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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroUrinFuncFU.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroUrinFuncFU" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<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">*U23*</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>
<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 Urinary Function Follow-Up</span></td>
<td width="325" align="center" valign="bottom"> <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 %>
</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"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date: <% =apptClinicDate %><img src="../../Images/shim.gif" border="0" width="220" height="1">Physician: <% =apptPhysicianName %></span></td>
</tr>
<tr>
<td height="90" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">HPI</span></td>
</tr>
<tr class="FormOuterTableRow">
<td valign="top" class="FormOuterTableRow">
<table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td width="290" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Interval History</span></td>
<td width="360" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Other Treatments</span>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td align="center" class="FormInsideTableTopCell">Start Date</td>
<td align="center" class="FormInsideTableTopCell">TX<br><img src="../../Images/shim.gif" border="0" width="90" height="1"></td>
<td align="center" class="FormInsideTableTopCell">Protocol #</td>
<td align="center" class="FormInsideTableTopCell">Stop Date</td>
</tr>
<tr>
<td height="20" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td colspan="2" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Late Complications: <input type="checkbox" name="No">No <input type="checkbox" name="Yes">Yes (specify): </td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow" valign="middle">
<img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Disease State</span>
<img src="../../Images/shim.gif" border="0" width="26" height="1"><input type="checkbox" name="NED2">Stable
<img src="../../Images/shim.gif" border="0" width="26" height="1"><input type="checkbox" name="NED">NED
<img src="../../Images/shim.gif" border="0" width="26" height="1"><input type="checkbox" name="BCR">BCR
<img src="../../Images/shim.gif" border="0" width="26" height="1"><input type="checkbox" name="LCR">LCR
<img src="../../Images/shim.gif" border="0" width="20" height="1"><input type="checkbox" name="Mets">Mets
<img src="../../Images/shim.gif" border="0" width="20" height="1">Date:</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td valign="top" height="55" class="FormInnerRowRightBorder"><span class="blackBoldText">Past Medical History / Comorbidities</span><br>
<img src="../../Images/shim.gif" border="0" width="1" height="3"><br>
<asp:Repeater ID="comorbidities" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %>
-
<strong><%# DataBinder.Eval(Container.DataItem, "Comorbidity") %></strong>
</ItemTemplate>
<SeparatorTemplate>; </SeparatorTemplate>
</asp:Repeater>
</td>
</tr>
</table></td>
</tr>
<tr bgcolor="#ffffff">
<td valign="top" class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="3">
<tr valign="top">
<td width="335" height="140" class="FormInnerRowRightBorder" valign="top"><span class="blackBoldText">Medications</span> <span>
<input name="DateLastGnRH4" type="checkbox" id="DateLastGnRH4" value="yes">Unchanged Since Last Visit</span> <br><img src="../../Images/shim.gif" border="0" width="1" height="5"><br>
<asp:Repeater ID="medications" runat=server>
<HeaderTemplate>
<table width="325" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><strong>Agent</strong></td>
<td><strong>Dose</strong></td>
<td><strong>Schedule</strong></td>
</tr>
</HeaderTemplate>
<ItemTemplate>
<tr>
<td><%# DataBinder.Eval(Container.DataItem, "Medication") %></td>
<td><%# DataBinder.Eval(Container.DataItem, "MedDose") %><%# DataBinder.Eval(Container.DataItem, "MedUnits") %></td>
<td><%# DataBinder.Eval(Container.DataItem, "MedSchedule") %></td>
</tr>
</ItemTemplate>
<FooterTemplate>
</table>
</FooterTemplate>
</asp:Repeater>
</td>
<td width="315"><span class="blackBoldText">Allergies</span> <span>
<input name="DateLastGnRH22" type="checkbox" id="DateLastGnRH22" value="yes">NKA
<input name="DateLastGnRH3" type="checkbox" id="DateLastGnRH32" value="yes">Unchanged Since Last Visit</span><br>
<img src="../../Images/shim.gif" border="0" width="1" height="5"><br>
<asp:Repeater ID="allergies" runat=server>
<HeaderTemplate>
<table width="220" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><strong>Allergen</strong></td>
<td><strong>Reaction</strong></td>
</tr>
</HeaderTemplate>
<ItemTemplate>
<tr>
<td><%# DataBinder.Eval(Container.DataItem, "Allergen") %></td>
<td><%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %></td>
</tr>
</ItemTemplate>
<FooterTemplate>
</table>
</FooterTemplate>
</asp:Repeater>
</td>
</tr>
</table>
</td>
</tr>
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