urogennp.ascx

医疗决策支持系统

                </tr>
                <tr> 
                  <td class="FormInnerRowRightBorder">&nbsp;</td>
                  <td>&nbsp;</td>
                </tr>
              </table></td>
          </tr>
        </table></td>
    </tr>
    <tr > 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU17<img src="../../Images/shim.gif" border="0" width="45" height="1">U21<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/04<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">17</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">*U21*</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 MSKCC POLICY</font> <br>
  <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>
              Urology General Patient</span></td>
            <td width="325" align="center" valign="bottom" class="blackBoldText"> 
              <table  width="325" 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="260"><img src="../../Images/shim.gif" border="0" width="260" 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> 
                    <% =patientLastName  %>, <% =patientFirstName  %> <% =patientMiddleName  %>
                    </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 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 height="150" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15" />Comorbidities</span></td>
    </tr>
    <tr>
      <td height="250" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15" />Medical 
        &amp; Surgical History</span></td>
    </tr>
    <tr>
      <td valign="top" class="FormOuterTableRow"><table width="650" 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>&nbsp;</td>
                  <td align="center">Y</td>
                  <td align="center">N</td>
                  <td>&nbsp;</td>
                  <td>&nbsp;</td>
                </tr>
                <tr>
                  <td>Ca History</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:&nbsp;</td>
                  <td>No. 1&deg; relatives:&nbsp;&nbsp;_______</td>
                </tr>
                <tr>
                  <td colspan="3">&nbsp;</td>
                  <td>&nbsp;</td>
                  <td>No other relatives:&nbsp;_______</td>
                </tr>
                <tr>
                  <td colspan="3">&nbsp;</td>
                  <td colspan="2">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Side of Family:</td>
                </tr>
                <tr>
                  <td><img src="../../Images/shim.gif" border="0" width="10" height="30" /></td>
                  <td align="center" valign="bottom">&nbsp;</td>
                  <td align="center" valign="bottom">&nbsp;</td>
                  <td>&nbsp;</td>
                  <td valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" />&nbsp;&nbsp;Maternal&nbsp;&nbsp;&nbsp; <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" />&nbsp;&nbsp;Paternal</td>
                </tr>
                <tr valign="top">
                  <td colspan="5"><img src="../../Images/shim.gif" border="0" width="40" height="8" /></td>
                </tr>
                <tr valign="top">
                  <td>List Ca Types</td>
                  <td colspan="4" align="left">&nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Breast&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Prostate&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Testis<br />
                    &nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Bladder&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Kidney<br />
                    &nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Other: ____________</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="15" /></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>&nbsp;</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 />
            </td>
            <td width="330"><p><span class="blackBoldText">Social History:</span><br />
                    <br />
              Occupation: <br />
              <br />
              Marital Status:<img src="../../Images/shim.gif" border="0" width="100" height="1" />Children:<br />
              <img src="../../Images/shim.gif" border="0" width="1" height="12" /> <br />
              Tobacco Use: &nbsp;
              <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" />