             background-color: $headerColor;
  19.             color: $fontOnHeaderColor;
  20.             display: block;
  21.             padding: 2px;
  22.             font-weight: bold;
  23.         }
  24.         table.baseline-aligned td {
  25.             vertical-align: baseline;
  26.         }
  27.     </style>
  28. <style>
  29. table, tr, td
  30. {
  31. background-color:#E6E6E6;
  32. border:1px solid black;
  33. border-collapse: collapse;
  34. padding: 0.1cm;
  35. margin-left: 0.8cm;
  36.  
  37.  
  38. }
  39. </style>
  40.  
  41. <style>
  42. body {
  43.     font-family: "Arial";
  44.     font-size: 12px;
  45. }
  46.  
  47. body[Attributes Style] {
  48.     margin-right: 0px;
  49.     margin-left: 0px;
  50.     margin-bottom: 0px;
  51.     margin-top: 0px;
  52. }
  53.  
  54. body {
  55.     display: block;
  56.    
  57. }
  58.  
  59. article, aside, footer, header, hgroup, main, nav, section {
  60.     display: block;
  61. }
  62.  
  63.  
  64.  
  65. p {
  66.     padding-left: 0.8cm;
  67.     margin-top: 0.0cm;
  68.     margin-bottom: 0.0cm;
  69. }
  70.  
  71. p {
  72.     display: block;
  73.     -webkit-margin-before: 1em;
  74.     -webkit-margin-after: 1em;
  75.     -webkit-margin-start: 0px;
  76.     -webkit-margin-end: 0px;
  77. }
  78.  
  79. label {
  80.     cursor: default;
  81. }
  82.  
  83.  
  84. input[type="number"] {
  85.     width: 6em;
  86. }
  87.  
  88.  
  89.  
  90.  
  91.  
  92.  
  93.  
  94. textarea {
  95.     width: 55em;
  96.     height: 3em;
  97.     display: block;
  98. }
  99.  
  100.  
  101. textarea {
  102.     -webkit-appearance: textarea;
  103.     background-color: white;
  104.     border-image-source: initial;
  105.     border-image-slice: initial;
  106.     border-image-width: initial;
  107.     border-image-outset: initial;
  108.     border-image-repeat: initial;
  109.     -webkit-rtl-ordering: logical;
  110.     -webkit-user-select: text;
  111.     flex-direction: column;
  112.     resize: auto;
  113.     cursor: auto;
  114.     white-space: pre-wrap;
  115.     word-wrap: break-word;
  116.     border-width: 1px;
  117.     border-style: solid;
  118.     border-color: initial;
  119.     padding: 2px;
  120. }
  121.  
  122.  
  123.  
  124.  
  125.  
  126.  
  127. header.level1 {
  128.     font-family: "Arial";
  129.     font-size: medium;
  130.     font-weight: bold;
  131.     margin-top: 0.3cm;
  132.     margin-bottom: 0.0cm;
  133.         background-color: white;
  134.     color: black;
  135. }
  136.  
  137. input[type="text"] {
  138.     width: 20em;
  139. }
  140.  
  141.  
  142. header.level2 {
  143.     text-align: left;
  144.     font-family: "Arial";
  145.     font-size: small;
  146.     font-weight: bold;
  147.     margin-top: 0.3cm;
  148.     margin-bottom: 0.0cm;
  149.         background-color: white;
  150.     color: black;
  151. }
  152.  
  153. form input, form select, form textarea, form ul.select, .form input, .form select, .form textarea, .form ul.select {
  154.     min-width: 30%;
  155.     color: #363463;
  156.     display: block;
  157.     padding: 5px 10px;
  158.     margin: 0;
  159.     margin-top: 5px;
  160.     background-color: #FFF;
  161.     border: 1px solid #dddddd;
  162. }
  163.  
  164. #label_text{
  165.  
  166.  
  167. float:left;
  168.     /* padding-right: 10px; */
  169.     padding-right: 1%;
  170.  
  171. }
  172.  
  173.  
  174.  
  175. #label_placeholder{
  176.  
  177.  
