📄 urosexfuncnp.ascx
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<td> <img src="../../Images/FormImages/shim.gif" border="0" width="1" height="1">Relationship Status:
<img src="../../Images/FormImages/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="No22">Married
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No23">Divorced
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No24">Separated
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No25">Widowed
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No252">Single
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No252">Partnered<br />
<img src="../../Images/FormImages/shim.gif" border="0" width="1" height="11">If married, duration married: _______________ <img src="../../Images/FormImages/shim.gif" border="0" width="45" height="1">If
divorced/widowed, for how long? _______________<br> <img src="../../Images/FormImages/shim.gif" border="0" width="1" height="11">Duration
in current relationship: ____________ <br> <img src="../../Images/FormImages/shim.gif" border="0" width="1" height="11">Partner’s
Age: _______________ <img src="../../Images/FormImages/shim.gif" border="0" width="45" height="1">Partner’s
Name: ________________________________________</td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="12">Past Medical History</span><br>
<table width="650" border="0" cellspacing="0" cellpadding="1">
<tr>
<td width="20" valign="middle" class="FormInsideTableTopLeftCell"><input type="checkbox" name="No2432"></td>
<td width="300" valign="middle" class="FormInsideTableTopCell">Hypertension</td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableTopLeftCell"><input type="checkbox" name="No243132"></td>
<td width="300" valign="middle" class="FormInsideTableTopCell">Disc disease <input type="checkbox" name="No24312"> Lumbar <input type="checkbox" name="No24313"> Thoracic <input type="checkbox" name="No24314"> Cervical</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2433"></td>
<td valign="middle" class="FormInsideTableRegCell">Diabetes<br> </td>
<td valign="middle"> </td>
<td valign="top" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243133"></td>
<td class="FormInsideTableRegCell">Neurological Problems</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2434"></td>
<td valign="middle" class="FormInsideTableRegCell">High Cholesterol</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2434"></td>
<td class="FormInsideTableRegCell">Multiple Sclerosis</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2435"></td>
<td valign="middle" class="FormInsideTableRegCell">Heart Attack</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2435"></td>
<td class="FormInsideTableRegCell">Parkinson’s Disease</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2436"></td>
<td valign="middle" class="FormInsideTableRegCell">Angina</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2436"></td>
<td class="FormInsideTableRegCell">Thyroid Disease</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2437"></td>
<td valign="middle" class="FormInsideTableRegCell">Heart Bypass Surgery</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2437"></td>
<td class="FormInsideTableRegCell">Low Testosterone</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No2438"></td>
<td valign="middle" class="FormInsideTableRegCell">Coronary Artery Angioplasty </td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No2438"></td>
<td class="FormInsideTableRegCell">Prostate Cancer Surgery</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2434"></td>
<td valign="middle" class="FormInsideTableRegCell">Peripheral Vascular Disease</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243134"></td>
<td class="FormInsideTableRegCell">Bladder Cancer Surgery</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2435"></td>
<td valign="middle" class="FormInsideTableRegCell">Benign Prostate Surgery </td>
<td valign="middle"> </td>
<td valign="top" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243135"></td>
<td class="FormInsideTableRegCell">Bowel/Rectum Cancer Surgery</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2436"></td>
<td valign="middle" class="FormInsideTableRegCell">Lower Limb Bypass Surgery </td>
<td valign="middle"> </td>
<td valign="top" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243136"></td>
<td valign="middle" class="FormInsideTableRegCell">Prostate Radiation</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2437"></td>
<td valign="middle" class="FormInsideTableRegCell">Stroke</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243137"></td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Prostate Enlargement</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No2438"></td>
<td valign="middle" class="FormInsideTableRegCell">Carotid Artery Surgery</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24385"></td>
<td valign="middle" class="FormInsideTableRegCell">Pelvic Fracture</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24382"></td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Depression</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24386"></td>
<td valign="middle" class="FormInsideTableRegCell">HIV</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243832"></td>
<td valign="middle" class="FormInsideTableRegCell">Anxiety Disorder</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243872"></td>
<td valign="middle" class="FormInsideTableRegCell">Hepatitis B</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24383"></td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Priapism (prolonged erection)</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24387"></td>
<td class="FormInsideTableRegCell">Hepatitis C</td>
</tr>
<tr>
<td valign="top" class="FormInsideTableLeftCell"><input type="checkbox" name="No24384"></td>
<td align="left" valign="middle" class="FormInsideTableRegCell">Other Medical Conditons (Please List Below):</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24387"></td>
<td class="FormInsideTableRegCell">STD History</td>
</tr>
<tr>
<td align="left" valign="top" colspan="5" height="50" class="FormInsideTableRegCell"> </td>
</tr>
</table> </td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU11<img src="../../Images/shim.gif" border="0" width="45" height="1">U15<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<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/02.070.11</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">*U15*</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 <%= institutionShortName%> 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 Sexual Function<br>
New Patient</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>
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