<% ' FP_ASP ASP Automatically generated by a Frontpage Component. Do not Edit. On Error Resume Next strErrorUrl = "" If Request.ServerVariables("REQUEST_METHOD") = "POST" Then If Request.Form("VTI-GROUP") = "0" Then Err.Clear Set fp_conn = Server.CreateObject("ADODB.Connection") FP_DumpError strErrorUrl, "Cannot create connection" Set fp_rs = Server.CreateObject("ADODB.Recordset") FP_DumpError strErrorUrl, "Cannot create record set" fp_conn.Open Application("neurology_entry_ConnectionString") FP_DumpError strErrorUrl, "Cannot open database" fp_rs.Open "Results", fp_conn, 1, 3, 2 ' adOpenKeySet, adLockOptimistic, adCmdTable FP_DumpError strErrorUrl, "Cannot open record set" fp_rs.AddNew FP_DumpError strErrorUrl, "Cannot add new record set to the database" Dim arFormFields0(50) Dim arFormDBFields0(50) Dim arFormValues0(50) arFormFields0(0) = "investigations_eeg" arFormDBFields0(0) = "investigations_eeg" arFormValues0(0) = Request("investigations_eeg") arFormFields0(1) = "previously_seen_why" arFormDBFields0(1) = "previously_seen_why" arFormValues0(1) = Request("previously_seen_why") arFormFields0(2) = "speech" arFormDBFields0(2) = "speech" arFormValues0(2) = Request("speech") arFormFields0(3) = "Investigations_Requested_Normal" arFormDBFields0(3) = "Investigations_Requested_Normal" arFormValues0(3) = Request("Investigations_Requested_Normal") arFormFields0(4) = "investigations_ecg" arFormDBFields0(4) = "investigations_ecg" arFormValues0(4) = Request("investigations_ecg") arFormFields0(5) = "smoker" arFormDBFields0(5) = "smoker" arFormValues0(5) = Request("smoker") arFormFields0(6) = "Seen_Before_on_date" arFormDBFields0(6) = "Seen_Before_on_date" arFormValues0(6) = Request("Seen_Before_on_date") arFormFields0(7) = "Inpatient_review_when" arFormDBFields0(7) = "Inpatient_review_when" arFormValues0(7) = Request("Inpatient_review_when") arFormFields0(8) = "risk_factors" arFormDBFields0(8) = "risk_factors" arFormValues0(8) = Request("risk_factors") arFormFields0(9) = "Duration_Months" arFormDBFields0(9) = "Duration_Months" arFormValues0(9) = Request("Duration_Months") arFormFields0(10) = "suspected_diagnosis" arFormDBFields0(10) = "suspected_diagnosis" arFormValues0(10) = Request("suspected_diagnosis") arFormFields0(11) = "viewed" arFormDBFields0(11) = "viewed" arFormValues0(11) = Request("viewed") arFormFields0(12) = "consultant" arFormDBFields0(12) = "consultant" arFormValues0(12) = Request("consultant") arFormFields0(13) = "past_history" arFormDBFields0(13) = "past_history" arFormValues0(13) = Request("past_history") arFormFields0(14) = "deleted" arFormDBFields0(14) = "deleted" arFormValues0(14) = Request("deleted") arFormFields0(15) = "gait" arFormDBFields0(15) = "gait" arFormValues0(15) = Request("gait") arFormFields0(16) = "surname" arFormDBFields0(16) = "surname" arFormValues0(16) = Request("surname") arFormFields0(17) = "MRN" arFormDBFields0(17) = "MRN" arFormValues0(17) = Request("MRN") arFormFields0(18) = "bed_number" arFormDBFields0(18) = "bed_number" arFormValues0(18) = Request("bed_number") arFormFields0(19) = "Duration_days" arFormDBFields0(19) = "Duration_days" arFormValues0(19) = Request("Duration_days") arFormFields0(20) = "cranial_nerves" arFormDBFields0(20) = "cranial_nerves" arFormValues0(20) = Request("cranial_nerves") arFormFields0(21) = "investigations_emg" arFormDBFields0(21) = "investigations_emg" arFormValues0(21) = Request("investigations_emg") arFormFields0(22) = "first_name" arFormDBFields0(22) = "first_name" arFormValues0(22) = Request("first_name") arFormFields0(23) = "investigations_bloods" arFormDBFields0(23) = "investigations_bloods" arFormValues0(23) = Request("investigations_bloods") arFormFields0(24) = "Examination_Other" arFormDBFields0(24) = "Examination_Other" arFormValues0(24) = Request("Examination_Other") arFormFields0(25) = "medication" arFormDBFields0(25) = "medication" arFormValues0(25) = Request("medication") arFormFields0(26) = "specific_consult_question" arFormDBFields0(26) = "specific_consult_question" arFormValues0(26) = Request("specific_consult_question") arFormFields0(27) = "Extrapyramidal" arFormDBFields0(27) = "Extrapyramidal" arFormValues0(27) = Request("Extrapyramidal") arFormFields0(28) = "intellect" arFormDBFields0(28) = "intellect" arFormValues0(28) = Request("intellect") arFormFields0(29) = "suspected_diagnosis_other" arFormDBFields0(29) = "suspected_diagnosis_other" arFormValues0(29) = Request("suspected_diagnosis_other") arFormFields0(30) = "investigation_other_comments" arFormDBFields0(30) = "investigation_other_comments" arFormValues0(30) = Request("investigation_other_comments") arFormFields0(31) = "investigations_requested" arFormDBFields0(31) = "investigations_requested" arFormValues0(31) = Request("investigations_requested") arFormFields0(32) = "Duration_hours" arFormDBFields0(32) = "Duration_hours" arFormValues0(32) = Request("Duration_hours") arFormFields0(33) = "department" arFormDBFields0(33) = "department" arFormValues0(33) = Request("department") arFormFields0(34) = "referring_doctor" arFormDBFields0(34) = "referring_doctor" arFormValues0(34) = Request("referring_doctor") arFormFields0(35) = "investigations_mri" arFormDBFields0(35) = "investigations_mri" arFormValues0(35) = Request("investigations_mri") arFormFields0(36) = "cerbellar" arFormDBFields0(36) = "cerbellar" arFormValues0(36) = Request("cerbellar") arFormFields0(37) = "alcohol" arFormDBFields0(37) = "alcohol" arFormValues0(37) = Request("alcohol") arFormFields0(38) = "Previously_Seen_by_Neurology" arFormDBFields0(38) = "Previously_Seen_by_Neurology" arFormValues0(38) = Request("Previously_Seen_by_Neurology") arFormFields0(39) = "family_history" arFormDBFields0(39) = "family_history" arFormValues0(39) = Request("family_history") arFormFields0(40) = "presenting_complaint" arFormDBFields0(40) = "presenting_complaint" arFormValues0(40) = Request("presenting_complaint") arFormFields0(41) = "Date_of_Birth" arFormDBFields0(41) = "Date_of_Birth" arFormValues0(41) = Request("Date_of_Birth") arFormFields0(42) = "inpatient_review" arFormDBFields0(42) = "inpatient_review" arFormValues0(42) = Request("inpatient_review") arFormFields0(43) = "sex" arFormDBFields0(43) = "sex" arFormValues0(43) = Request("sex") arFormFields0(44) = "investigations_other" arFormDBFields0(44) = "investigations_other" arFormValues0(44) = Request("investigations_other") arFormFields0(45) = "investigations_ct" arFormDBFields0(45) = "investigations_ct" arFormValues0(45) = Request("investigations_ct") arFormFields0(46) = "motor_sensory" arFormDBFields0(46) = "motor_sensory" arFormValues0(46) = Request("motor_sensory") arFormFields0(47) = "Stroke_Suspected" arFormDBFields0(47) = "Stroke_Suspected" arFormValues0(47) = Request("Stroke_Suspected") arFormFields0(48) = "urgency" arFormDBFields0(48) = "urgency" arFormValues0(48) = Request("urgency") arFormFields0(49) = "doctor_phone" arFormDBFields0(49) = "doctor_phone" arFormValues0(49) = Request("doctor_phone") FP_SaveFormFields fp_rs, arFormFields0, arFormDBFields0 If Request.ServerVariables("HTTP_USER_AGENT") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("HTTP_USER_AGENT"), "Browser_type" End If If Request.ServerVariables("REMOTE_HOST") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_HOST"), "Remote_computer_name" End If FP_SaveFieldToDB fp_rs, Now, "Timestamp" If Request.ServerVariables("REMOTE_USER") <> "" Then FP_SaveFieldToDB fp_rs, Request.ServerVariables("REMOTE_USER"), "User_name" End If fp_rs.Update FP_DumpError strErrorUrl, "Cannot update the database" fp_rs.Close fp_conn.Close FP_FormConfirmation "text/html; charset=windows-1252",_ "Form Confirmation",_ "Thank you for submitting the following information:",_ "neurology_entry.asp",_ "Return to the form." End If End If %> Neurology Referal Form