  178. float:right;
  179.  
  180.         margin-top: -18px;
  181.         /* padding-right: 540px;
  182.         padding-right: 52%; */
  183.      
  184. }
  185.  
  186.  
  187. header {
  188.     position: relative;
  189.     /* background-color: #00463f; */
  190.     color: #CCC;
  191.     line-height: 1em;
  192.     -moz-border-radius: 5px;
  193.     -webkit-border-radius: 5px;
  194.     -o-border-radius: 5px;
  195.     -ms-border-radius: 5px;
  196.     -khtml-border-radius: 5px;
  197.     border-radius: 5px;
  198. }
  199.  
  200.  
  201.  
  202. </style>
  203.  
  204.     <span style="float:right">Paper Form ID: $paperFormId</span>
  205.     <h2>Cardiac MRI Adenosine Stress Protocol</h2>
  206.  
  207.     <section headerLabel="1. Encounter Details">
  208.         <table class="baseline-aligned">
  209.             <tr>
  210.                 <td>Date:</td>
  211.                 <td><encounterDate default="today"/></td>
  212.             </tr>
  213.             <tr>
  214.                 <td>Location:</td>
  215.                 <td><encounterLocation/></td>
  216.             </tr>
  217.             <tr>
  218.                 <td>Provider:</td>
  219.                 <td><encounterProvider/></td>
  220.             </tr>
  221.         </table>
  222.     </section>
  223.  
  224. <section data-section-name="Procedure">
  225. <header class="level1">Cardiac MRI: Adenosine Stress Protocol</header>
  226.  
  227. <p>
  228. <label for="label_text" id="label_text">Field strength:</label>
  229. <obs conceptId="164107" type="number" id="field_strength_input" name="Field strength" data-field-units="T" min="" max="" value="1.5"/>
  230. <label for="label_placeholder" id="label_placeholder" style="padding-right: 540px;">T</label>
  231. </p>
  232.  
  233.  
  234.  
  235. <p>
  236. <label for="label_text">Adenosine stress protocol:</label>
  237. <obs conceptId="164108" style="textarea" defaultValue="0.14 mg/kg/min adenosine infused over 4 minutes with stress perfusion imaging performed during the last minute of the adenosine infusion using an FGRE-ET sequence and a gadolinium dose of 0.1 mmol/kg. Rest perfusion imaging was performed was then performed after appropriate delay using additional gadolinium dose of 0.1 mmol/kg. Cine white blood imaging including short axis and two, three and four chamber long axis views was performed using a FIESTA sequence to evaluate cardiac morphology and function. Delayed enhanced imaging was performed using an Inversion recovery prepared gradient echo sequence. Images were postprocessed on a computer workstation to assess cardiac anatomy and ventricular function."  />
  238. </p>
  239. </section>
  240.  
  241. <section data-section-name="Clinical information">
  242. <header class="level1">Clinical information</header>
  243. <p>
  244. <obs conceptId="164109" style="textarea" name="Clinical information"/>
  245. </p>
  246. </section>
  247.  
  248. <section data-section-name="Comparison">
  249. <header class="level1">Comparison</header>
  250. <p>
  251. <obs conceptId="164110" style="textarea" defaultValue="None"/>
  252. </p>
  253. </section>
  254.  
  255.  
  256.  
  257.  
  258. <section data-section-name="Findings">
  259. <header class="level1">Findings</header>
  260. <p>
  261. <label for="label_text">Stress perfusion imaging:</label>
  262. <obs conceptId="164111" name="Stress perfusion imaging" defaultValue="Normal"/>
  263. </p>
  264.  
  265. <p>
  266. <label for="label_text">Rest perfusion imaging:</label>
  267. <obs conceptId="164112" name="Rest perfusion imaging" defaultValue="Normal"/>
  268. </p>
  269.  
  270. <p>
  271. <label for="label_text">Cine images:</label>
  272. <obs conceptId="164113" style="textarea" defaultValue="Normal cardiac anatomy and normal cardiac chamber size. Normal left ventricular wall motion and function. "/>
  273. </p>
  274.  
