📄 urosexfuncfu.ascx
字号:
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td width="7%" height="20" align="center" valign="middle" class="FormInsideTableLeftCell">Agent</td>
<td width="13%" class="FormInsideTableRegCell"> </td>
<td width="7%" align="center" valign="middle" class="FormInsideTableRegCell"># Doses</td>
<td width="13%" class="FormInsideTableRegCell"> </td>
<td width="7%" align="center" valign="middle" class="FormInsideTableRegCell">Starting BP</td>
<td width="13%" class="FormInsideTableRegCell"> </td>
<td width="10%" align="center" valign="middle" class="FormInsideTableRegCell">Completion BP</td>
<td width="10%" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="center" valign="middle" class="FormInsideTableLeftCell">BQE</td>
<td class="FormInsideTableRegCell"> </td>
<td colspan="2" align="center" valign="middle" class="FormInsideTableRegCell">Oral Agent Response</td>
<td align="center" colspan="2" valign="middle" class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell">ICI Response</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td width="8%" height="20" align="center" valign="middle" class="FormInsideTableTopLeftCell">Dose</td>
<td width="8%" height="20" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Right PSV</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Left PSV</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Right EDV</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Left EDV</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Right RI</td>
<td width="14%" align="center" valign="middle" class="FormInsideTableTopCell">Left RI</td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell" align="center" valign="middle">Dose 1</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell" align="center" valign="middle">Dose 2</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" class="FormInsideTableLeftCell" align="center" valign="middle">Dose 3</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td> </td>
</tr>
<tr>
<td>
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td width="25%" height="20" align="center" valign="middle" class="FormInsideTableTopLeftCell">Curvature</td>
<td width="15%" class="FormInsideTableTopCell"> </td>
<td width="15%" align="center" valign="middle" class="FormInsideTableTopCell">Location</td>
<td width="15%" class="FormInsideTableTopCell"> </td>
<td width="15%" align="center" valign="middle" class="FormInsideTableTopCell">Degree</td>
<td width="15%" class="FormInsideTableTopCell"> </td>
</tr>
<tr>
<td align="center" height="20" valign="middle" class="FormInsideTableLeftCell">Other Deformity</td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell">Location</td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell">Magnitude</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" height="20" valign="middle" class="FormInsideTableLeftCell">Stretched Flaccid Length (cm)</td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell"> Erect Length (cm)</td>
<td colspan="3" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" height="20" valign="middle" class="FormInsideTableLeftCell">Neo-Synephrine Administration</td>
<td colspan="2" class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell">Dose</td>
<td colspan="2" class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU18<img src="../../Images/shim.gif" border="0" width="45" height="1">U22<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/04<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">3</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">18</span></td>
</tr>
</table>
</div>
<div align="left" 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">*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="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow">
<table border="0" width="700" cellpadding="4" cellspacing="0">
<tr>
<td width="50%" 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 Follow Up</span></td>
<td width="50%" 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">
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Duplex Doppler Ultrasonography Diagnosis</strong></td>
</tr>
<tr>
<td align="center" width="2%" height="30" class="FormInsideTableTopCell"><strong>1.</strong></td>
<td width="98%" class="FormInsideTableTopCell"> </td>
</tr>
<tr>
<td align="center" height="30" class="FormInsideTableRegCell"><strong>2.</strong></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" height="30" class="FormInsideTableRegCell"><strong>3.</strong></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table align="center" border="0" width="700" cellpadding="0" cellspacing="0">
<tr>
<td width="500">
<table align="left" width="100%" border="0" cellpadding="5" cellspacing="0">
⌨️ 快捷键说明
复制代码
Ctrl + C
搜索代码
Ctrl + F
全屏模式
F11
切换主题
Ctrl + Shift + D
显示快捷键
?
增大字号
Ctrl + =
减小字号
Ctrl + -