<!-- BEGIN [% template.name %] -->
[% # INCLUDE dumper.tt dump = # automatic = session, vars, params, request & settings
# settings;
# session;
# request;
# params;
# env;
# errs;
# vars;
%]
[% # pds_.tt also sets pds_code param & 'is_validated' if SMSP-0000
IF pds.size; pds_display = PROCESS pds.tt; END;
# flag for loading info and setting submit button text:
generate_pdf = ( params.item('_skip_pds') || is_validated );
PROCESS headers.tt; # sets header
%]
<div class="container">
<div class="row">
<img src="[% request.uri_base %]/images/[% header.logos.large %]" alt=""
class="img-responsive" border="0" align="right" />
</div>
<div class="row">
<fieldset><legend>HMDS [% 'BCR-ABL Monitoring' IF params.bcr_abl_req %]
Request Form</legend></fieldset>
</div>
<form class="form-horizontal" action="[% request.uri_base %]/"
[% IF generate_pdf %]target="_blank"[% END %] method="post">
<input type="hidden" name="pds_code" value="[% pds.ErrorCode
|| params.pds_code # latter if _skip_pds employed %]" />
<div class="row">
<div class="text-info indent strong">
<span class="pull-right">
[<a href="[% request.uri_base;
'/bcr-abl' IF params.bcr_abl_req %]">load new request form</a>]
</span>
[% IF vars.found_patient.match('yes') %]
Matching patient details found
<span class="found">please check and amend if necessary</span>
[% ELSIF vars.found_patient.match('no'); # use para for extra spacing: %]
<p class="bg-info">No matching patient details found</p>
[% END %]
</div>
[% IF errs %]
<p class="dfv-err">Form validation failed, please correct error(s) below:</p>
[% ELSIF generate_pdf %]
<p class="bg-success col-md-7 indent">Form passed validation. Please check
details are correct and re-submit. The completed request form
will open in a new tab/window as a PDF. Please print it and send
with your specimen(s) to the laboratory at the address provided.
</p>
<input type="hidden" name="generate_pdf" value="1" />
[% ELSE %]
<!--[if lt IE 10]>
<p class="strong">All <span class="text-danger">highlighted</span>
fields are required:</p>
[%# can't use this - submits watermark as field content !!
INCLUDE watermarks.tt; # placeholder doesn't work IE <10 %]
<![endif]-->
[% END %]
</div>
[% IF pds.size %]
<div class="row">
<div class="col-md-8">[% pds_display %]</div>
</div>
[% END %]
<div class="row">
<div class="indent">
<fieldset>
[% class = vars.found_patient.match('yes') ? 'found' : 'normal' %]
<div class="col-md-8 [% class # pale background if found %]">
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="nhs_number">
NHS number</label>
<div class="col-md-4">
[% errs.nhs_number %]
<div id="nhsno_result" class="dfv-err"></div>
<input id="nhs_number" name="nhs_number" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.nhs_number %]">
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="last_name">
Last name</label>
<div class="col-md-4">
[% errs.last_name %]
<input id="last_name" name="last_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.last_name.upper %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="first_name">Forename</label>
<div class="col-md-4">
[% errs.first_name %]
<input id="first_name" name="first_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.first_name %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="middle_name">Middle name</label>
<div class="col-md-4">
[% errs.middle_name %]
<input id="middle_name" name="middle_name" placeholder="optional field"
class="form-control input-md" type="text"
value="[% params.middle_name %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="textinput">
Date of Birth</label>
<div class="col-md-4">
[% errs.day OR errs.month OR errs.year %]
[% INCLUDE dateselect.tt %]
</div>
</div>
<!-- Multiple Radios (inline) -->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="radios">
Gender</label>
<div class="col-md-3">
[% errs.gender %]
<label class="radio-inline" for="gender-0">
<input name="gender" id="gender-0" value="M" type="radio"
[% 'checked' IF params.gender.match('M') %] />M
</label>
<label class="radio-inline" for="gender-1">
<input name="gender" id="gender-1" value="F" type="radio"
[% 'checked' IF params.gender.match('F') %] />F
</label>
<label class="radio-inline" for="gender-2">
<input name="gender" id="gender-2" value="U" type="radio"
[% 'checked' IF params.gender.match('U') %] />U
</label>
</div>
</div>
</div>
[% IF vars.cml_data.size; # PROCESS dumper.tt dump = vars.cml_data;
USE date = DateTime(today = 1); # PROCESS dumper.tt dump = date
%]
<div class="col-md-12">
<h4>Previous BCR-ABL results
[% '[last 5]' IF vars.cml_data.results.size == 5 %]</h4>
[% IF vars.cml_data.results.size %]
<ol id="bcr-abl-results">
[% FOREACH row IN vars.cml_data.results;
delta = row.registered.delta_days(date).delta_days;
class = row.result.match('BCR-ABL : ABL ratio') AND
delta < vars.min_delta ? 'highlight' : 'normal';
%]
<li>[% row.registered.strftime('%d.%b.%Y') %]
[<span class="[% class %]">[% delta %]d</span>]
[% row.result %]</li>
[% END %]
</ol>
[% ELSE %]
<p class="text-info strong bg-info">