Neurology Referral Form

Please fill in the details below. Some fields are mandatory and the form will not save without them. Fields marked with an asterix "*" are mandatory, and the form will not save unless you have filled in all the information.

N.B. Please note that the referrals form will be checked twice daily up to 3PM. Any forms filled in after 3PM may not be checked until the following day. For urgent consults please call the registrar from the Neurology team.

MRN:* Surname:*
D.O.B:* Please use the dd/mm/yyyy format  First Name:*
Sex:
Consultant:* <% fp_sQry="SELECT * FROM consultants" fp_sDefault="" fp_sNoRecords="No records returned." fp_sDataConn="neurology_entry" fp_iMaxRecords=256 fp_iCommandType=1 fp_iPageSize=0 fp_fTableFormat=False fp_fMenuFormat=True fp_sMenuChoice="consultants" fp_sMenuValue="consultants" fp_iDisplayCols=1 fp_fCustomQuery=False BOTID=0 fp_iRegion=BOTID %> Referring Doctor:*
Department/Ward:* Contact Number:*
Urgency:* Bed No.*
Presenting Complaint:*
Specific Consult Question:*
Suspected Diagnosis:* Other:
Duration:* Hours  Days Months
Past History:*
Family History:

Stroke: Epilepsy:  MS: IPD: Other: 
Is Stroke Suspected
If stroke is suspected what are the risk factors: DM Smoker FHx BP Cholesterol Other
Needs Inpatient Review:* If No, in ADC?: Yes
Previously seen by Neurology:* If Yes, when: Please enter year only
Why were they previously seen by Neurology?:
Current Medication:*
Smoker:*
Alcohol: Nil Mild Moderate Excessive
 

Examination Details 
Gait: *

Speech:*

 

Intellect:*

 

Cranial Nerves:*

 

Motor Sensory:*

 

Cerebellar:*

 

Extrapyramidal:*

 

Other:
Investigations Requested:
Bloods ECG EEG EMG/NCS MRI-Brain MRI-Cervical MRI-Thoracic MRI-Lumbar CT-Brain CT-Cervical CT-Thoracic CT-Lumbar Other
Completed  Results:
 Bloods:* Normal: Please check box for Yes  (If not fill in box below with details)

 ECG:* Normal: Please check box for Yes  (If not fill in box below with details)

 EEG:* Normal: Please check box for Yes  (If not fill in box below with details)

 EMG/NCS:* Normal: Please check box for Yes  (If not fill in box below with details)

 MRI:* Normal: Please check box for Yes  (If not fill in box below with details)

 CT:* Normal: Please check box for Yes  (If not fill in box below with details)

 Other:
   
Other comments: