📄 uroprosnp.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroProsNP.ascx.cs" Inherits="Caisis.UI.Modules.Prostate.PaperForms.UroProsNP" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<asp:PlaceHolder id="SurveyFormHolder" runat="server"></asp:PlaceHolder>
<div id="PaperFormStart">
<div align="center" >
<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">*U05*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font>
<table width="650" cellpadding="0" cellspacing="0">
<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"><span class="blackBoldText"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><%= institutionName%><br>Urology Prostate New Patient<br></span></td>
<td width="50%" align="center" valign="bottom" class="blackBoldText">
<table width="100%" 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>
<% =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="15">Date: <% =apptClinicDate %><img src="../../Images/shim.gif" border="0" width="220" height="1">Physician: <% =apptPhysicianName %></td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellpadding="1" cellspacing="0">
<tr>
<td colspan="2" align="left" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Category of Service</span></td>
</tr>
<tr>
<td width="23%" valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop"> New Patient Encounter<br />(CPT 99201-99205)</td>
<td width="77%" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Use for patients who have not been see by anyone in your billing group in the last 3 years <strong>AND</strong><br />
<img src="../../Images/shim.gif" border="0" width="12" height="1"><strong>-</strong>Are self referred (includes those referred by friend or patient)<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1"><strong>-</strong>Do not have physician asking for your advice/opinion (see PIF sheet or PAS info)<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1"><strong>-</strong>Are referred solely for management and/or treatment of aspect of care<br /> </td>
</tr>
<tr>
<td valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop"> Office Consultation <br />(CPT 99241- 99245)</td>
<td class="FormInnerRowBottomBorder">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td class="FormInnerRowBottomBorder" colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1">Office Consultation is requested by _________________________ MD/PA/NP for my advice &<br/><img src="../../Images/shim.gif" border="0" width="4" height="1">opinion regarding this patient抯 ______________________________________________________</td>
</tr>
<tr>
<td colspan="2"><table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td align="left" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0" />Requesting M.D.:
<asp:Repeater ID="ReferringMD" runat=server >
<ItemTemplate> <%# DataBinder.Eval(Container.DataItem, "phFirstName") %> <%# DataBinder.Eval(Container.DataItem, "phLastName") %> ( <%# DataBinder.Eval(Container.DataItem, "phInstitution") %> )</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater>
<asp:Label ID="blankReferrringMD" Runat="server"></asp:Label> </td>
</tr>
</table></td>
</tr>
</table> </td>
<!--<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Office Consultation is requested by _________________________ MD/PA/NP for my advice & opinion<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">regarding this patient抯 ______________________________________________________</td>-->
</tr>
<tr>
<td valign="top" align="center" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop"> Established Patient Visit<br />(CPT 99212-99215)</td>
<td><img src="../../Images/shim.gif" border="0" width="4" height="1" />Use for patients who<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1"><strong>-</strong>Are seeing you for the first time for management or treatment (Not a consult) and have been seen<br />
<img src="../../Images/shim.gif" border="0" width="18" height="1">by someone else in your billing group in the last 3 years<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1"><strong>-</strong>Are seeing you for follow-up care/visits </td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td align="left" valign="top" height="30" class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="12">Chief
Complaint<br/>
<br/><br/></td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableRow" height="470" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">HPI</span><br>
<table cellpadding="4" cellspacing="0" border="0">
<tr>
<td class="FormPopulatedSmallerText"><asp:Repeater ID="hpi" runat=server OnItemDataBound="hpiItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "patientHPI") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> </td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableTopRow" valign="bottom"><img src="../../Images/shim.gif" border="0" width="4" height="1">Dx Date:<img src="../../Images/shim.gif" border="0" width="105" height="1">2002 TNM Stage:<img src="../../Images/shim.gif" border="0" width="105" height="1">Gleason:<img src="../../Images/shim.gif" border="0" width="105" height="1">PreTx PSA:</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="150" rowspan="2" valign="top" class="FormInsideTableTopLeftCell"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="12">Nomogram
Predictions </span></td>
<td width="62" align="right" class="FormInsideTableTopCell">PreRP:</td>
<td width="63" class="FormInsideTableTopCell"> <asp:Label ID="preRPNomo" Runat=server /></td>
<td width="62" align="right" class="FormInsideTableTopCell">PreXRT:</td>
<td width="63" class="FormInsideTableTopCell"> <asp:Label ID="preXRTNomo" Runat=server /></td>
<td width="62" align="right" class="FormInsideTableTopCell">PreBrachy:</td>
<td width="63" class="FormInsideTableTopCell"> <asp:Label ID="preBrachyNomo" Runat=server /></td>
<td width="62" align="right" class="FormInnerRowBottomBorder"> </td>
<td width="63" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td align="right" class="FormInsideTableRegCell">OCD:</td>
<td class="FormInsideTableRegCell"> </td>
<td align="right" class="FormInsideTableRegCell">ECE:</td>
<td class="FormInsideTableRegCell"> </td>
<td align="right" class="FormInsideTableRegCell">SVI:</td>
<td class="FormInsideTableRegCell"> </td>
<td align="right" class="FormInsideTableRegCell">LNI:</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table> </td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU01<img src="../../Images/shim.gif" border="0" width="45" height="1">U05<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<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">1</span> of <span id="TotalPages">6</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">01</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">*U05*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
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