📄 urosexfuncfu.ascx
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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">2</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>
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</table>
</div>
<div id="LastPageInForm" runat="server" 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="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow">
<table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td width="50%" align="center" valign="top" 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="50%" border="0" cellspacing="0" 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 align="center" border="0" width="700" cellpadding="3" cellspacing="0">
<tr>
<td colspan="3" class="blackBoldText">Impression & Plan</td>
</tr>
<tr>
<td width="200" align="center" class="FormInsideTableTopCell"><strong>Diagnoses / Problem List</strong></td>
<td width="20" align="center" class="FormInsideTableTopCell"><strong>New</strong></td>
<td width="480" align="center" class="FormInsideTableTopCell"><strong>Plan & Referrals</strong></td>
</tr>
<tr>
<td height="60" valign="top" class="FormInsideTableRegCell">1.</td>
<td align="center" valign="middle" class="FormInsideTableRegCell"><input name="diagnosisNew1" type="checkbox" id="diagnosisNew1"></td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="60" valign="top" class="FormInsideTableRegCell">2.</td>
<td align="center" valign="middle" class="FormInsideTableRegCell"><input name="diagnosisNew2" type="checkbox" id="diagnosisNew2"></td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="60" valign="top" class="FormInnerRowRightBorder">3.</td>
<td align="center" valign="middle" class="FormInnerRowRightBorder"><input name="diagnosisNew3" type="checkbox" id="diagnosisNew3"></td>
<td> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="100%" class="FormInnerRowRightBorder"> <input type="checkbox" name="50% of Time22">≥ 50% of attending time was spent in counseling<img src="../../Images/shim.gif" border="0" width="4" height="1">(If so, mark total attending time in minutes):<img src="../../Images/shim.gif" border="0" width="4" height="1">
<input type="checkbox" name="15-24 (3)22">15-24 (3) <input type="checkbox" name="25-39 (4)22">25-39 (4) <input type="checkbox" name="40+ (5)22">40+ (5)
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td colspan="3" align="left" valign="top"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Describe Counseling or Dictate Note</span></td>
</tr>
<tr>
<td width="30%" height="20" align="left" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Oral erectogenic therapy</td>
<td width="25%" align="left" valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Penile rehabilitation</td>
<td width="45%" class="FormInsideTableTopCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Intracavernosal injections</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Vacuum device therapy</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Intraurethral agents</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Penile implant surgery</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" colspan="2" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Duplex Doppler US</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" colspan="2" align="left" valign="middle" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Peyronie's disease medical therapy</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Intralesional injection therapy</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Peyronie's disease surgery</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> DICC</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" colspan="2" align="left" valign="middle" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Orgasm associated incontinence</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Intralesional injection therapy</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Low testosterone</td>
<td align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Testosterone supplementation</td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"><table width="700" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="325" height="22" class="FormInnerRowRightBorder">Circle
Level of Service:<img src="../../Images/shim.gif" border="0" width="15" height="1">1<img src="../../Images/shim.gif" border="0" width="22" height="1">2<img src="../../Images/shim.gif" border="0" width="22" height="1">3<img src="../../Images/shim.gif" border="0" width="22" height="1">4<img src="../../Images/shim.gif" border="0" width="22" height="1">5</td>
<td width="325">Circle if Dictated:<img src="../../Images/shim.gif" border="0" width="30" height="1">Fellow/ Resident<img src="../../Images/shim.gif" border="0" width="30" height="1">Attending</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="700" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">Signatures</span><br></td>
<td colspan="2"> </td>
</tr>
<tr>
<td width="100"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Fellow:</span></td>
<td width="400"><span class="blackBoldText">___________________________________________</span></td>
<td width="200"> </td>
</tr>
<tr>
<td><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">NP / PA: </span></td>
<td><span class="blackBoldText">___________________________________________</span></td>
<td> </td>
</tr>
<tr align="center">
<td colspan="3"> <table width="692" cellpadding="4" cellspacing="0" class="FormOuterTableTopRow">
<tr>
<td>I personally performed or was physically present during the <strong>key portions</strong> of the visit today. I agree with the history, physical exam, and assessment/plan as documented by the <strong>fellow</strong> above.<br /><img src="../../Images/shim.gif" border="0" width="1" height="20"><span class="blackBoldText">MD / Attending: ________________________________________________</span>
<p align="center"><span class="smallGrayText">**Please verify that the service date is printed on each page**</span></p></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">3</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>
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