<span class="indent">None</span>
</p>
[% END %]
</div>
[% BLOCK reason %]
<div class="col-md-12">
<input type="hidden" name="reason_required" value="1" />
<div class="form-group">
<label class="col-md-2 control-label text-danger"
for="reason">Reason for request
</label>
<div class="col-md-4">
[% IF errs.reason; errs.reason; ELSIF NOT skip_min_delta %]
<span class="dfv-err">Last result <
[% vars.min_delta %] days ago</span>[% END %]
<input id="reason" name="reason" type="text"
placeholder="required field"
class="form-control input-md"
value="[% params.reason %]" />
</div>
</div>
</div>
[% END %]
[%
IF vars.cml_data.date_last;
delta_days =
vars.cml_data.date_last.delta_days(date).delta_days;
INCLUDE reason IF delta_days < vars.min_delta;
ELSIF errs.reason; # errs.reason if failed validation
INCLUDE reason;
END;
%]
[% ELSIF params.reason; # form submission, passed validation
INCLUDE reason skip_min_delta = 1; # skip info message
END %]
<div class="col-md-12">
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="patient_number">
Patient/unit number
</label>
<div class="col-md-4">
[% errs.patient_number %]
<input id="patient_number" name="patient_number" type="text"
placeholder="optional field" class="form-control input-md"
value="[% params.patient_number %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="location">
Referring hospital
</label>
<div class="col-md-4">
[% IF errs.location_id; errs.location_id; ELSE %]
<div class="text-info text-centre strong bg-info">select
from suggestion list (min 3 chars):</div>
[% END %]
<input id="location" name="location_name" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.location_name %]" />
<input type="hidden" id="location_id" name="location_id"
value="[% params.location_id # in case resubmitted %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="referrer">
Consultant</label>
<div class="col-md-4">
[% IF errs.referrer; errs.referrer; ELSE %]
<div class="text-info text-centre strong bg-info">select
from suggestion list (min 3 chars):</div>
[% END %]
<input id="referrer" name="referrer" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.referrer %]" />
</div>
</div>
<!-- jquery autosuggest js -->
<script type="text/javascript">
$( '#location' ).autocomplete({
source: "[% uri_for_autosuggest_location %]",
select: function( event, ui ) { // alert(ui.item.id);
$('#location_id').val(ui.item.id);
var newURL = '/ajax/jquery_referrer?location_id=' + ui.item.id;
$('#referrer').autocomplete('option', 'source', newURL);
}
});
$( '#referrer' ).autocomplete({
source: "[% uri_for_autosuggest_referrer %]",
});
</script>
<hr />
<!-- Radio input-->
<div class="form-group">
[% errs.doi %]
<label class="col-md-4 text-danger" for="doi">
Danger of infection sample?
</label>
<label class="radio-inline">
<input type="radio" name="doi" id="doi-yes" value="YES"
[% 'checked' IF params.doi.match('YES') %] /> YES
</label>
<label class="radio-inline">
<input type="radio" name="doi" id="doi-no" value="NO"
[% 'checked' IF params.doi.match('NO') %] /> NO
</label>
</div>
<!-- Radio input-->
<div class="form-group">
[% errs.tb %]
<label class="col-md-4 text-danger" for="tb">
Microbiological or radiological evidence of TB?
</label>
<label class="radio-inline">
<input type="radio" name="tb" id="tb-yes" value="YES"
[% 'checked' IF params.tb.match('YES') %] /> YES
</label>
<label class="radio-inline">
<input type="radio" name="tb" id="tb-no" value="NO"
[% 'checked' IF params.tb.match('NO') %] /> NO
</label>
</div>
<!-- Radio input-->
<div class="form-group">
[% errs.previous %]
<label class="col-md-4 text-danger" for="previous">
Previously investigated by [% header.lab_name %]?
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-yes" value="YES"
[% 'checked' IF params.previous.match('YES')
|| vars.found_patient.match('yes') %] />
[% class= vars.found_patient.match('yes') ? 'previous' : 'normal' %]
<span class="[% class %]">YES</span>
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-no" value="NO"
[% 'checked' IF params.previous.match('NO') %] /> NO
</label>
<label class="radio-inline">
<input type="radio" name="previous" id="previous-unknown" value="UNKNOWN"
[% 'checked' IF params.previous.match('UNKNOWN') %] /> UNKNOWN
</label>
</div>
<hr />
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="specimen">
Specimen type(s)
</label>
<div class="col-md-4">
[% errs.specimen %]
[% DEFAULT params.specimen = 'veneous blood' IF params.bcr_abl_req %]
<input id="specimen" name="specimen" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.specimen %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label" for="sample_ref">
Sample ref
</label>
<div class="col-md-4">
[% errs.sample_ref %]
<input id="sample_ref" name="sample_ref" placeholder="optional field"
class="form-control input-md" type="text"
value="[% params.sample_ref %]" />
</div>
</div>
<!-- Text input-->
[% UNLESS params.bcr_abl_req %]
<div class="form-group">
<label class="col-md-3 control-label" for="report_to">
Who should report be returned to?
