📄 urosurveyurinsexfunc.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroSurveyUrinSexFunc.ascx.cs" Inherits="Caisis.UI.Modules.Prostate.PaperForms.UroSurveyUrinSexFunc" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="NonBreakingPage">
<div id="LastPageInForm" runat="server" align="left">
<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">*U24*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<div align="center"><font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font></div>
<table width="700" border="0" cellpadding="0" cellspacing="0" bgcolor="ffffff">
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="700" cellpadding="4" cellspacing="0">
<tr>
<td width="375" 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>
Urinary and Sexual Function<br>
Questionnaire</span><br>
</td>
<td width="375" align="center" valign="bottom"> <table width="325" 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="260"><img src="../../Images/shim.gif" border="0" width="260" 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="12">Date: <% =apptClinicDate %>
<img src="../../Images/shim.gif" border="0" width="220" height="1">Physician: <% =apptPhysicianName %>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow">
<table width="700" border="0" cellspacing="0" cellpadding="0">
<tr valign="top">
<td width="45"> </td>
<td width="610" height="20"> </td>
<td width="45"> </td>
</tr>
<tr valign="top">
<td> </td>
<td> <span class="SurveyTitle">URINARY AND SEXUAL FUNCTION QUESTIONNAIRE</span><br>
Please answer the following questions about your urinary and sexual
functions over the past four (4) weeks.<br> <br> <strong>Circle
ONE number for each question.<br>
</strong> <br>
<table width="660" border="0" align="center" cellpadding="0" cellspacing="0">
<tr valign="top">
<td width="20"><strong>1.</strong></td>
<td width="270"><strong>Over the past four (4) weeks, how often
have you leaked urine?</strong><br> <br> <table width="270" border="0" cellspacing="0" cellpadding="0">
<tr valign="top">
<td width="30" height="20">1</td>
<td width="240">Not at all</td>
</tr>
<tr valign="top">
<td height="20">2</td>
<td>Rarely</td>
</tr>
<tr valign="top">
<td height="20">3</td>
<td>More than once a week</td>
</tr>
<tr valign="top">
<td height="20">4</td>
<td>About once a day</td>
</tr>
<tr valign="top">
<td height="20">5</td>
<td>More than once a day</td>
</tr>
</table></td>
<td width="80"> </td>
<td width="20"><strong>4.</strong></td>
<td width="270"><strong>During the last four (4) weeks when you attempted to have erections, how often did you use a pill like viagra?</strong><br>
<br> <table width="270" border="0" cellspacing="0" cellpadding="0">
<tr valign="top">
<td width="30" height="20">1</td>
<td width="240">No attempt at erections</td>
</tr>
<tr valign="top">
<td height="20">2</td>
<td>Almost never / never</td>
</tr>
<tr valign="top">
<td height="20">3</td>
<td>A few times (much less than half of the time)</td>
</tr>
<tr valign="top">
<td height="20">4</td>
<td>Sometimes (about half of the time)</td>
</tr>
<tr valign="top">
<td height="20">5</td>
<td>Most times (much more than half of the time)</td>
</tr>
<tr valign="top">
<td height="20">6</td>
<td>Almost always / always</td>
</tr>
</table></td>
</tr>
<tr valign="top">
<td height="20" colspan="5"> </td>
</tr>
<tr valign="top">
<td><strong>2.</strong></td>
<td width="270"><strong>Over the past four (4) weeks, how much
urine did you leak?</strong><br> <br> <table width="270" border="0" cellspacing="0" cellpadding="0">
<tr valign="top">
<td width="30" height="20">1</td>
<td width="240">Did not leak urine</td>
</tr>
<tr valign="top">
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