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<td align="center" valign="bottom">Y</td>
<td align="center" valign="bottom">N</td>
<td> </td>
<td> </td>
</tr>
<tr valign="top">
<td>Other 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">List: </td>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Breast</td>
<td align="left"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Testis</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Bladder</td>
<td align="left" valign="top" rowspan="2"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Other:</td>
</tr>
<tr>
<td><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Kidney</td>
</tr>
</table> </td>
</tr>
<tr>
<td colspan="5">
<table width="312" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="40" height="8"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="122" height="8"></td>
</tr>
<tr>
<td> </td>
<td align="center">Alive</td>
<td align="center">Dead</td>
<td align="center">Age</td>
<td align="center">Cause of Death</td>
</tr>
<tr>
<td>Mother</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="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Father</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="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Other</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="center">______</td>
<td align="center">________________</td>
</tr>
</table> </td>
</tr>
</table>
<br> <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> </td>
<td width="330"><p><span class="blackBoldText">Social History:</span><br>
<img src="../../Images/shim.gif" width="5" height="9" hspace="0" vspace="0" border="0"><br>
Occupation:
<asp:Label ID="socHxOccupation" Runat="server" /><br>
<img src="../../Images/shim.gif" width="5" height="9" hspace="0" vspace="0" border="0"><br>
Marital Status:
<asp:Label ID="socHxMaritalStatus" Runat="server" /><img src="../../Images/shim.gif" border="0" width="70" height="1">Children:
<asp:Label ID="socHxChildren" Runat="server" /><br>
<img src="../../Images/shim.gif" border="0" width="1" height="8"><br>
Tobacco Use:
<input type="checkbox" name="Digitized222222">
None <br>
<img src="../../Images/shim.gif" border="0" width="73" height="8">
<asp:Label ID="socHxTobaccoType" Runat="server">
<input type="checkbox" name="Digitized2222">
Cigarettes <img src="../../Images/shim.gif" border="0" width="10" height="8">
<input type="checkbox" name="Digitized22222">
Cigar<img src="../../Images/shim.gif" border="0" width="10" height="1">
<input type="checkbox" name="Digitized22223">
Pipe</asp:Label>
<br>
<img src="../../Images/shim.gif" border="0" width="73" height="1">
<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>
<br>
<img src="../../Images/shim.gif" border="0" width="73" height="1">
<input type="checkbox" id="socHxTobaccoQuitYearCheckbox" runat="server" NAME="socHxTobaccoQuitYearCheckbox"/>
Quit Year:
<asp:Label ID="socHxTobaccoQuitYear" Runat="server">______ </asp:Label>
<br>
<br>
Alcohol Use:
<asp:Label ID="socHxAlcohol" Runat="server" /><br>
<br>
Carcinogen Exposure:
<asp:Label ID="socHxCarcinogen" Runat="server" /><br>
</p></td>
</tr>
</table> </td>
</tr>
<tr bgcolor="#FFFFFF">
<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">2</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>
<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 align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td colspan="2" valign="top" class="blackBoldText"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Biochemical
Markers / Lab Tests</span> </td>
</tr>
<tr >
<td valign="top" class="FormInnerRowRightBorder">
<table width="100%" border="0" cellpadding="1" cellspacing="0" class="FormInnerRowRightBorder">
<tr >
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Date
<br>
(mm/dd/yyyy)</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Marker</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Value</td>
<td align="center" valign="middle" class="FormInsideTableTopCell">Data<br>
Source</td>
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