</label>
<div class="col-md-4">
[% errs.report_to %]
<input id="report_to" name="report_to" value="[% params.report_to %]"
placeholder="optional; only required if NOT referring consultant"
class="form-control input-md" type="text" />
</div>
</div>
[% END %]
<hr />
[%
IF params.bcr_abl_req;
INCLUDE bcr_abl_fields.tt;
ELSE %]
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="clinical_details">
Clinical details & suspected diagnosis
</label>
<div class="col-md-5">
[% errs.clinical_details %]
<textarea id="clinical_details" name="clinical_details"
class="form-control" rows="3">[% params.clinical_details %]</textarea>
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-3 control-label text-danger" for="treatment">
Chemo/radiotherapy details?
</label>
<div class="col-md-4">
[% errs.treatment %]
<input id="treatment" name="treatment" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.treatment %]" />
</div>
</div>
[% END %]
<hr />
<div class="form-group">
<label class="col-md-1 control-label text-danger" for="hb">
Hb</label>
<div class="col-md-1">
[% errs.hb %]
<input type="text" class="form-control" id="hb" required
name="hb" placeholder="req'd" value="[% params.hb %]" />
</div>
<label class="col-md-1 control-label text-danger" for="wbc">
WBC</label>
<div class="col-md-1">
[% errs.wbc %]
<input type="text" class="form-control" id="wbc" required
name="wbc" placeholder="req'd" value="[% params.wbc %]" />
</div>
<label class="col-md-1 control-label text-danger" for="wbc">
Plts</label>
<div class="col-md-1">
[% errs.plt %]
<input type="text" class="form-control" id="plt" required
name="plt" placeholder="req'd" value="[% params.plt %]" />
</div>
</div>
<div class="form-group">
<label class="col-md-1 control-label" for="lymphs">Lymphs</label>
<div class="col-md-1">
[% errs.lymphs %]
<input type="text" class="form-control" id="lymphs"
name="lymph" value="[% params.lymph %]" />
</div>
<label class="col-md-1 control-label" for="neut">Neut</label>
<div class="col-md-1">
[% errs.neut %]
<input type="text" class="form-control" id="neut"
name="neut" value="[% params.neut %]" />
</div>
<label class="col-md-1 control-label" for="other">Other</label>
<div class="col-md-1">
[% errs.other %]
<input type="text" class="form-control" id="other"
name="other" value="[% params.other %]" />
</div>
</div>
<hr />
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="requested_by">
Requested by
</label>
<div class="col-md-4">
[% errs.requested_by %]
<input id="requested_by" name="requested_by" required="" type="text"
placeholder="full name required" class="form-control input-md"
value="[% params.requested_by || session.user.first_name.ucfirst
_ ' ' _ session.user.last_name.ucfirst %]" />
</div>
</div>
<!-- Text input-->
<div class="form-group">
<label class="col-md-2 control-label text-danger" for="contact">
Contact details
</label>
<div class="col-md-4">
[% errs.contact %]
<input id="contact" name="contact" placeholder="required field"
class="form-control input-md" required="" type="text"
value="[% params.contact %]" />
</div>
</div>
<!-- // moved to pdf form for manual completion
<h4 class="text-info">To be completed on date of specimen:</h4>
<div class="form-group">
<label class="col-md-2 control-label" for="taken_by">
Specimen taken by
</label>
<div class="col-md-4">
[% errs.taken_by %]
<input id="taken_by" name="taken_by" placeholder="full name required"
class="form-control input-md" type="text"
value="[% params.taken_by %]" />
</div>
</div>
<div class="form-group">
<label class="col-md-2 control-label" for="datetime">
Date & time of sample
</label>
<div class="col-md-4">
[% errs.datetime %]
<input id="datetime" name="datetime" placeholder="dd/mm/yyyy hh:mm"
class="form-control input-md" type="text"
value="[% params.datetime %]" />
</div>
</div>
-->
<!-- Button -->
<div class="col-sm-offset-5 control-group">
<label class="control-label" for="submit"></label>
<div class="controls">
[% IF generate_pdf; btn_type = 'success'; btn_label = 'Submit';
ELSE; btn_type = 'primary'; btn_label = 'Validate'; END %]
<input id="submit" name="submit" type="submit"
value="[% btn_label %]" class="btn btn-[% btn_type %]" />
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
</form>
<script type="text/javascript">
// nhs number ajax validation:
$('#nhs_number').blur(function() { // alert("Handler for .blur() called.");
var formData = { 'nhs_number' : $('input[name=nhs_number]').val() };
var appMethod = "[% uri_for_nhs_number_validation %]";
$.ajax({
url: appMethod,
data: formData,
type: 'post',
dataType: 'json',
// the response is passed to the function
success: function( json ) { // alert(json.result);
$( "#nhsno_result" ).text(json.result);
},
});
// this also works as a simple 'get' request:
// $.get( appMethod, formData )
// .done( function(data) { $( "#nhsno_result" ).text(data) } );
});
</script>
<!-- END [% template.name %] -->