📄 uroprossurvivor.ascx
字号:
</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">*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 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 Survivorship Form</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 valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="2">
<tr valign="top">
<td width="50%" class="FormInnerRowRightBorder"><span class="blackBoldText">Family History:</span><img src="../../Images/shim.gif" border="0" width="50" height="1"><input type="checkbox" name="famHxProstateCancerYes2" runat="server" ID="famHxProstateCancerYes2"/>No known family history of ca<br>
<table width="100%" border="0" cellspacing="0" cellpadding="0" id="BlankFamilyHistoryTable" runat="server">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="72" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="40" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="150" height="1"></td>
</tr>
<tr>
<td> </td>
<td align="center">Y</td>
<td align="center">N</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Prostate Ca</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="right">If Y: </td>
<td>Num. 1° relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td> </td>
<td>Num. other relatives: _______</td>
</tr>
<tr>
<td colspan="5"> </td>
</tr>
<tr>
<td colspan="2">Side of Family</td>
<td colspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Maternal<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Paternal</td>
</tr>
<tr>
<td><img src="../../Images/shim.gif" border="0" width="10" height="15"></td>
<td align="center" valign="bottom">Y</td>
<td align="center" valign="bottom">N</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>Other Ca</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="right">List: </td>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Breast</td>
<td align="left"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Testis</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Bladder</td>
<td align="left" valign="top" rowspan="2"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Other:</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Kidney</td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="5">
<table width="312" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="40" height="8"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="122" height="8"></td>
</tr>
<tr>
<td> </td>
<td align="center">Alive</td>
<td align="center">Dead</td>
<td align="center">Age</td>
<td align="center">Cause of Death</td>
</tr>
<tr>
<td>Mother</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Father</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Other</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
</table>
</td>
</tr>
</table>
<br> <asp:Repeater ID="familyHistory" runat=server OnItemCreated="FamilyHistoryItemCreated">
<ItemTemplate> <strong>
<%# DataBinder.Eval(Container.DataItem, "FamMemNum") %>
<%# DataBinder.Eval(Container.DataItem, "FamMemRelation") %>
<asp:Label ID="FamMemSide" Runat="server">(
<%# DataBinder.Eval(Container.DataItem, "FamMemSide") %>
)</asp:Label>
</strong>
<asp:Label ID="FamMemDiagnosis" Runat="server" >with
<%# DataBinder.Eval(Container.DataItem, "FamMemDiagnosis") %>
</asp:Label>
<br>
</ItemTemplate>
</asp:Repeater>
</td>
<td width="330"><p><span class="blackBoldText">Social History:</span><br>
<img src="../../Images/shim.gif" width="5" height="9" hspace="0" vspace="0" border="0"><br>
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