guprosfu.ascx

医疗决策支持系统

            <td class="FormInsideTableRegCell" align="center" rowspan="2">Y<img src="../../Images/shim.gif" border="0" width="24" height="1">N</td>
            <td class="FormInsideTableRegCell" align="left">Inten. (0-10):<img src="../../Images/shim.gif" border="0" width="8" height="0"></td>
            <td class="FormInsideTableRegCell" align="center" rowspan="2">&nbsp;</td>
            <td class="FormInsideTableRegCell" align="center" rowspan="2">&nbsp;</td>
            <td class="FormInsideTableRegCell" align="center" rowspan="2">-</td>
            <td class="FormInsideTableRegCell" align="center" rowspan="2">&nbsp;</td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top">Relief:<img src="../../Images/shim.gif" border="0" width="12" height="1">Y<img src="../../Images/shim.gif" border="0" width="24" height="1">N</td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" colspan="8" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Other:</td>
          </tr>
        </table>
	  </td>
    </tr>
    <tr> 
      <td height="25" class="FormOuterTableRow">&nbsp; <input name="HistoryROSReview" type="checkbox" id="HistoryROSReview" value="Yes"> 
        <span class="blackBoldText"> ROS performed by RN: _____________________________________<img src="../../Images/shim.gif" border="0" width="100" height="1">Date: ___/____/____ </span></td>
    </tr>
    <tr> 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU15<img src="../../Images/shim.gif" border="0" width="45" height="1">U19<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 8/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page 
        <span id="PageNumber">1</span> of <span id="TotalPages">3</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">15</span></td>
    </tr>
  </table>
</div>
<div align="left" style="page-break-before:always">
<div align="center">
	<div align="right" class="VerticalBarCodeDiv">
	  <div  class="VerticalBarCodeStatement"><img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"><br/>
        <img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121" vspace="220"><br/>
        <img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"></div>
	<div  class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
	<div  class="VerticalBarCodeDocType">*U19*</div>
	<div  class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
	<div  class="VerticalBarCodeDate"><% =BarCodeDate %></div>
	</div>
</div>

<div align="center"><font size="-1">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font></div>
  <table width="700" border="0" cellspacing="0" cellpadding="0">
    <tr> 
      <td class="FormOuterTableTopRow">
	  	<table align="center" border="0" width="700" cellpadding="4" cellspacing="0">
            
            <tr> 
              <td width="325" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br/>
                GU Prostate Follow-Up Patient</span></td>
              <td width="325" align="center" valign="bottom">
              
              <table  width="340" border="0" cellspacing="1" cellpadding="0" >
					<tr> 
						<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
						<td align="left" width="274"><img src="../../Images/shim.gif" border="0" width="274" height="1"></td>
					</tr>
					<tr> 
						<td align="right"><% =patientMRNLabel  %>&nbsp;&nbsp;&nbsp;</td>
						<td align="left"><strong><% =patientMRN  %></strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<% =patientDOB  %></td>
					</tr>
					<tr> 
						<td  align="right"><% =patientNameLabel  %>&nbsp;&nbsp;&nbsp;</td>
						<td  align="left"><strong><% =patientFirstName  %> <% =patientMiddleName  %> <% =patientLastName  %></strong></td>
					</tr>
					<tr> 
						<td align="right" valign="top"><% =patientAddressLabel  %>&nbsp;&nbsp;&nbsp;</td>
						<td align="left" valign="top"><% =patientAddress1  %><% =patientAddress2  %><% =patientCity  %> <% =patientState  %> <% =patientPostalCode  %></td>
					</tr>
					 <tr> 
						<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
					</tr>
					<tr> 
						<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient Identification</td>
					</tr>
				</table>
              
              </td>
            </tr>
             
		</table>
	  </td>
    </tr>
    <tr> 
      <td width="700" height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
    </tr>
    <tr > 
      <td class="FormOuterTableRow">
	  	<table align="center" border="0" width="700" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="10%" rowspan="2" align="left" valign="top" class="FormInnerRowRightBorder"><span class="blackBoldText">Vital Signs</span></td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp:</td>
          </tr>
          <tr> 
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">KPS:</span></td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Height:</td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Weight:</td>
            <td height="15" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BSA:</td>
          </tr>
        </table>
		</td>
    </tr>
	<tr > 
      <td colspan="8" class="FormOuterTableRow" valign="middle"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Exam</span>&nbsp;&nbsp;&nbsp;<span class="smallGrayText">
        <img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">
        PA&nbsp;&nbsp;&nbsp; 
        <img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">
        NP&nbsp;&nbsp;&nbsp; 
        <img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">
        Attending Confirmed</span> <table align="center" border="0" width="700" cellpadding="0" cellspacing="0">
          <tr > 
            <td class="FormInsideTableTopCell" align="center"><strong>System</strong></td>
            <td class="FormInsideTableTopCell" align="center"><strong>Normal Findings</strong></td>
            <td class="FormInsideTableTopCell" align="center"><strong>Abn</strong></td>
            <td class="FormInsideTableTopCell" align="center"><strong>Not<br/>Done</strong></td>
            <td class="FormInsideTableTopCell" align="center"><strong>Comments</strong></td>
          </tr>
		  <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Gen/MS&nbsp;</td>
            <td class="FormInsideTableRegCell" align="left">
				<table width="100%" cellpadding="0" cellspacing="0" border="0">
					<tr>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">WD WN</td>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">NAD</td>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">A&amp;O</td>
					</tr>
				</table>
			</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" width="50%" rowspan="13" align="center" valign="bottom"><img src="../../Images/ProstateImageURONVWeb.gif" width="251" height="125"></td>
          </tr>
          <tr > 
		  	<td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Eyes&nbsp;</td>
            <td class="FormInsideTableRegCell" align="left">
				<table width="100%" cellpadding="0" cellspacing="0" border="0">
					<tr>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Scleral Icterus</td>
						<td>&nbsp;</td>
					</tr>
				</table>
			</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">ENT&nbsp;</td>
            <td class="FormInsideTableRegCell" align="left">
				<table width="100%" cellpadding="0" cellspacing="0" border="0">
					<tr>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Mucositis</td>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Thrush</td>
					</tr>
						<td valign="middle" colspan="2"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">Mucous Membranes Moist</td>
					<tr>
					</tr>
				</table>
			</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Nodes</td>
            <td  class="FormInsideTableRegCell" align="left">
				<table width="100%" cellpadding="0" cellspacing="0" border="0">
					<tr>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Cervical</td>
						<td valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Axillary</td>
					</tr>
						<td valign="middle" colspan="2"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0">No Supraclavicular</td>
					<tr>
					</tr>
				</table>
			</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr >