📄 uroprosnp.ascx
字号:
<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font>
<table width="650" cellpadding="0" cellspacing="0">
<tr bgcolor="#FFFFFF" >
<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</span> </td>
<td width="50%" align="center" valign="bottom" class="blackBoldText">
<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><% =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 height="20" 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>
<tr>
<td rowspan="2" width="50%" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="blackBoldText">Medications</td>
<td colspan="2" align="right"> </td>
</tr>
<tr align="center">
<td width="195" class="FormInsideTableTopCell">Agent</td>
<td width="60" class="FormInsideTableTopCell">Dose</td>
<td width="70" class="FormInsideTableTopCell">Schedule</td>
</tr>
<asp:Repeater ID="medications" runat=server>
<ItemTemplate>
<tr>
<td class="FormInsideTableRegCell" height="20"> <%# DataBinder.Eval(Container.DataItem, "Medication") %></td>
<td class="FormInsideTableRegCell"> <%# DataBinder.Eval(Container.DataItem, "MedDose") %></td>
<td class="FormInsideTableRegCell"> <%# DataBinder.Eval(Container.DataItem, "MedSchedule") %></td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
<td><table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td colspan="5"><img src="../../Images/shim.gif" border="0" width="4" height="1" /><span class="blackBoldText">Radiation Therapy</span></td>
</tr>
<tr class="eFormInnerTableRow">
<td width="65" align="center" class="FormInsideTableTopLeftCell">Start</td>
<td width="65" align="center" class="FormInsideTableTopCell">Stop</td>
<td width="65" align="center" class="FormInsideTableTopCell">Target</td>
<td width="65" align="center" class="FormInsideTableTopCell">Total Dose</td>
<td width="65" align="center" class="FormInsideTableTopCell">Notes</td>
</tr>
<asp:Repeater ID="XRT" runat=server>
<ItemTemplate>
<tr>
<td height="20" class="FormInsideTableLeftCell"> <strong><%# DataBinder.Eval(Container.DataItem, "RadTxDateText") %></strong></td>
<td class="FormInsideTableRegCell"> <strong><%# DataBinder.Eval(Container.DataItem, "RadTxStopDateText") %></strong></td>
<td class="FormInsideTableRegCell"> <strong><%# DataBinder.Eval(Container.DataItem, "RadTxType") %> <%# DataBinder.Eval(Container.DataItem, "RadTxTarget") %></strong></td>
<td class="FormInsideTableRegCell"> <strong><%# DataBinder.Eval(Container.DataItem, "RadTxTotalDose") %></strong></td>
<td class="FormInsideTableRegCell"> <strong><%# DataBinder.Eval(Container.DataItem, "RadTxNotes") %></strong></td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
</tr>
<tr>
<td width="325"><table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td colspan="4"><img src="../../Images/shim.gif" border="0" width="4" height="1" /><span class="blackBoldText">Hormone Therapy</span></td>
</tr>
<tr>
<td height="18" colspan="1" align="center" class="FormInsideTableTopLeftCell">Start Date</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">TX<br/>
<img src="../../Images/shim.gif" border="0" width="90" height="1" /></td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Notes Protocol #)</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Stop Date</td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td width="650" class="FormOuterTableRow" height="45" 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 class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td align="left" valign="top" height="90"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Medical & Surgical History / Comorbidities</span><br/> <img src="../../Images/shim.gif" border="0" width="1" height="14">
<asp:Repeater ID="comorbidities" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %>
- <strong>
<%# DataBinder.Eval(Container.DataItem, "Comorbidity") %>
</strong> </ItemTemplate>
<SeparatorTemplate><br>
</SeparatorTemplate>
</asp:Repeater> </td>
<td width="310" align="right" valign="middle">
<table border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="155"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Cor. Artery Disease / MI</td>
<td width="155"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Pulm. Disease / Asthma</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Other Cardiac: __________</td>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Diabetes (IDDM/NIDDM)</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Hypertension</td>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Hypercholesterolemia</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">CVA</td>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Depression</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Thrombo. Events / DVT</td>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Back Pain / DJD</td>
</tr>
</table> </td>
</tr>
</table> </td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr valign="top">
<td width="320" class="FormInnerRowRightBorder"><span class="blackBoldText">Family History:</span><img src="../../Images/shim.gif" border="0" width="50" height="1"><input type="checkbox" name="famHxProstateCancerYes2" runat="server" ID="famHxProstateCancerYes2"/>No known family history of ca<br>
<table width="312" border="0" cellspacing="0" cellpadding="0" id="BlankFamilyHistoryTable" runat="server">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="72" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="40" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="150" height="1"></td>
</tr>
<tr>
<td> </td>
<td align="center">Y</td>
<td align="center">N</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Prostate Ca</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="right">If Y: </td>
<td>Num. 1° relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td> </td>
<td>Num. other relatives: _______</td>
</tr>
<tr>
<td colspan="5"> </td>
</tr>
<tr>
<td colspan="2">Side of Family</td>
<td colspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Maternal<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Paternal</td>
</tr>
<tr>
<td><img src="../../Images/shim.gif" border="0" width="10" height="15"></td>
⌨️ 快捷键说明
复制代码
Ctrl + C
搜索代码
Ctrl + F
全屏模式
F11
切换主题
Ctrl + Shift + D
显示快捷键
?
增大字号
Ctrl + =
减小字号
Ctrl + -