uroprossurvivor.ascx

医疗决策支持系统

            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
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            <td height="10" align="left" class="FormInsideTableRegCell">Frequency</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Penile Pain, curvature, length</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Groin Masses</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Flank 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">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="6" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">GYN&nbsp;</td>
            <td height="10" align="left" class="FormInsideTableRegCell">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">&nbsp;</td>
            <td rowspan="6" class="FormInnerRowBottomBorder" align="left" valign="bottom">&nbsp;<img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13">Amenorrhea <img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13">Irregular Menses <img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13">Dysmenorrhea</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Discharge</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Pre-Menopausal</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Post-Menopausal: <span class="smallGrayText">Vaginal Bleeding</span></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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">LMP: __________</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">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Sexuality Difficulty</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">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">Psych&nbsp;</td>
            <td height="10" align="left" class="FormInsideTableRegCell">Depression</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">&nbsp;</td>
            <td rowspan="2" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Mood 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">&nbsp;</td>
          </tr>
		  <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">Neuro&nbsp;</td>
            <td height="10" align="left" class="FormInsideTableRegCell">Numbness / Tingling</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">&nbsp;</td>
            <td rowspan="2" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td height="10" align="left" class="FormInsideTableRegCell">Headaches</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">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../images/shim.gif" border="0" width="4" height="0">MS&nbsp;</td>
			<td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../images/shim.gif" border="0" width="4" height="0">Fatigue&nbsp;</td>
            <td class="FormInsideTableRegCell" align="center">Y<img src="../../images/shim.gif" border="0" width="24" height="1">N</td>
            <td class="FormInsideTableRegCell" align="left" nowrap>Inten. (0-10):<img src="../../images/shim.gif" border="0" width="8" height="0"></td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
	      </tr>
		  <tr> 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../images/shim.gif" border="0" width="4" height="0">Pain&nbsp;</td>
            <td class="FormInsideTableRegCell" align="center">Y<img src="../../images/shim.gif" border="0" width="24" height="1">N</td>
            <td class="FormInsideTableRegCell" align="left" nowrap>Inten. (0-10):<img src="../../images/shim.gif" border="0" width="8" height="0"></td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
            <td align="left" valign="bottom" class="FormInsideTableRegCell">Relief:<img src="../../images/shim.gif" border="0" width="12" height="1">Y<img src="../../images/shim.gif" border="0" width="24" height="1">N</td>
	      </tr>
		  <tr> 
            <td align="left" valign="top" class="FormInnerRowRightBorder"><img src="../../images/shim.gif" border="0" width="4" height="0">Other:<br> 
            <td align="center" class="FormInnerRowRightBorder"><img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInnerRowRightBorder"><img src="../../images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="left" valign="top" class="FormInnerRowRightBorder">&nbsp;</td>
            <td valign="top">&nbsp;</td>
            <td align="left" valign="top">&nbsp;</td>
          </tr>
        </table>
		</td>
    </tr>
    <tr> 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU34<img src="../../Images/shim.gif" border="0" width="45" height="1">U38<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/05<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">34</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">*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 align="center" 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  %>
                    &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">
	  	<table width="100%" align="center" cellpadding="0" cellspacing="0">
			<tr>
				<td width="50%" class="FormInsideTableTopLeftCell"><img src="../../images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Urinary Function Survey </span></td>			
				<td