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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroSexFuncFU.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroSexFuncFU" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="left">
<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">*U22*</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="700" cellpadding="2" cellspacing="0">
<tr>
<td width="350" 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 Follow Up</span><br>
</td>
<td width="350" 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 height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %><img src="../../Images/shim.gif" border="0" width="220" height="1">Physician: <% =apptPhysicianName %></span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="15">Chief Complaint</span>
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Erectile dysfunction</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Penile curvature</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Ejaculation problems</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Orgasm problems</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"><input type="checkbox" name="No242">Hypogonadism</td>
<td colspan="3" class="FormInsideTableRegCell"><input type="checkbox" name="No242">Other:</td>
</tr>
</table>
</td>
</tr>
<tr bgcolor="#ffffff">
<td height="130" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">HPI</span><br>
<table width="100%" cellpadding="4" cellspacing="0" border="0">
<tr>
<td class="HPIText" valign="top"> <asp:Repeater ID="hpi" runat=server OnItemDataBound="hpiItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "patientHPI") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Repeater ID="HpiProstatectomies" runat=server OnItemDataBound="HpiProstatectomiesItemDataBound">
<ItemTemplate> <strong>
<%# DataBinder.Eval(Container.DataItem, "OpType") %>
</strong> on
<%# DataBinder.Eval(Container.DataItem, "SurgDateText") %>
<asp:Label ID="CaseSurgeonLabel" Runat="server">by
<%# DataBinder.Eval(Container.DataItem, "SurgCaseSurgeon") %>
</asp:Label>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Label ID="PreTxPot" Runat="server" /> <asp:Repeater ID="hpiProtocols" runat=server OnItemDataBound="appendToHpiItemDataBound">
<ItemTemplate> Protocol
<%# DataBinder.Eval(Container.DataItem, "ProtocolNum") %> <%# DataBinder.Eval(Container.DataItem, "ProtocolNotes") %>
<%# DataBinder.Eval(Container.DataItem, "PtProtocolStatus") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Repeater ID="hpiBiopsies" runat=server >
<ItemTemplate> Biopsy:
<%# DataBinder.Eval(Container.DataItem, "BxDateText") %>
<%# DataBinder.Eval(Container.DataItem, "BxType") %>
Result:
<%# DataBinder.Eval(Container.DataItem, "BxResult") %>
<%# DataBinder.Eval(Container.DataItem, "bxQuality") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Label ID="NVB_Left" Runat="server" /> <asp:Label ID="NVB_Right" Runat="server" />
</td>
</tr>
</table></td>
</tr>
<tr>
<td height="100" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Erectile Function<br>
</span> <table width="700" border="0" cellspacing="0" cellpadding="1">
<tr align="center">
<td width="70" class="FormInsideTableTopCell">Date</td>
<td width="40" class="FormInsideTableTopCell">Duration<br>
Post Tx</td>
<td class="FormInsideTableTopCell">Spont<br>
EF%</td>
<!--What does the S Mean here Surgical?-->
<td class="FormInsideTableTopCell"><p>Spont<br>
EFD</p></td>
<td width="70" class="FormInsideTableTopCell">Oral Agent</td>
<td class="FormInsideTableTopCell">Dose</td>
<td class="FormInsideTableTopCell">Resp<br>
(%)</td>
<td class="FormInsideTableTopCell">Oral<br>
EFD</td>
<td class="FormInsideTableTopCell">ICI<br>
Agent</td>
<td class="FormInsideTableTopCell">Dose</td>
<td class="FormInsideTableTopCell">Peak<br>
Resp%</td>
<td class="FormInsideTableTopCell">Pen Rig<br>
Duration</td>
<td class="FormInsideTableTopCell">ICI<br>
EFD</td>
</tr>
<asp:Repeater ID="erectileFunction" runat=server >
<ItemTemplate>
<tr>
<td class="FormInsideTableRegCell" align="center">
<%# DataBinder.Eval(Container.DataItem, "Date") %>
</td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Duration Post TX") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Spontaneous Erectile Function %") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Spontaneous Erectile Function Domain") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Oral Agent") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Dose") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Response %") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Oral Erectile Function Domain") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "ICI Agent") %></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Peak Response %") %></td>
<td class="FormInsideTableRegCell" align="center"> <%# DataBinder.Eval(Container.DataItem, "Penile Rigidity Duration") %></td>
<td class="FormInnerRowBottomBorder" align="center"> <%# DataBinder.Eval(Container.DataItem, "ICI Erectile Function Domain") %></td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table>
</td>
</tr>
<tr>
<td height="20" class="FormOuterTableRow">
<table width="100%" height="100%" border="0" cellspacing="0" cellpadding="1">
<tr>
<td align="center" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">Nocturnal erections<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No<img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"></td>
<td align="center" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">_____ / 10</td>
<td align="center" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">First noted _____ months postop</td>
<td align="center" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">ICI / Week = _____</td>
<td align="center" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"># Erections / Week = _____</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" valign="top" class="FormOuterTableRow" height="60"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Comments:</span></td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Duplex Doppler Ultrasonography</span></td>
</tr>
<tr>
<td height="20" align="left" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Indications</strong>:</td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Procedure</strong>: Patient Consented<img src="../../Images/shim.gif" border="0" width="10" height="1"><input type="checkbox" name="No242">Yes<img src="../../Images/shim.gif" border="0" width="10" height="1"><input type="checkbox" name="No243">No</td>
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