guprosnp.ascx

医疗决策支持系统

          <tr > 
            <td class="FormInsideTableRegCell" align="left" height="20">Incontinence</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" height="20">Impotency</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">MS</td>
            <td class="FormInsideTableRegCell" align="left" height="20">Joint Pain</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></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">Psych</td>
            <td class="FormInsideTableRegCell" align="left" height="20">Anxiety/Depression</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">Heme</td>
            <td class="FormInsideTableRegCell" align="left" height="20">Anemia</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" rowspan="2" align="center">&nbsp;</td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" height="20">Adenopathy</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Skin</td>
            <td class="FormInsideTableRegCell" align="left" height="20">Rash</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">Endo</td>
            <td class="FormInsideTableRegCell" align="left" height="20">Heat/cold Intolerance</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" rowspan="3" align="center">&nbsp;</td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" height="20">Thirst</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" height="20">Hot Flashes</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell"align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
		  </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Other</td>
            <td class="FormInsideTableRegCell" align="center" height="20">&nbsp;</td>
			<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center">&nbsp;</td>
          </tr>
        </table>
		</td>
		</tr>
		<tr >
      		<td colspan="8" class="FormOuterTableRow">
				<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
					<tr >
					  <td class="FormInsideTableRegCell" width="50%" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0"><strong>Pain:</strong><img src="../../Images/shim.gif" border="0" width="18" height="0">Y<img src="../../Images/shim.gif" border="0" width="18" height="0">N
						<br/><img src="../../Images/shim.gif" border="0" width="4" height="0">Location:
						<br/>
              <img src="../../Images/shim.gif" border="0" width="4" height="0"><img src="../../Images/shim.gif" border="0" width="1" height="22">Intensity 
              (0-10):<img src="../../Images/shim.gif" border="0" width="62" height="1">Post 
              Relief(0-10):</td>
						<td class="FormInsideTableRegCell" width="50%" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Precipitating Factors:<br/>
              <img src="../../Images/shim.gif" border="0" width="4" height="0"><img src="../../Images/shim.gif" border="0" width="1" height="32">Alleviating 
              Factors:<br/>
              <img src="../../Images/shim.gif" border="0" width="0" height="18"></td>
					</tr>
   			  </table>		
			</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">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">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  %>&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><% =patientFirstName  %> <% =patientMiddleName  %> <% =patientLastName  %></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 width="650" height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
    </tr>
	<tr>