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javascript/frontpage

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wantfree

wantfree

Technical User
Jan 17, 2007
1
US
I need help with this forum. This is my first Javascript/frontpage exp. In this form, I am trying to figure out the way to force the user to must select yes/no when tab from one radio button to another. I Can't use submit button the bottom. I can only use tabbing. I need validation starting (from Yes/No Allergic to iodine contrast --- to Yes/No Breastfeeding) End. starting from the empty text field name Comments: when I skip the first radio button I get message but i can only click Yes and it won't let me click No. Also, on the very top left I have a Yes radio button which i can't get rid of. Please Help!!Thanks.



<html>

<head>
<meta http-equiv="Content-Language" content="en-us">
<meta http-equiv="Content-Type" content="text/html; charset=windows-1252">
<title>MRI Safety Screening</title>
<SCRIPT LANGUAGE="Javascript">
function validateRadioButtonChecked(radioButton1, radioButton2, errorMessage)
{

if(!document.getElementById(radioButton1).checked && !document.getElementById(radioButton2).checked)


{
alert(errorMessage);

document.getElementById(radioButton1).focus();

return false;
}



}
var nonigc_text_area_array = new Array() ;

function nonigc_textarea_obj(form_name, textarea_name, rowsize, colsize)
{
this.formname = form_name;
this.areaname = textarea_name;
this.rowsize = rowsize;
this.colsize = colsize;
}

function nonigc_body()
{
var nonigc_array_count = 0;

for(var i=0;i<document.forms.length;i++)
for(var j=0; j<document.forms.elements.length;j++)
if(document.forms.elements[j].type == "textarea" && document.forms.elements[j].name)
{
nonigc_text_area_array[nonigc_array_count] = new nonigc_textarea_obj(document.forms.name, document.forms.elements[j].name, document.forms.elements[j].rows, document.forms.elements[j].cols);
nonigc_array_count++;
}
}

function nonigc_resize_textarea_onkeyup(obj)
{
var nonigc_line_array = obj.value.split('\n');
var nonigc_text_area_size = 0;

for (x=0;x < nonigc_line_array.length; x++)
if (nonigc_line_array[x].length >= obj.cols)
nonigc_text_area_size += Math.ceil(nonigc_line_array[x].length/obj.cols);

nonigc_text_area_size += nonigc_line_array.length;
nonigc_text_area_size = nonigc_text_area_size + parseInt(nonigc_text_area_size/10);

if (nonigc_text_area_size > obj.rows)
obj.rows = nonigc_text_area_size;
}

function nonigc_resize_textarea_onblur(obj)
{
var nonigc_line_array = obj.value.split('\n');
var nonigc_text_area_size = 0;

for (x=0;x < nonigc_line_array.length; x++)
if (nonigc_line_array[x].length >= obj.cols)
nonigc_text_area_size += Math.ceil(nonigc_line_array[x].length/obj.cols);

nonigc_text_area_size += nonigc_line_array.length;
nonigc_text_area_size = nonigc_text_area_size + parseInt(nonigc_text_area_size/10);

for(x=0; x < nonigc_text_area_array.length; x++)
if(nonigc_text_area_array[x].areaname == obj.name)
{
if(nonigc_text_area_array[x].rowsize > nonigc_text_area_size)
nonigc_text_area_size = nonigc_text_area_array[x].rowsize;
break;
}

obj.rows = nonigc_text_area_size;
}

function validateRadioButtons(thisform,order)
{
myOption = -1;
if (order==1)
{
for (i=thisform.YesNo1.length-1; i > -1; i--)
{
if (thisform.YesNo1.checked)
myOption = i;
}

if (myOption == -1) {
alert("Please select Yes/No for 'Any surgery on this body part(s)'");
return false;
}
}
else if (order==2)
{
for (i=thisform.YesNo1.length-1; i > -1; i--)
{
if (thisform.YesNo1.checked)
myOption = i;
}
if (myOption == -1) {
alert("Please select Yes/No for 'Any surgery on this body part(s)'");
return false;
}

myOption = -1;
for (i=thisform.YesNo2.length-1; i > -1; i--)
{
if (thisform.YesNo2.checked)
myOption = i;
}

if (myOption == -1) {
alert("Please select Yes/No for 'Previous MRI studies on this body part(s) '");
return false;
}
}
else if (order==3)
{
for (i=thisform.YesNo1.length-1; i > -1; i--)
{
if (thisform.YesNo1.checked)
myOption = i;
}
if (myOption == -1) {
alert("Please select Yes/No for 'Patient instructed to bring a driver'");
return false;
}

myOption = -1;
for (i=thisform.YesNo2.length-1; i > -1; i--)
{
if (thisform.YesNo2.checked)
myOption = i;
}

if (myOption == -1) {
alert("Please select Yes/No for 'Previous MRI studies on this body part(s)'");
return false;
}

myOption = -1;
for (i=thisform.YesNo2.length-1; i > -1; i--)
{
if (thisform.YesNo2.checked)
myOption = i;
}
if (myOption == -1) {
alert("Please select Yes/No 'Allergic to iodine contrast '");
return false;
}

