urourinfuncnp.ascx

医疗决策支持系统

                  <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 class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
          <tr> 
            <td colspan="6" align="left" valign="top" ><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Review 
              of Systems</span><span class="smallGrayText">&nbsp;&nbsp;<span class="smallGrayText">Clinician 
              Performing Review:<span class="smallGrayText"> &nbsp;&nbsp; 
              <input type="checkbox" name="PA22" value="Yes">
              NP / </span>PA&nbsp;&nbsp;&nbsp; 
              <input type="checkbox" name="Fellow2" value="Yes">
              Fellow&nbsp;&nbsp;&nbsp; 
              <input type="checkbox" name="Attending2" value="Yes">
              Attending</span></span></td>
          </tr>
          <tr> 
            <td align="center" class="FormInsideTableTopCell" ><strong> System</strong></td>
            <td align="center" class="FormInsideTableTopCell" ><strong>Symptom</strong></td>
            <td align="center" class="FormInsideTableTopCell" ><strong>Not Present</strong></td>
            <td align="center" class="FormInsideTableTopCell" ><strong>Present</strong></td>
            <td align="center" class="FormInsideTableTopCell" ><strong>Disease 
              Related</strong></td>
            <td width="50%" align="center" class="FormInsideTableTopCell" ><strong>Notes</strong></td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">General</td>
            <td align="left" class="FormInsideTableRegCell" >Fever</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Weight Loss</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Neuro</td>
            <td align="left" class="FormInsideTableRegCell" >CVA</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="3" align="left" valign="bottom" class="FormInnerRowBottomBorder">If SCI: Level:&nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">&nbsp;Lumbar<img src="../../Images/shim.gif" border="0" width="8" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">&nbsp;Cervical<img src="../../Images/shim.gif" border="0" width="8" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">&nbsp;Sacral</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">LE Weakness / Paresthesia</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Spinal Disease</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Eyes</td>
            <td align="left" class="FormInsideTableRegCell" >Vision Changes</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell" >Glaucoma</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">CV</td>
            <td align="left" class="FormInsideTableRegCell" >Angina</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Palpitations</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Peripheral Edema</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Respiratory</td>
            <td align="left" class="FormInsideTableRegCell" >Cough</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Shortness of Breath</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Hemoptysis</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="5" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">GI</td>
            <td align="left" class="FormInsideTableRegCell" >Nausea</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="5" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Vomiting</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Abdominal Pain</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Rectal Bleeding</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Stool Incontinence</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="8" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">GU</td>
            <td align="left" class="FormInsideTableRegCell" >Frequency / Urgency</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="8" valign="top" class="FormInnerRowBottomBorder" >&nbsp;<br>Urinary QOL Score (Q1-Q3):________ / 15<br>Sexual QOL Score (Q5-Q6):________ / 12<br>
              Pads:________<br> <table width="100%" border="0" align="left" cellpadding="0" cellspacing="0" class="FormOuterTableTopRow">
                <tr > 
                  <td colspan="4"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Urinary Function Survey </span></td>
                </tr>
                <tr > 
                  <td width="48" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
                  <td width="97" align="center" valign="middle" class="FormInsideTableTopCell">Code</td>
                  <td width="48" align="center" valign="middle" class="FormInsideTableTopCell">Value</td>
                  <td width="130" align="center" valign="middle" class="FormInsideTableTopCell">Comments</td>
                </tr>
                <tr > 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" valign="middle" class="FormInsideTableRegCell">IPSS 
                    Symptoms</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr > 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" valign="middle" class="FormInsideTableRegCell">Continence