📄 uroprossurvivor.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroProsSurvivor.ascx.cs" Inherits="Caisis.UI.Modules.Prostate.PaperForms.UroProsSurvivor" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/FormStyles.css" rel="stylesheet" type="text/css">
<asp:PlaceHolder id="SurveyFormHolder" runat="server"></asp:PlaceHolder>
<div id="PaperFormStart">
<div align="center" >
<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">*U38*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font size="-1">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> 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="80" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>Urology Survivorship Form</span><br>
</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">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<tr>
<td class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="15">Date:<img src="../../images/shim.gif" border="0" width="80" height="1">Nurse Practitioner:
<% =apptClinicDate %>
<img src="../../images/shim.gif" border="0" width="120" height="1">Primary Physician:
<% =apptPhysicianName %>
</td>
</tr>
</table>
</td>
</tr>
<tr bgcolor="#FFFFFF">
<td class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="1" cellspacing="0">
<tr>
<td width="325" align="left" class="FormInnerRowRightBorder" valign="top"><img src="../../images/shim.gif" border="0" width="4" height="1">Local M.D.: <asp:Label ID="ReferringMd1Name" Runat="server" CssClass="blackBoldText" /></td>
<td width="325" align="left"><img src="../../images/shim.gif" border="0" width="4" height="1">Local M.D.: <asp:Label ID="ReferringMd2Name" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="left" class="FormInnerRowRightBorder">
<table height="100%" width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="70" height="20" align="right" valign="bottom">Address</td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">City, State, Zip</td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="20" align="right" valign="bottom">Phone</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table>
</td>
<td align="left">
<table height="100%" width="100%" border="0" cellspacing="0" cellpadding="1">
<tr>
<td width="70" height="20" align="right" valign="bottom">Address</td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">City, State, Zip</td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">Phone</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td width="70" height="20" align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td align="left" height="22"><img src="../../images/shim.gif" border="0" width="4" height="0">Referring M.D.:
<asp:Repeater ID="ReferringMD" runat=server >
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "phFirstName") %>
<%# DataBinder.Eval(Container.DataItem, "phLastName") %>
(
<%# DataBinder.Eval(Container.DataItem, "phInstitution") %>
)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater> <asp:Label ID="blankReferrringMD" Runat="server"></asp:Label>
</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<tr>
<td height="30" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="12">Chief Complaint</td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="95" valign="top" class="FormOuterTableRow"><img src="../../images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">HPI</span><br>
<table cellpadding="4" cellspacing="0" border="0">
<tr>
<td class="HPIText" valign="top"> <asp:Repeater ID="hpi" runat=server OnItemDataBound="hpiItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "patientHPI") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Repeater ID="HpiProstatectomies" runat=server OnItemDataBound="HpiProstatectomiesItemDataBound">
<ItemTemplate> <strong>
<%# DataBinder.Eval(Container.DataItem, "OpType") %>
</strong> on
<%# DataBinder.Eval(Container.DataItem, "SurgDateText") %>
<asp:Label ID="CaseSurgeonLabel" Runat="server">by
<%# DataBinder.Eval(Container.DataItem, "SurgCaseSurgeon") %>
</asp:Label>
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