}
else if (order==4)
{
for (i=thisform.YesNo1.length-1; i > -1; i--)
{
if (thisform.YesNo1.checked)
myOption = i;
}
if (myOption == -1) {
alert("Please select Yes/No for 'Any surgery on this body part(s)'");
return false;
}

myOption = -1;
for (i=thisform.YesNo2.length-1; i > -1; i--)
{
if (thisform.YesNo2.checked)
myOption = i;
}

if (myOption == -1) {
alert("Please select Yes/No for 'Previous MRI studies on this body part(s)'");
return false;
}

myOption = -1;
for (i=thisform.YesNo3.length-1; i > -1; i--)
{
if (thisform.YesNo3.checked)
myOption = i;
}
if (myOption == -1) {
alert("Please select Yes/No for 'Allergic to iodine contrast '");
return false;
}

myOption = -1;
for (i=thisform.YesNo4.length-1; i > -1; i--)
{
if (thisform.YesNo4.checked)
myOption = i;
}

if (myOption == -1) {
alert("Please select all Yes/No for 'Patient verbalizes understanding of above information'");
return false;
}

}



}

</SCRIPT>

<style>
<!--
div.Section1
{page:Section1;}
-->
</style>

</head>

<body>
<form method="POST" name="myForm" action="--WEBBOT-SELF--">

<table border="1" width="650" id="table1" cellspacing="1" cellpadding="0">
<tr>
<td colspan="2">
<u>
<img border="0" src=" width="87" height="70" align="left"></u><p>&nbsp;</p>
<p>&nbsp;</td>
</tr>
<tr>
<td colspan="2"><font size="2">Date: #?[Date]?#<br>
Patient's Name: #?[PatFullName]?#<br>
Clinic #: #?[MRN]?#<br>
Home Phone: #?[PatHomePhone]?#<br>
Work Phone: #?[PatWorkPhone]?#<br>
Other Phone:&nbsp; </font>
<input type="text" name="Other_Phone" size="40" style="font-size: 10pt; font-family: Times New Roman"><br>
<font size="2">Insurance</font>:
<input type="text" name="Insurance" size="43" style="font-size: 10pt; font-family: Times New Roman">
</td></tr>


<tr>
<td width="375"><font size="2">Height: #?[VsignsHeight1]?#
#?[VsignsHeightUnit1]?# <font face="Times New Roman">
#?[VsignsHeight2_1]?#&nbsp;#?[VsignsHeightUnt2_1]?#&nbsp; &nbsp; </font> </font>
<input type="text" name="Height" size="10" style="font-size: 10pt; font-family: Times New Roman"></td>
<td><font size="2">Weight:
#?[VsignsWeight1]?##?[VsignsWeightUnit1]?#&nbsp;
#?[VsignsWeight2_1]?#&nbsp;#?[VsignsWeightUnt2_1]?#&nbsp;&nbsp;&nbsp;</font> &nbsp;<input type="text" name="Weight" size="10" style="font-size: 10pt; font-family: Times New Roman"></td>
</tr>

<tr>
<td colspan="2"><font size="2" face="Times New Roman">Reason for
study </font><font size="1">
<textarea rows="1" name="ReasonforStudy" cols="124" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td width="99%" colspan="2"><font size="2">Body part(s) to be scanned </font><font size="1">
<textarea rows="1" name="BodyPartToBeScanned" cols="111" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-family:Times New Roman; font-size:8pt" style="font-size: 8pt; font-family: Times New Roman"></textarea></font> </td>
</tr>
<tr>
<td width="99%" colspan="2"><font size="2" face="Times New Roman">Any surgery on this body part(s) </font>
<font size="2" face="Times New Roman">test&nbsp;</font><span style="font-size: 11pt"><font face="Times New Roman"><input type="radio" value="Yes" name="YesNo1"></font></span><font size="2" face="Times New Roman">Yes&nbsp;
</font><span style="font-size: 11pt">
<font face="Times New Roman">
<input type="radio" name="YesNo1" value="No"></font></span><font size="2" face="Times New Roman">No<br>
NPO after </font>

<input type="radio" value="V1" name="Any_Surgery_on_this_body_part" onFocus="validateRadioButtons(myForm,1)" onkeyup="nonigc_resize_textarea_onkeyup(this)" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;&nbsp;&nbsp;&nbsp;
Explain:</font><font size="1">
<textarea rows="1" name="Surgery_on_body_part" cols="69" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" onFocus="validateRadioButtons(myForm,1)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>

<tr>
<td width="99%" colspan="2"><font size="2">Previous MRI studies on this body part(s) </font>
<input type="radio" value="Yes" name="YesNo2"><font size="2">Yes&nbsp;
</font>
<!--<input type="radio" value="V1" name="Previous_MRI_studies" style="font-size: 10pt; font-family: Times New Roman"><font size="2">No&nbsp;-->
<input type="radio" name="YesNo2" value="No"> </font></span><font size="2" face="Times New Roman">No<br>
</font><font size="1">

