uroprosfu.ascx

医疗决策支持系统

                  <td class="FormInsideTableLeftCell">Vacuum Erection Device</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr> 
                  <td class="FormInsideTableLeftCell">Intracorp. Injection</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr> 
                  <td class="FormInsideTableLeftCell">MUSE</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr> 
                  <td class="FormInsideTableLeftCell">Penile Prosthesis</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
              </table>
			</td>
          </tr>
          <tr> 
            <td nowrap class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">8.</span>&nbsp;Current Erectile Function:</td>
            <td align="left" class="FormInsideTableRegCell"><input type="text" name="CurrentErectileFunctionTextbox" runat="server" id="CurrentErectileFunctionTextbox" class="inputFieldFlat" size="10"></td>
          </tr>
		  <tr> 
            <td nowrap class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">9.</span>&nbsp;Date 
              #3 Achieved On:</td>
            <td align="left" class="FormInsideTableRegCell"> <input type="text" name="potLv3Textbox" runat="server" id="potLv3Textbox" class="inputFieldFlat" size="10"></td>
          </tr>
          <tr> 
            <td nowrap class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">10.</span>&nbsp;Date 
              #2 Achieved On:</td>
            <td class="FormInsideTableRegCell"> <input type="text" name="potLv2Textbox" runat="server" id="potLv2Textbox" class="inputFieldFlat" size="10"></td>
          </tr>
          <tr> 
            <td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">11.</span>&nbsp;Date 
              #1 Achieved On: </td>
            <td align="left" class="FormInsideTableRegCell"> <input type="text" name="potLv1Textbox" runat="server" id="potLv1Textbox" class="inputFieldFlat" size="10"></td>
          </tr>
          <tr> 
            <td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">% Best erection w/ PO meds:</td>
            <td align="left" class="FormInsideTableRegCell" nowrap><input type="text" name="textfield242" class="inputFieldFlat" size="10">%</td>
          </tr>
          <tr> 
            <td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">% Best erection, w/o meds:</td>
            <td align="left" class="FormInsideTableRegCell" nowrap><input type="text" name="textfield243" class="inputFieldFlat" size="10">%</td>
          </tr>
        </table></td>
    </tr>
    <tr bgcolor="#FFFFFF"> 
      <td class="FormOuterTableRow">&nbsp; <input name="HistoryROSReview" type="checkbox" id="HistoryROSReview" value="Yes"> 
        <span class="blackBoldText"> PFSH and ROS performed by: _____________________________________ 
        &nbsp;&nbsp;&nbsp;&nbsp;Date: ____/____/____ </span></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">2</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 colspan="8" 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  %>
                    &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 colspan="1" align="right"> 
                    <% =patientNameLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td colspan="1" align="left"><strong> 
                    <% =patientLastName  %>, <% =patientFirstName  %> <% =patientMiddleName  %>
                    </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 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"> <span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Biopsies&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
        <input type="checkbox" name="PA222" value="Yes"><strong>Check if None</strong><br> 
		<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="15%" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
            <td width="25%" align="center" valign="middle" class="FormInsideTableTopCell">Result</td>
            <td width="60%" align="center" valign="middle" class="FormInsideTableTopCell">Comments</td>
          </tr>
          <tr > 
            <td height="24" align="center" class="FormInsideTableRegCell">/<span><img src="../../Images/shim.gif" border="0" width="22" height="1"></span>/</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td height="24" align="center" class="FormInsideTableRegCell">/<span><img src="../../Images/shim.gif" border="0" width="22" height="1"></span>/</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr > 
            <td height="24" align="center" class="FormInsideTableRegCell">/<span><img src="../../Images/shim.gif" border="0" width="22" height="1"></span>/</td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
            <td class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
        </table>		</td>
    </tr>
	<tr> 
      <td class="FormOuterTableRow"><table align="center" border="0" width="100%" 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="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp:</td>
          </tr>
          <tr> 
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">KPS:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Height:</td>
            <td height="22" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Weight:</td>
            <td height="22" 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 class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Exam</span>&nbsp;&nbsp;&nbsp;<span class="smallGrayText">Clinician 
        Performing Initial Exam: 
        <input type="checkbox" name="NP2" value="Yes">
        PA / NP&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Fellow2" value="Yes">
        Fellow&nbsp;&nbsp;&nbsp; 
        <input type="checkbox" name="Attending2" value="Yes">
        Attending</span> <table align="center" border="0" width="100%" cellpadding="2" cellspacing="0" >
          <tr> 
            <td align="center" class="FormInsideTableTopCell"><strong>System</strong></td>
            <td colspan="2" align="center" class="FormInsideTableTopCell"><strong>Normal 
              Findings</strong><strong></strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Abnormal</strong></td>
            <td align="center" class="FormInsideTableTopCell"><strong>Attnd<br>
              Performed</strong></td>
            <td width="50%" align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Gen</td>
            <td align="left" class="FormInsideTableRegCell">Vital Signs Verified</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"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Abdomen&nbsp;</td>
            <td align="left" class="FormInsideTa