urourinfuncnp.ascx

医疗决策支持系统

                    (1-5)</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">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr > 
                  <td colspan="4"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
                      <tr > 
                        <td colspan="2" align="left" class="smallGrayText">Continence 
                          Codes:</td>
                      </tr>
                      <tr > 
                        <td class="smallGrayText">1 - </td>
                        <td class="smallGrayText">Continent (No pads)</td>
                      </tr>
                      <tr > 
                        <td class="smallGrayText">2 - </td>
                        <td class="smallGrayText">Mild SUI (Leaks only during 
                          heavy activity/ 1-2 pads)</td>
                      </tr>
                      <tr > 
                        <td class="smallGrayText">3 - </td>
                        <td class="smallGrayText">Moderate SUI (Leaks with moderate 
                          activity/ (3-4 pads)</td>
                      </tr>
                      <tr > 
                        <td class="smallGrayText">4 - </td>
                        <td class="smallGrayText">Severe SUI (Leaks during norm. 
                          activity, dry at night &amp; rest)</td>
                      </tr>
                      <tr > 
                        <td class="smallGrayText">5 - </td>
                        <td class="smallGrayText">Total incontinence (Continuous 
                          leakage of urine at rest)</td>
                      </tr>
                    </table></td>
                </tr>
              </table></td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Nocturia</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">Dysuria</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">Slow Stream</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">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 align="left" class="FormInsideTableRegCell">Hematuria</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">Infection</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">Erectile Function 
              / Peyronies</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" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">MS</td>
            <td align="left" class="FormInsideTableRegCell" >Joint 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>
            <td align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Psych</td>
            <td align="left" class="FormInsideTableRegCell" >Anxiety/Depression</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 align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Heme</td>
            <td align="left" class="FormInsideTableRegCell" >Anemia</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">Adenopathy</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" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Skin</td>
            <td align="left" class="FormInsideTableRegCell" >Rash</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 align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="4" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Endo</td>
            <td align="left" class="FormInsideTableRegCell">Heat/cold Intolerance</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="4" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
          <tr > 
            <td align="left" class="FormInsideTableRegCell">Thirst</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">Hot Flashes</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">Diabetes Mellitus</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" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Other</td>
            <td align="left" class="FormInsideTableRegCell" >&nbsp;</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 align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td height="35" class="FormOuterTableRow">&nbsp; <input name="HistoryROSReview2" type="checkbox" id="HistoryROSReview2" value="Yes"> 
        <span class="blackBoldText"> PFSH and ROS performed by: _____________________________________ 
        &nbsp;&nbsp;&nbsp;&nbsp;Date: ____/____/____ </span></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">3</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;">CONT