📄 uroprosfu.ascx
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<input type="checkbox" name="Films Reviewed">
Films Reviewed<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Compared to Past">
Compared to Past<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Reviewed with Radiologist">
Reviewed with Radiologist<img src="../../Images/shim.gif" border="0" width="12" height="1">
<input type="checkbox" name="Digitized">
Digitized<br>
</span> <table align="center" border="0" width="650" cellpadding="1" cellspacing="0">
<tr>
<td width="100" align="center" valign="middle" class="FormInsideTableTopLeftCell">Date</td>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Study</td>
<td width="150" align="center" valign="middle" class="FormInsideTableTopCell">Results</td>
<td width="300" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
</tr>
<asp:Repeater ID="images" runat=server>
<ItemTemplate>
<tr >
<td align="center" class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "DxDateText") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "DxType") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "DxResult") %>
</td>
<td class="FormInnerRowBottomBorder">
<%# DataBinder.Eval(Container.DataItem, "DxNotes") %>
</td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU02<img src="../../Images/shim.gif" border="0" width="45" height="1">U06<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<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">4</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">02</span></td>
</tr>
</table>
</div>
<div align="center" 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">*U06*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font>
<table width="650" cellpadding="0" cellspacing="0" bgcolor="#ffffff">
<tr>
<td class="FormOuterTableTopRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<tr>
<td width="50%" 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>
Urology Prostate Follow- Up Patient</span></td>
<td width="50%" 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 colspan="1" align="right">
<% =patientNameLabel %>
</td>
<td colspan="1" align="left"><strong>
<% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %>
</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 class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Review
of Systems</span> <span class="smallGrayText">Clinician
Performing Review:
<input type="checkbox" name="PA22" value="Yes">
RN
<input type="checkbox" name="PA3" value="Yes">
PA/NP
<input type="checkbox" name="Fellow3" value="Yes">
Fellow
<input type="checkbox" name="Attending3" value="Yes">
Attending</span>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<!-- <tr>
<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
<td colspan="1" align="left" valign="top"></td>
</tr> -->
<tr>
<td align="center" class="FormInsideTableTopCell"><strong>System</strong></td>
<td align="center" class="FormInsideTableTopCell"><strong>Symptom</strong></td>
<td align="center" class="FormInsideTableTopCell"><strong>Not<br>
Present</strong></td>
<td align="center" class="FormInsideTableTopCell"><strong>Present</strong></td>
<td align="center" class="FormInsideTableTopCell"><strong>Disease<br>
Related</strong></td>
<td width="50%" align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Gen </td>
<td height="16" align="left" class="FormInsideTableRegCell">Fatigue</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="2" align="center" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Fever</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Skin </td>
<td height="16" align="left" class="FormInsideTableRegCell">Wounds</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="2" align="center" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Breast
Pain</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp </td>
<td height="16" align="left" class="FormInsideTableRegCell">Cough</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="2" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Dyspnea</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">CV </td>
<td height="16" align="left" class="FormInsideTableRegCell"> Edema</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="2" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Chest
Pain</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">GI </td>
<td height="16" align="left" class="FormInsideTableRegCell">Dyspepsia</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
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