<textarea rows="1" name="Previous_MRI" cols="69" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" onFocus="validateRadioButtons(myForm,2)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
<input type="radio" value="YesNo2" name="Previous MRI studies on this body part(s)" onFocus="validateRadioButtons(myForm,1)" onkeyup="nonigc_resize_textarea_onkeyup(this)" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes&nbsp;
</tr>
<tr>
<td width="99%" colspan="2"><font size="2">Allergies:</font><font size="2" face="Times New Roman">#?[AllergyDesc1]?#&nbsp;
#?[AllergyDesc2]?#&nbsp;&nbsp; #?[AllergyDesc3]?#&nbsp;
#?[AllergyDesc4]?#&nbsp; <br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #?[AllergyDesc5]?#&nbsp; #?[AllergyDesc6]?#&nbsp;&nbsp; #?[AllergyDesc7]?#&nbsp;
#?[AllergyDesc8]?#&nbsp;<br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; #?[AllergyDesc9]?#&nbsp; #?[AllergyDesc10]?#&nbsp; #?[AllergyDesc11]?#&nbsp;
#?[AllergyDesc12]?#&nbsp; <br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
#?[AllergyDesc13]?#&nbsp; #?[AllergyDesc14]?#&nbsp;&nbsp; #?[AllergyDesc15]?#&nbsp;
#?[AllergyDesc16]?#&nbsp; <br>
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
#?[AllergyDesc17]?#&nbsp; #?[AllergyDesc18]?#&nbsp;&nbsp; #?[AllergyDesc19]?#&nbsp;
#?[AllergyDesc20]?#&nbsp;<br>
Comments: </font><font size="1">
<textarea rows="1" name="Comments_for_Allergies" cols="134" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-family:Times New Roman; font-size:8pt"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td width="99%" colspan="2">
<input id="AllergicToIodineContrastYes" onblur="validateRadioButtonChecked('AllergicToIodineContrastYes', 'AllergicToIodineContrastNo', 'Please Select Yes/No for Allergic To Iodine Contrast');" <input type="radio" value="V1" name="AllergicToIodineContrast" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="AllergicToIodineContrastNo" onblur="validateRadioButtonChecked('AllergicToIodineContrastYes', 'AllergicToIodineContrastNo', 'Please Select Yes/No for Allergic To Iodine Contrast');" <input type="radio" value="V1" name="AllergicToIodineContrast" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;
Allergic to iodine contrast
</font></td>
</tr>
<tr>
<td width="99%" colspan="2">
<input id="AllergicToGadoliniumYes" onblur="validateRadioButtonChecked('AllergicToGadoliniumYes', 'AllergicToGadoliniumNo', 'Please Select Yes/No for Allergic To Gadolinium');" <input type="radio" value="V1" name="AllergicToGadolinium" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="AllergicToGadoliniumNo" onblur="validateRadioButtonChecked('AllergicToGadoliniumYes', 'AllergicToGadoliniumNo', 'Please Select Yes/No for Allergic To Gadolinium');" <input type="radio" value="V1" name="AllergicToGadolinium" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;
Allergic to gadolinium
</font><font size="1" face="Times New Roman"><b>&nbsp;</b><i>(if yes,
call MRI department before completing the rest of the form)</i></font></td>
</tr>
<tr>
<td width="99%" colspan="2">
<input id="No_Previous_historyYes" onblur="validateRadioButtonChecked('No_Previous_historyYes', 'No_Previous_historyNo', 'Please Select Yes/No for Previous History of cancer / type or location');" <input type="radio" value="V1" name="No_Previous_history" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="No_Previous_historyNo" onblur="validateRadioButtonChecked('No_Previous_historyYes', 'No_Previous_historyNo', 'Please Select Yes/No for Previous History of cancer / type or location');" <input type="radio" value="V1" name="No_Previous_history" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;&nbsp;
Previous history of cancer / type or location </font><font size="1">
<textarea rows="1" name="Previous_history_of_cancer" cols="68" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td width="48%">
<input id="ClaustrophobicYes" onblur="validateRadioButtonChecked('ClaustrophobicYes', 'ClaustrophobicNo', 'Please Select Yes/No for Claustrophobic');" <input type="radio" value="V1" name="Claustrophobic" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="ClaustrophobicNo" onblur="validateRadioButtonChecked('ClaustrophobicYes', 'ClaustrophobicNo', 'Please Select Yes/No for Claustrophobic');" <input type="radio" value="V1" name="Claustrophobic" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;&nbsp;
Claustrophobic</font></td>
<td width="51%">
<input id="RX_givenYes" onblur="validateRadioButtonChecked('RX_givenYes', 'RX_givenNo', 'Please Select Yes/No for RX given (If yes, driver required)');" <input type="radio" value="V1" name="RX_given" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="RX_givenNo" onblur="validateRadioButtonChecked('RX_givenYes', 'RX_givenNo', 'Please Select Yes/No for RX given (If yes, driver required');" <input type="radio" value="V1" name="RX_given" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;&nbsp;
RX given (If yes, driver required)</font></td>
</tr>
<tr>
<td width="99%" height="25" colspan="2">
<input id="Are_you_PregnantYes" onblur="validateRadioButtonChecked('Are_you_PregnantYes', 'Are_you_PregnantNo', 'Please Select Yes/No. Are you pregnant or do you suspect that you are pregnant?)');" <input type="radio" value="V1" name="Are_you_Pregnant" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Are_you_PregnantNo" onblur="validateRadioButtonChecked('Are_you_PregnantYes', 'Are_you_PregnantNo', 'Please Select Yes/No. Are you pregnant or do you suspect that you are pregnant?');" <input type="radio" value="V1" name="Are_you_Pregnant" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;&nbsp;
Are you pregnant or do you suspect that you are pregnant&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
If Yes, how many weeks </font>
<input type="text" name="Weeks_of_gestation" size="5" style="font-size: 10pt; font-family: Times New Roman"></td>
</tr>
<tr>
<td width="99%" height="25" colspan="2">
<input id="BreastfeedingYes" onblur="validateRadioButtonChecked('BreastfeedingYes', 'BreastfeedingNo', 'Please Select Yes/No for Breastfeeding');" <input type="radio" value="V1" name="Breastfeeding" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="BreastfeedingNo" onblur="validateRadioButtonChecked('BreastfeedingYes', 'BreastfeedingNo', 'Please Select Yes/No for Breastfeeding');" <input type="radio" value="V1" name="Breastfeeding" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp; Breastfeeding</font></td>
</tr>