  275. <section data-section-name="Left ventricle">
  276. <header class="level2">Left ventricle</header>
  277. <p>
  278. <label for="label_text" id="label_text">End-diastole volume:</label>
  279. <obs conceptId="164114" name="End-diastole volume" data-field-units="mL" min="0" max=""/>
  280. <label for="label_placeholder" id="label_placeholder" style="padding-right: 500px;">mL</label>
  281. </p>
  282.  
  283. <p>
  284. <label for="label_text" id="label_text">End-systolic volume:</label>
  285. <obs conceptId="164115" name="End-systolic volume" data-field-units="mL" min="0" max=""/>
  286. <label for="label_placeholder" id="label_placeholder" style="padding-right: 500px;">mL</label>
  287. </p>
  288. <p>
  289. <label for="label_text" id="label_text">Stroke volume:</label>
  290. <obs conceptId="164116" name="Stroke volume" data-field-units="mL" min="0" max=""/>
  291. <label for="label_placeholder" id="label_placeholder" style="padding-right: 530px;">mL</label>
  292. </p>
  293. <p>
  294. <label for="label_text" id="label_text">Ejection fraction:</label>
  295. <obs conceptId="164117" name="Ejection fraction" value="" data-field-units="%"/>
  296. <label for="label_placeholder" id="label_placeholder" style="padding-right: 530px;">%</label>
  297. </p>
  298. <p>
  299. <label for="label_text" id="label_text">Mass:</label>
  300. <obs conceptId="164118" name="Mass" data-field-units="g" min="0" max=""/>
  301. <label for="label_placeholder" id="label_placeholder" style="padding-right: 590px;">g</label>
  302. </p>
  303. <p>
  304. <label for="label_text" id="label_text">Antero-septal wall (end-diastole):</label>
  305. <obs conceptId="164119" name="Antero-septal wall" data-field-units="cm" min="0" max=""/>
  306. <label for="label_placeholder" id="label_placeholder" style="padding-right: 435px;">cm</label>
  307. </p>
  308. <p>
  309. <label for="label_text" id="label_text">Infero-lateral wall (end-diastole):</label>
  310. <obs conceptId="164120" name="Infero-lateral wall" data-field-units="cm" min="0" max=""/>
  311. <label for="label_placeholder" id="label_placeholder" style="padding-right: 435px;">cm</label>
  312. </p>
  313. <p>
  314. <label for="label_text" id="label_text">Left ventricular diameter measured at the base (end-diastole):</label>
  315. <obs conceptId="164121" name="Left ventricular diameter end-diastole" value=""/>
  316. <label for="label_placeholder" id="label_placeholder" style="padding-right: 280px;">cm</label>
  317. </p>
  318. <p>
  319. <label for="label_text" id="label_text">Left ventricular diameter measured at the base (end-systole):</label>
  320. <obs conceptId="164122" name="Left ventricular diameter end-systole" value=""/>
  321. <label for="label_placeholder" id="label_placeholder" style="padding-right: 280px;">cm</label>
  322. </p>
  323. <p>
  324. <label for="label_text" id="label_text">Delayed enhancement:</label>
  325. <obs conceptId="164123" name="Delayed enhancement" defaultValue="There is no delayed enhancement of the myocardium or pericardium"/>
  326. </p>
  327.  
  328.  
  329. </section>
  330. <section data-section-name="Reference">
  331. <header class="level2">Reference</header>
  332. <p>
  333. Reference values from: Maceira et al., Normalized left ventricular systolic and diastolic function by steady state free precession cardiovascular magnetic resonance. J Cardiovascular Magn Reson 2006; 8:417-426.
  334. </p>
  335. </section>
  336.  
  337. </section>
  338.  
  339. <section data-section-name="Impression">
  340. <header class="level1">Impression</header>
  341. <p>
  342. <obs conceptId="
  343. 164124
  344. " name="Impression" style="textarea"/>
  345. </p>
  346. </section>
  347.  
  348.     <submit/>
  349.  
  350.  
  351.  
  352.  
  353. </htmlform>
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