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<td class="FormInsideTableTopCell" width="65%" align="center" valign="middle">Results/ Comments/ Comparisons</td>
</tr>
<asp:Repeater ID="images" runat="server" OnItemCreated="imagesItemCreated">
<ItemTemplate>
<tr >
<td align="center" class="FormInsideTableRegCell"> <%# DataBinder.Eval(Container.DataItem, "DxDateText") %></td>
<td class="FormInsideTableRegCell"> <%# DataBinder.Eval(Container.DataItem, "DxType") %></td>
<td class="FormInnerRowBottomBorder"> Result: <%# DataBinder.Eval(Container.DataItem, "DxResult") %><asp:Literal ID="ImagesNotesBullet" Runat="Server"> -- </asp:Literal><%# DataBinder.Eval(Container.DataItem, "DxNotes") %></td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table>
</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">2</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 id="LastPageInForm" runat="server" 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 %> </td>
<td align="left"><strong><% =patientMRN %></strong> <% =patientDOB %></td>
</tr>
<tr>
<td align="right"><% =patientNameLabel %> </td>
<td align="left"><strong><% =patientFirstName %> <% =patientMiddleName %> <% =patientLastName %></strong></td>
</tr>
<tr>
<td align="right" valign="top"><% =patientAddressLabel %> </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 colspan="8" class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td class="FormInsideTableTopCell" width="48%" align="center"><strong>Diagnoses / Problem List</strong></td>
<td class="FormInsideTableTopCell" width="2%" align="center"><strong>New</strong></td>
<td class="FormInsideTableTopCell" width="50%" align="center"><strong>Plan / Work-up / Referrals</strong></td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">1.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">2.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">3.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">4.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">5.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">6.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">7.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">8.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">9.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" valign="top" height="36"><img src="../../Images/shim.gif" border="0" width="4" height="0">10.</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" valign="top" class="FormOuterTableRow" height="40"><img src="../../Images/shim.gif" border="0" width="8" height="8"><span class="blackBoldText">Additional
Records/Films to Request:</span></td>
</tr>
<tr>
<td align="left" valign="top" class="FormOuterTableRow" height="40"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Procedures:</span>
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td><img src="../../Images/icon_checkBoxBlank2.gif" width="18" height="10" alt="" border="0">Port Flush</td>
<td><img src="../../Images/icon_checkBoxBlank2.gif" width="18" height="10" alt="" border="0">Patient Education_____________________</td>
<td align="left" valign="top" rowspan="2" width="350">Comments:</td>
</tr>
<tr>
<td><img src="../../Images/icon_checkBoxBlank2.gif" width="18" height="10" alt="" border="0">GNRH</td>
<td align="left"><img src="../../Images/icon_checkBoxBlank2.gif" width="18" height="10" alt="" border="0">Other Intervention_____________________</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table align="center" border="0" width="700" cellpadding="0" cellspacing="0">
<tr>
<td colspan="3" class="FormInsideTableTopLeftCell"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="8" height="8">Disposition</span></td>
</tr>
<tr>
<td class="FormInsideTableRegCell" width="200" align="center">
<table align="left" width="100%">
<tr>
<td>Dictation for today's visit?</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="0">No</td>
</tr>
</table>
</td>
<td class="FormInsideTableRegCell" width="200" align="center">
<table align="left" width="100%">
<tr>
<td>See dispo for orders?</td>
<td align="center">Yes<img src="../../Imag⌨️ 快捷键说明
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