</table>

<table border="1" width="650" id="table4">
<tr>
<td colspan="2"><b>The following items could result in device
malfunction, injury, blindness, or death if put in the MRI scanner</b></td>
</tr>
<tr>
<td width="14%">
<input id="Cardiac_PacemakerYes" onblur="validateRadioButtonChecked('Cardiac_PacemakerYes', 'Cardiac_PacemakerNo', 'Please Select Yes/No for Cardiac Pacemaker, Pacing Wires or Implanted Defibrillator');" <input type="radio" value="V1" name="Cardiac_Pacemaker" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Cardiac_PacemakerNo" onblur="validateRadioButtonChecked('Cardiac_PacemakerYes', 'Cardiac_PacemakerNo', 'Please Select Yes/No for Cardiac Pacemaker, Pacing Wires or Implanted Defibrillator');" <input type="radio" value="V1" name="Cardiac_Pacemaker" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No&nbsp;
</font></td>
<td width="83%"><font size="2" face="Times New Roman">Cardiac Pacemaker,
Pacing Wires or Implanted Defibrillator&nbsp; <br>
**If yes, these devices are not compatible with a MRI, contact the Radiologist
for alternative imaging solutions and do not complete the rest of the
form</font></td>
</tr>
<tr>
<td>
<input id="Brain_AneurysmYes" onblur="validateRadioButtonChecked('Brain_AneurysmYes', 'Brain_AneurysmNo', 'Please Select Yes/No for Brain Aneurysm Clip or other Vascular clip');" <input type="radio" value="V1" name="Brain_Aneurysm" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Brain_AneurysmNo" onblur="validateRadioButtonChecked('Brain_AneurysmYes', 'Brain_AneurysmNo', 'Please Select Yes/No for Brain Aneurysm Clip or other Vascular clip');" <input type="radio" value="V1" name="Brain_Aneurysm" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Brain Aneurysm Clip or other Vascular clip.&nbsp; If
yes, documentation or MRI compatibility required.<br>
Model #, manufacturing #: </font><font size="1">
<textarea rows="1" name="Brain_Aneurysm_model_manufacturing" cols="91" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Ear_SurgeryYes" onblur="validateRadioButtonChecked('Ear_SurgeryYes', 'Ear_SurgeryNo', 'Please Select Yes/No for Ear Surgery including Cochlear Implant, Stapedectomy or Prosthesis Placement Location, type, model #, manufacturing #');" <input onblur="validateRadioButtonCheckeds('Ear_SurgeryYes', 'Ear_SurgeryNo', 'Please Select Yes/No for Ear Surgery including Cochlear Implant, Stapedectomy or Prosthesis Placement Location, type, model #, manufacturing #');" <input type="radio" value="V1" name="Ear_Surgery" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Ear_SurgeryNo" onblur="validateRadioButtonChecked('Ear_SurgeryYes', 'Ear_SurgeryNo', 'Please Select Yes/No for Ear Surgery including Cochlear Implant, Stapedectomy or Prosthesis Placement Location, type, model #, manufacturing #');" <input onblur="validateRadioButtonCheckeds('Ear_SurgeryYes', 'Ear_SurgeryNo', 'Please Select Yes/No for Ear Surgery including Cochlear Implant, Stapedectomy or Prosthesis Placement Location, type, model #, manufacturing #');" <input type="radio" value="V1" name="Ear_Surgery" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Ear Surgery including Cochlear Implant, Stapedectomy
or Prosthesis Placement<br>
Location, type, model #, manufacturing #: </font><font size="1">
<textarea rows="1" name="Ear_Surgery" cols="70" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="NeurostimulatorsYes" onblur="validateRadioButtonChecked('NeurostimulatorsYes', 'NeurostimulatorsNo', 'Please Select Yes/No for Neurostimulators (TENS Unit)');" <input type="radio" value="V1" name="Neurostimulators" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="NeurostimulatorsNo" onblur="validateRadioButtonChecked('NeurostimulatorsYes', 'NeurostimulatorsNo', 'Please Select Yes/No for Neurostimulators (TENS Unit)');" <input type="radio" value="V1" name="Neurostimulators" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Neurostimulators (TENS Unit)<br>
If yes, can wires be removed from patient </font>
<input id="Y_N_wiresYes" onblur="validateRadioButtonChecked('Y_N_wiresYes', 'Y_N_wiresNo', 'Can wires be removed from Patient? Please Select Yes/No');" <input type="radio" value="V1" name="Y_N_wires" style="font-size: 10pt; font-family: Times New Roman" onFocus="validateRadioButtons(myForm,'Neurostimulators')"><font size="2" face="Times New Roman">Yes
</font>
<input id="Y_N_wiresNo" onblur="validateRadioButtonChecked('Y_N_wiresYes', 'Y_N_wiresNo', 'Can wires be removed from Patient? Please Select Yes/No');" <input type="radio" value="V1" name="Y_N_wires" style="font-size: 10pt; font-family: Times New Roman" onFocus="validateRadioButtons(myForm,'Neurostimulators')"><font size="2" face="Times New Roman">No </font></td>
</tr>
<tr>
<td>
<input id="Bone_Growth_StimulatorYes" onblur="validateRadioButtonChecked('Bone_Growth_StimulatorYes', 'Bone_Growth_StimulatorNo', 'Please Select Yes/No for Bone Growth Stimulator/Bladder Stimulator');" <input type="radio" value="V1" name="Bone_Growth_Stimulator" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Bone_Growth_StimulatorNo" onblur="validateRadioButtonChecked('Bone_Growth_StimulatorYes', 'Bone_Growth_StimulatorNo', 'Please Select Yes/No for Bone Growth Stimulator/Bladder Stimulator');" <input type="radio" value="V1" name="Bone_Growth_Stimulator" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Bone Growth Stimulator / Bladder Stimulator<br>
If yes, can wires be removed from patient </font>
<input id="Y_N_wires_neuroYes" onblur="validateRadioButtonChecked('Y_N_wires_neuroYes', 'Y_N_wires_neuroNo', 'Please Select Yes/No If yes, can wires be removed from patient');" <input type="radio" value="V1" name="Y_N_wires_neuro" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Y_N_wires_neuroNo" onblur="validateRadioButtonChecked('Y_N_wires_neuroYes', 'Y_N_wires_neuroNo', 'Please Select Yes/No If yes, can wires be removed from patient');"<input type="radio" value="V1" name="Y_N_wires_neuro" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
</tr>
<tr>
<td>
<font size="2" face="Times New Roman">
<input id="Pump_for_MedicationYes" onblur="validateRadioButtonChecked('Pump_for_MedicationYes', 'Pump_for_MedicationNo', 'Please Select Yes/No for Pump for Medication delivery (Insulin, Morphine, etc)');" <input type="radio" value="V2" name="Pump_for_Medication" style="font-size: 10pt; font-family: Times New Roman">Yes
</font>
<input id="Pump_for_MedicationNo" onblur="validateRadioButtonChecked('Pump_for_MedicationYes', 'Pump_for_MedicationNo', 'Please Select Yes/No for Pump for Medication delivery (Insulin, Morphine, etc)');" <input type="radio" value="V1" name="Pump_for_Medication" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Pump for Medication delivery (Insulin, Morphine,
etc.)<br>
If yes, can pump be removed from patient </font>
<input id="Yes_No_pumpYes" onblur="validateRadioButtonChecked('Yes_No_pumpYes', 'Yes_No_pumpNo', 'If yes, can pump be removed from patient Yes/No');" <input type="radio" value="V1" name="Yes_No_pump" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Yes_No_pumpNo" onblur="validateRadioButtonChecked('Yes_No_pumpYes', 'Yes_No_pumpNo', 'If yes, can pump be removed from patient Yes/No');" <input type="radio" value="V1" name="Yes_No_pump" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
</tr>
<tr>
<td>
<input id="Currently_using_medication_patchYes" onblur="validateRadioButtonChecked('Currently_using_medication_patchYes', 'Currently_using_medication_patchNo', 'Please Select Yes/No for Currently using a medication patch (Nitro, Nicotine, Pain, Birth Control, etc.)');" <input type="radio" value="V1" name="Currently_using_medication_patch" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Currently_using_medication_patchNo" onblur="validateRadioButtonChecked('Currently_using_medication_patchYes', 'Currently_using_medication_patchNo', 'Please Select Yes/No for Currently using a medication patch (Nitro, Nicotine, Pain, Birth Control, etc.)');" <input type="radio" value="V1" name="Currently_using_medication_patch" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Currently using a medication patch (Nitro, Nicotine,
Pain, Birth Control, etc.)</font></td>
</tr>
<tr>
<td>
<input id="Other_implantableYes" onblur="validateRadioButtonChecked('Other_implantableYes', 'Other_implantableNo', 'Please Select Yes/No for Other implantable or indwelling devices containing metal component');" <input type="radio" value="V1" name="Other_implantable" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Other_implantableNo" onblur="validateRadioButtonChecked('Other_implantableYes', 'Other_implantableNo', 'Please Select Yes/No for Other implantable or indwelling devices containing metal component');" <input type="radio" value="V1" name="Other_implantable" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Other implantable or indwelling devices containing
metal component<br>
Explain: </font><font size="1">
<textarea rows="1" name="Other_implantable" cols="116" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Metal_fragmentsYes" onblur="validateRadioButtonChecked('Metal_fragmentsYes', 'Metal_fragmentsNo', 'Please Select Yes/No for Metal fragments: bullets, shrapnel in head, eye, spine and other parts of body Location and how many years in the body:');" <input type="radio" value="V1" name="Metal_fragments" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Metal_fragmentsNo" onblur="validateRadioButtonChecked('Metal_fragmentsYes', 'Metal_fragmentsNo', 'Please Select Yes/No for Metal fragments: bullets, shrapnel in head, eye, spine and other parts of body Location and how many years in the body:');" <input type="radio" value="V1" name="Metal_fragments" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Metal fragments: bullets, shrapnel in head, eye,
spine and other parts of body<br>
Location and how many years in the body: </font><font size="1">
<textarea rows="1" name="Metal_fragments" cols="70" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Has_patient_ever_done_any_weldingYes" onblur="validateRadioButtonChecked('Has_patient_ever_done_any_weldingYes', 'Has_patient_ever_done_any_weldingNo', 'Please Select Yes/No for Has patient ever done any welding or metal working');" <input type="radio" value="V1" name="Has_patient_ever_done_any_welding" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Has_patient_ever_done_any_weldingNo" onblur="validateRadioButtonChecked('Has_patient_ever_done_any_weldingYes', 'Has_patient_ever_done_any_weldingNo', 'Please Select Yes/No for Has patient ever done any welding or metal working');" <input type="radio" value="V1" name="Has_patient_ever_done_any_welding" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td>
<div class="Section1">
<font face="Times New Roman" color="black" size="2">
<span style="color: black">Has patient <b><u>ever </u></b>done any
welding or metal working?&nbsp; If yes, patient will need orbit xrays
done prior to MRI.&nbsp; (<i><span style="FONT-STYLE: italic">If patient
has had orbit xrays and has not been exposed to welding or metal
working since previous xrays, new orbit xrays are not required)</span></i></span></font></div>
</td>
</tr>
<tr>
<td>
<input id="Artificial_Heart_ValveYes" onblur="validateRadioButtonChecked('Artificial_Heart_ValveYes', 'Artificial_Heart_ValveNo', 'Please Select Yes/No for Artificial Heart Valve');" <input type="radio" value="V1" name="Artificial_Heart_Valve" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Artificial_Heart_ValveNo" onblur="validateRadioButtonChecked('Artificial_Heart_ValveYes', 'Artificial_Heart_ValveNo', 'Please Select Yes/No for Artificial Heart Valve');" <input type="radio" value="V1" name="Artificial_Heart_Valve" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Artificial Heart Valve:</font><br>
<font size="2">Model #, manufacturing #:</font> <font size="1">
<textarea rows="1" name="Artifical_Heart" cols="92" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<font size="2" face="Times New Roman">
<input id="Vascular_Stent_FiltersYes" onblur="validateRadioButtonChecked('Vascular_Stent_FiltersYes', 'Vascular_Stent_FiltersNo', 'Please Select Yes/No for Vascular Stent/Filters');" <input id="Vascular_Stent_FiltersYes" onblur="validateRadioButtonChecked('Vascular_Stent_FiltersYes', 'Vascular_Stent_FiltersNo', 'Please Select Yes/No for Vascular Stent/Filters');" <input type="radio" value="V2" name="Vascular_Stent_Filters" style="font-size: 10pt; font-family: Times New Roman">Yes
</font>
<input id="Vascular_Stent_FiltersNo" onblur="validateRadioButtonChecked('Vascular_Stent_FiltersYes', 'Vascular_Stent_FiltersNo', 'Please Select Yes/No for Vascular Stent/Filters');" <input type="radio" value="V1" name="Vascular_Stent_Filters" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Vascular Stent/Filters:</font><br>
<font size="2">Location, model #, manufacturing # and surgery date: </font><font size="1">
<textarea rows="1" name="Vascular_Stent" cols="57" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Surgical_ClipsYes" onblur="validateRadioButtonChecked('Surgical_ClipsYes', 'Surgical_ClipsNo', 'Please Select Yes/No for Surgical_Clips/Wire Sutures/Metal Mesh Implants');" <input type="radio" value="V1" name="Surgical_Clips" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Surgical_ClipsNo" onblur="validateRadioButtonChecked('Surgical_ClipsYes', 'Surgical_ClipsNo', 'Please Select Yes/No for Surgical_Clips/Wire Sutures/Metal Mesh Implants');" <input type="radio" value="V1" name="Surgical_Clips" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Surgical Clips/Wire Sutures/Metal Mesh Implants:<br>
Location and surgery date: </font><font size="1">
<textarea rows="1" name="Surgical_Clips" cols="92" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Penile_implantsYes" onblur="validateRadioButtonChecked('Penile_implantsYes', 'Penile_implantsNo', 'Please Select Yes/No for Penile Implants');" <input type="radio" value="V1" name="Penile_implants" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Penile_implantsNo" onblur="validateRadioButtonChecked('Penile_implantsYes', 'Penile_implantsNo', 'Please Select Yes/No for Penile Implants');" <input type="radio" value="V1" name="Penile_implants" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Penile Implants:</font><br>
<font size="2">Model #, manufacturing #: </font><font size="1">
<textarea rows="1" name="Penile_Implants" cols="92" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="IUDYes" onblur="validateRadioButtonChecked('IUDYes', 'IUDNo', 'Please Select Yes/No for IUD');" <input type="radio" value="V1" name="IUD" style="font-size: 10pt; font-family: Times New Roman"><font size="2">Yes</font>
<input id="IUDNo" onblur="validateRadioButtonChecked('IUDYes', 'IUDNo', 'Please Select Yes/No for IUD');" <input type="radio" value="V1" name="IUD" style="font-size: 10pt; font-family: Times New Roman"><font size="2">No</font></td>
<td><font size="2">I.U.D.</font></td>
</tr>
<tr>
<td>
<input id="DiaphragmYes" onblur="validateRadioButtonChecked('DiaphragmYes', 'DiaphragmNo', 'Please Select Yes/No for Diaphragm');" <input type="radio" value="V1" name="Diaphragm" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="DiaphragmNo" onblur="validateRadioButtonChecked('DiaphragmYes', 'DiaphragmNo', 'Please Select Yes/No for Diaphragm');" <input type="radio" value="V1" name="Diaphragm" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Diaphragm (can not be in place during the time
of scan)</font></td>
</tr>
<tr>
<td>
<input id="ShuntYes" onblur="validateRadioButtonChecked('ShuntYes', 'ShuntNo', 'Please Select Yes/No for Shunt: Spinal or Ventricular');" <input type="radio" value="V1" name="Shunt" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="ShuntNo" onblur="validateRadioButtonChecked('ShuntYes', 'ShuntNo', 'Please Select Yes/No for Shunt: Spinal or Ventricular');" <input type="radio" value="V1" name="Shunt" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Shunt: Spinal or Ventricular</font>
<input type="text" name="Shunt" size="30" style="font-size: 10pt; font-family: Times New Roman"></td>
</tr>
<tr>
<td>
<input id="Spinal_Surgical_Fusion_rodYes" onblur="validateRadioButtonChecked('Spinal_Surgical_Fusion_rodYes', 'Spinal_Surgical_Fusion_rodNo', 'Please Select Yes/No for Spinal Surgical Fusion rod, Joint Replacement, Prosthesis');" <input type="radio" value="V1" name="Spinal_Surgical_Fusion_rod" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Spinal_Surgical_Fusion_rodNo" onblur="validateRadioButtonChecked('Spinal_Surgical_Fusion_rodYes', 'Spinal_Surgical_Fusion_rodNo', 'Please Select Yes/No for Spinal Surgical Fusion rod, Joint Replacement, Prosthesis');" <input type="radio" value="V1" name="Spinal_Surgical_Fusion_rod" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Spinal Surgical Fusion rod, Joint Replacement,
Prosthesis<br>
Explain with location: </font><font size="1">
<textarea rows="1" name="Spinal_Surgical" cols="92" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Fractures_treated_with_rodsYes" onblur="validateRadioButtonChecked('Fractures_treated_with_rodsYes', 'Fractures_treated_with_rodsNo', 'Please Select Yes/No for Fractures treated with rods, metal plates, pins, nails, clips');" <input type="radio" value="V1" name="Fractures_treated_with_rods" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Fractures_treated_with_rodsNo" onblur="validateRadioButtonChecked('Fractures_treated_with_rodsYes', 'Fractures_treated_with_rodsNo', 'Please Select Yes/No for Fractures treated with rods, metal plates, pins, nails, clips');" <input type="radio" value="V1" name="Fractures_treated_with_rods" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Fractures treated with rods, metal plates, pins,
nails, clips</font><br>
<font size="2">Explain with location: </font><font size="1">
<textarea rows="1" name="Fractures_treated_with_rods" cols="92" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Hearing_AidsYes" onblur="validateRadioButtonChecked('Hearing_AidsYes', 'Hearing_AidsNo', 'Please Select Yes/No for Hearing Aids');" <input type="radio" value="V1" name="Hearing_Aids" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Hearing_AidsNo" onblur="validateRadioButtonChecked('Hearing_AidsYes', 'Hearing_AidsNo', 'Please Select Yes/No for Hearing Aids');" <input type="radio" value="V1" name="Hearing_Aids" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Hearing Aids</font></td>
</tr>
<tr>
<td>
<input id="DenturesYes" onblur="validateRadioButtonChecked('DenturesYes', 'DenturesNo', 'Please Select Yes/No for Dentures');" <input type="radio" value="V1" name="Dentures" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="DenturesNo" onblur="validateRadioButtonChecked('DenturesYes', 'DenturesNo', 'Please Select Yes/No for Dentures');" <input type="radio" value="V1" name="Dentures" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Dentures</font></td>
</tr>
<tr>
<td>
<input id="BracesYes" onblur="validateRadioButtonChecked('BracesYes', 'BracesNo', 'Please Select Yes/No for Braces');" <input type="radio" value="V1" name="Braces" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="BracesNo" onblur="validateRadioButtonChecked('BracesYes', 'BracesNo', 'Please Select Yes/No for Braces');" <input type="radio" value="V1" name="Braces" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Braces</font></td>
</tr>
<tr>
<td>
<input id="Body_PiercingsYes" onblur="validateRadioButtonChecked('Body_PiercingsYes', 'Body_PiercingsNo', 'Please Select Yes/No for Body Piercings');" <input id="Body_PiercingsYes" onblur="validateRadioButtonChecked('Body_PiercingsYes', 'Body_PiercingsNo', 'Please Select Yes/No for Body Piercings');" <input type="radio" value="V1" name="Body_Piercings" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Body_PiercingsNo" onblur="validateRadioButtonChecked('Body_PiercingsYes', 'Body_PiercingsNo', 'Please Select Yes/No for Body Piercings');" <input id="Body_PiercingsNo" onblur="validateRadioButtonChecked('Body_PiercingsYes', 'Body_PiercingsNo', 'Please Select Yes/No for Body Piercings');" <input type="radio" value="V1" name="Body_Piercings" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Body Piercings-all piercings <b><u>must</u></b> be
removed-no exceptions (could cause a burn in that area)</font></td>
</tr>
<tr>
<td>
<input id="Permanent_Eyeliners_TattoosYes" onblur="validateRadioButtonChecked('Permanent_Eyeliners_TattoosYes', 'Permanent_Eyeliners_TattoosNo', 'Please Select Yes/No for Permanent Eyeliners/Tattoos');" <input type="radio" value="V1" name="Permanent_Eyeliners_Tattoos" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Permanent_Eyeliners_TattoosNo" onblur="validateRadioButtonChecked('Permanent_Eyeliners_TattoosYes', 'Permanent_Eyeliners_TattoosNo', 'Please Select Yes/No for Permanent Eyeliners/Tattoos');" <input type="radio" value="V1" name="Permanent_Eyeliners_Tattoos" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Permanent Eyeliner/Tattoos<br>
Location: </font><font size="1">
<textarea rows="1" name="Permanent_Eyeliner" cols="105" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
<tr>
<td>
<input id="Does_the_patient_have_special_needsYes" onblur="validateRadioButtonChecked('Does_the_patient_have_special_needsYes', 'Does_the_patient_have_special_needsNo', ' Does the patient have special needs? Please Select Yes/No');" <input type="radio" value="V1" name="Does_the_patient_have_special_needs" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input id="Does_the_patient_have_special_needsNo" onblur="validateRadioButtonChecked('Does_the_patient_have_special_needsYes', 'Does_the_patient_have_special_needsNo', ' Does the patient have special needs? Please Select Yes/No');" <input type="radio" value="V1" name="Does_the_patient_have_special_needs" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td><font size="2">Does the patient have special needs that may required
extra time to get the patient set up? (Wheelchair, Hoyer Lift, Unable to
speak English, Learning Disability): </font><font size="1">
<textarea rows="1" name="Special_needs" cols="60" onkeyup="nonigc_resize_textarea_onkeyup(this)" onblur="nonigc_resize_textarea_onblur(this)" style="font-size:8pt; font-family:Times New Roman"style="font-size: 8pt; font-family: Times New Roman"></textarea></font></td>
</tr>
</table>

