📄 urourinfuncnp.ascx
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<td width="150" height="15" class="FormInsideTableRegCell">Allergen</td>
<td width="165" class="FormInnerRowBottomBorder">Reaction</td>
</tr>
<asp:Repeater ID="allergies" runat=server>
<ItemTemplate>
<tr>
<td class="FormInsideTableRegCell"> <strong>
<%# DataBinder.Eval(Container.DataItem, "Allergen") %>
</strong></td>
<td class="FormInnerRowBottomBorder"> <strong>
<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>
</strong></td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
</tr>
</table></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU16<img src="../../Images/shim.gif" border="0" width="45" height="1">U20<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 9/03<img src="../../Images/shim.gif" border="0" width="45" height="1">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">5</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">16</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">*U20*</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" cellpadding="0" cellspacing="0" bgcolor="#FFFFFF">
<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 Urinary Function<br>
New Patient</span></td>
<td width="50%" 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 width="650" 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 valign="top" class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="3">
<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
<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>Bladder 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>No. 1° relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td> </td>
<td>No other relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td colspan="2"> Side of Family:</td>
</tr>
<tr>
<td><img src="../../Images/shim.gif" border="0" width="10" height="30" /></td>
<td align="center" valign="bottom">Y</td>
<td align="center" valign="bottom">N</td>
<td> </td>
<td valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Maternal <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Paternal</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> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Breast <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Prostate<br />
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Kidney <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" /> Testis<br />
<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="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 />
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