urosexfuncnp.ascx

医疗决策支持系统

          <tr> 
            <td align="left" class="FormInsideTableRegCell">Adenopathy</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" valign="top" class="FormInsideTableLeftCell">Skin</td>
            <td align="left" class="FormInsideTableRegCell">Rash</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td rowspan="3" align="left" valign="top" class="FormInsideTableLeftCell">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" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
            <td rowspan="3" align="center" class="FormInsideTableRegCell">&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" vspace="0"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></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" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td colspan="7" align="left" valign="top">Other:</td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="1">
          <tr> 
            <td colspan="4" class="FormInnerRowBottomBorder"><span class="blackBoldText">Family History</span></td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td width="30" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td width="270" class="FormInsideTableRegCell">High Blood Pressure<br></td>
            <td width="30" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td width="270" class="FormInsideTableRegCell">Diabetes</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">High Cholesterol / Triglycerides</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">Depression</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">Heart Attack</td>
            <td align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">Stroke</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">Prostate Cancer</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td class="FormInsideTableRegCell">Bladder Cancer</td>
          </tr>
          <tr> 
            <td height="26" align="center" class="FormInnerRowRightBorder"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td colspan="3">Other:</td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="4" class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../Images/FormImages/shim.gif" border="0" width="2" height="1">Medications</span></td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td width="30" height="30" align="center" valign="top" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td width="270" valign="top" class="FormInsideTableRegCell">Blood Pressure Pills<br></td>
            <td width="30" valign="top" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td width="270" valign="top" class="FormInnerRowBottomBorder"> Incontinence Medications</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td height="30" align="center" valign="top" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInsideTableRegCell">Cholesterol lowering Medications</td>
            <td valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInnerRowBottomBorder">Blood Thinning Medications</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td valign="top" height="30" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInsideTableRegCell"> Diabetes Medications</td>
            <td valign="top" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInnerRowBottomBorder"> Stomach Ulcer Medications</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td valign="top" height="30" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInsideTableRegCell"> Depression / Anxiety Medications</td>
            <td valign="top" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInnerRowBottomBorder">Hormone Medications</td>
          </tr>
          <tr class="FormInsideTableRegCell"> 
            <td valign="top" height="30" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInsideTableRegCell"> Prostate Medications</td>
            <td valign="top" align="center" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" class="FormInnerRowBottomBorder"> Nitroglycerin-Containing Medications</td>
          </tr>
          <tr> 
            <td valign="top" height="30" align="center" class="FormInnerRowRightBorder"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"></td>
            <td valign="top" colspan="3">Others: ______________________________________________________________________________</td>
          </tr>
        </table>
		</td>
    </tr>
    <tr bgcolor="#FFFFFF"> 
      <td height="35" bgcolor="#FFFFFF" class="FormOuterTableRow">&nbsp; <input name="HistoryROSReview" type="checkbox" id="HistoryROSReview" value="Yes"> 
        <span class="blackBoldText"> PFSH and ROS reviewed by: _____________________________________</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">2</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>
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<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>



  <div align="center"><font style="font-size: 12px;">CONTAINS PROTECTED  HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font></div>
  <table width="700" border="0" cellspacing="0" cellpadding="0">
    <tr> 
      <td class="FormOuterTableTopRow">
	  	<table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
          <tr> 
            <td width="50%" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="80" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
              Urology Sexual Function </span><span class="blackBoldText"><br>
              New Patient</span><br></td>
            <td width="50%" align="center" valign="bottom">
				<table  width="50%" 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  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td align="left"><strong> 
                    <% =patientMRN  %>
                    </strong>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
                    <% =patientDOB  %>
                  </td>
                </tr>
                <tr> 
                  <td colspan="1" align="right"> 
                    <% =patientNameLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td colspan="1" align="left"><strong> 
                    <% =patientLastName  %>, <% =patientFirstName  %> <% =patientMiddleName  %>
                    </strong></td>
                </tr>
                <tr> 
                  <td align="right" valign="top"> 
                    <% =patientAddressLabel  %>
                    &nbsp;&nbsp;&nbsp;</td>
                  <td align="left" valign="top"> 
                    <% =patientAddress1  %>
                    <% =patientAddress2  %>
                    <% =patientCity  %>