<table border="1" width="650" id="table5">
<tr>
<td colspan="2">
<p align="left"><b>Hospital Patients Nurse Must Fill Out</b></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Swan_Ganz" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Swan_Ganz" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Swan Ganz</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="ICP_Probe" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="ICP_Probe" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">ICP Probe</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Chest_Tube" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Chest_Tube" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Chest Tube</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Telemetry" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Telemetry" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Telemetry</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="O2" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="O2" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">O2</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Vent" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Vent" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Vent</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="IV_Heplock" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="IV_Heplock" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">IV/Heplock</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Nurse_Assist" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Nurse_Assist" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Nurse Assist</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Monitor" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Monitor" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Is the patient being monitored</font></td>
</tr>
<tr>
<td width="14%">
<input type="radio" value="V1" name="Respiratory_Assistant" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">Yes
</font>
<input type="radio" value="V1" name="Respiratory_Assistant" style="font-size: 10pt; font-family: Times New Roman"><font size="2" face="Times New Roman">No</font></td>
<td width="84%"><font size="2">Respiratory Assistant</font></td>
</tr>
<tr>
<td width="98%" colspan="2">
<font size="2" face="Times New Roman">Mode of transportation
</font><font face="Times New Roman">
<input type="radio" value="V1" name="Mode_of_transporation"></font><font size="2" face="Times New Roman">Cart&nbsp;
</font><font face="Times New Roman">
<input type="radio" value="V1" name="Mode_of_transporation"></font><font size="2" face="Times New Roman">Bed&nbsp;
</font><font face="Times New Roman">
<input type="radio" value="V1" name="Mode_of_transporation"></font><font size="2" face="Times New Roman">Wheelchair&nbsp;
</font><font face="Times New Roman">
<input type="radio" value="V1" name="Mode_of_transporation"></font><font size="2" face="Times New Roman">Wagon</font></td>
</tr>
</table>
</form>
</body>

</html>
 
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