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</table>
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<tr>
<td valign="top" class="FormOuterTableRow" valign="top">
<table width="650" border="0" cellspacing="0" cellpadding="2">
<tr valign="top">
<td width="325" height="30" class="FormInsideTableRegCell" valign="top"><span class="blackBoldText">Nomogram Predictions</span><img src="../../Images/shim.gif" border="0" width="30" height="1"><asp:Label ID="preRPNomo" Runat=server /><asp:Label ID="preXRTNomo" Runat=server /><asp:Label ID="preBrachyNomo" Runat=server />
</td>
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</table>
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<tr >
<td>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td colspan="8" valign="middle" height="6" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Current
Disease State</span><br/> <img src="../../Images/shim.gif" border="0" width="3" height="0">
<input type="checkbox" name="Localized" id="Localized" value="Localized" runat="server">Localized<img src="../../Images/shim.gif" border="0" width="9" height="1">
<input type="checkbox" name="RisingPSA_NonCastrate" id="RisingPSA_NonCastrate" value="Rising PSA: Non-Castrate" runat="server">Rising PSA/ Non-castrate<img src="../../Images/shim.gif" border="0" width="9" height="1">
<input type="checkbox" name="RisingPSA_Castrate" id="RisingPSA_Castrate" value="Rising PSA: Castrate" runat="server">Rising PSA/ Castrate<img src="../../Images/shim.gif" border="0" width="9" height="1">
<input type="checkbox" name="ClinMetsNonCastrate" id="ClinMetsNonCastrate" value="Clin Mets: Non-Castrate" runat="server">Clin mets/ Non-castrate<img src="../../Images/shim.gif" border="0" width="9" height="1">
<input type="checkbox" name="ClinMetsCastrate" id="ClinMetsCastrate" value="Clin Mets: Castrate" runat="server">Clin mets/ Castrate</td>
</tr>
</table>
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<tr>
<td valign="top" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr valign="top">
<td width="325" class="FormInnerRowRightBorder"><span class="blackBoldText">Family and Social History</span><br/>Family History:
<asp:Label ID="FamilyHistoryFiller" Runat="server" ><br/><br/><img src="../../Images/shim.gif" border="0" width="12" height="1">
-Cancer:<br/><br/><br/><img src="../../Images/shim.gif" border="0" width="12" height="4">
-Other:<br/><br/></asp:Label>
<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>
<br/>Occupation: <asp:Label ID="socHxOccupation" Runat="server" />
</td>
<td width="325">Marital Status: <asp:Label ID="socHxMaritalStatus" Runat="server" />
<br/>Children: <asp:Label ID="socHxChildren" Runat="server" />
<br/><img src="../../Images/shim.gif" border="0" width="1" height="19">
<br/>Alcohol Use: <asp:Label ID="socHxAlcohol" Runat="server"><img src="../../Images/shim.gif" border="0" width="55" height="1"></asp:Label>
<br/>
<br/>Carcinogen Exposure: <asp:Label ID="socHxCarcinogen" Runat="server" /><br/>
<br/>
Tobacco Use: <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/><img src="../../Images/shim.gif" border="0" width="45" height="1"><input type="checkbox" id="socHxTobaccoQuitYearCheckbox" runat="server" NAME="socHxTobaccoQuitYearCheckbox"/>
Quit: <asp:Label ID="socHxTobaccoQuitYear" Runat="server">______ years ago</asp:Label><img src="../../Images/shim.gif" border="0" width="10" height="1"><input type="checkbox" name="No History">No Tobacco Usage
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table align="left" border="0" cellpadding="4" cellspacing="0">
<tr>
<td height="80" valign="top"> <img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Medications</span><br/>
<asp:Repeater ID="medications" runat=server OnItemDataBound="medicationsItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "Medication") %> <%# DataBinder.Eval(Container.DataItem, "MedDose") %> <%# DataBinder.Eval(Container.DataItem, "MedUnits") %> <%# DataBinder.Eval(Container.DataItem, "MedSchedule") %><br/><asp:Literal ID="StartNextMedColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td width="650" class="FormOuterTableRow" height="30" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Allergies</span>
<input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">NKA
<asp:Repeater ID="allergies" runat=server>
<ItemTemplate><%# DataBinder.Eval(Container.DataItem, "Allergen") %> (<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater>
</td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU14<img src="../../Images/shim.gif" border="0" width="45" height="1">U18<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 8/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:12/09/04<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">1</span> of <span id="TotalPages">4</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">14</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">*U18*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<div align="center"><font size="-1">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font></div>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow">
<table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td width="325" 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/>
GU Prostate New Patient</span></td>
<td width="325" 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><% =patientFirstName %> <% =patientMiddleName %> <% =patientLastName %></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>
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