📄 uroprossurvivor.ascx
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Occupation: <asp:Label ID="socHxOccupation" Runat="server" /><br>
<img src="../../Images/shim.gif" width="5" height="9" hspace="0" vspace="0" border="0"><br>
Marital Status: <asp:Label ID="socHxMaritalStatus" Runat="server" /><img src="../../Images/shim.gif" border="0" width="70" height="1">Children:
<asp:Label ID="socHxChildren" Runat="server" /><br>
<img src="../../Images/shim.gif" border="0" width="1" height="8"><br>
Tobacco Use: <input type="checkbox" name="Digitized222222">None <br>
<img src="../../Images/shim.gif" border="0" width="73" height="8"><asp:Label ID="socHxTobaccoType" Runat="server"><input type="checkbox" name="Digitized2222">Cigarettes
<img src="../../Images/shim.gif" border="0" width="10" height="8"><input type="checkbox" name="Digitized22222">Cigar
<img src="../../Images/shim.gif" border="0" width="10" height="1"><input type="checkbox" name="Digitized22223">Pipe</asp:Label>
<br>
<img src="../../Images/shim.gif" border="0" width="73" height="1"><input type="checkbox" id="socHxTobaccoPacksPerDayCheckBox" runat="server" NAME="socHxTobaccoPacksPerDayCheckBox"/>
<asp:Label ID="socHxTobaccoPacksPerDay" Runat="server">______</asp:Label>packs / day for <asp:Label ID="socHxTobaccoYears" Runat="server">______</asp:Label>years<br>
<br>
<img src="../../Images/shim.gif" border="0" width="73" height="1"><input type="checkbox" id="socHxTobaccoQuitYearCheckbox" runat="server" NAME="socHxTobaccoQuitYearCheckbox"/>
Quit Year: <asp:Label ID="socHxTobaccoQuitYear" Runat="server">______ </asp:Label><br>
<br>
Alcohol Use: <asp:Label ID="socHxAlcohol" Runat="server" /><br><br>
Carcinogen Exposure: <asp:Label ID="socHxCarcinogen" Runat="server" /></p></td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<td valign="top" width="50%"><span class="blackBoldText"><img src="../../images/shim.gif" border="0" width="4" height="16">Biochemical Markers / Lab Tests</span>
<table width="100%" border="0" cellpadding="1" cellspacing="0" class="FormInnerRowRightBorder">
<tr>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Marker</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Value</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Data Source</td>
</tr>
<asp:Repeater ID="labTests" runat=server>
<ItemTemplate>
<tr>
<td height="17" align="center" class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "LabDateText") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "LabTest") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "LabResult") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "LabQuality") %>
</td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table>
</td>
<td valign="top" width="50%"><span class="blackBoldText">Allergies</span> <img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13">Yes <img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13"> No <span>
<input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">NKA
<input name="DateLastGnRH3" type="checkbox" id="DateLastGnRH3" value="yes">Unchanged</span>
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr align="center">
<td width="150" class="FormInsideTableTopCell">Allergen</td>
<td width="165" class="FormInsideTableTopCell">Reaction</td>
</tr>
<asp:Repeater ID="allergies" runat=server>
<ItemTemplate>
<tr>
<td height="17" class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "Allergen") %>
</td>
<td class="FormInnerRowBottomBorder">
<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>
</td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table>
</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Review of Systems</span>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<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="3" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">Gen </td>
<td height="10" align="left" class="FormInsideTableRegCell">Weight Changes</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="3" align="center" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="10" align="left" class="FormInsideTableRegCell">Fever / Chills</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 height="10" align="left" class="FormInsideTableRegCell">Skin Changes</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="10" 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="10" 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">Heme </td>
<td height="10" align="left" class="FormInsideTableRegCell">Anemia</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="10" align="left" class="FormInsideTableRegCell">Adenopathy</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="10" 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="10" 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="10" 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="10" 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="3" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">GI </td>
<td height="10" align="left" class="FormInsideTableRegCell">Dyspepsia</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="3" class="FormInnerRowBottomBorder" valign="bottom"><img src="../../images/shim.gif" border="0" width="4" height="0">Last Colonoscopy:______________________ </td>
</tr>
<tr>
<td height="10" align="left" class="FormInsideTableRegCell">Diarrhea</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 height="10" align="left" class="FormInsideTableRegCell">Melena</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="7" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">GU </td>
<td height="10" align="left" class="FormInsideTableRegCell">Obstruction</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="7" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="10" align="left" class="FormInsideTableRegCell">Hematuria</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 height="10" align="left" class="FormInsideTableRegCell">Dysuria</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>
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