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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroGenEndo.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroGenEndo" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="center">
<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">*U25*</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 MSKCC POLICY</font> <br>
<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>
General Urology Endoscopy</span><br> </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>
</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 class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span></td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Verification:</span>
Patient Identity has been confirmed and agreement of planned procedure
with patient ensured.<br> <img src="../../Images/shim.gif" border="0" width="315" height="20">
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Yes </td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Site
Marking :</span> The procedure site/side has been marked and the
marking is in concordance with the consent and patient.<br> <img src="../../Images/shim.gif" border="0" width="295" height="20">
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
N/A</td>
</tr>
<tr >
<td class="FormOuterTableRow"> <table align="center" border="0" width="650" cellpadding="2" cellspacing="0">
<tr>
<td width="100" align="left" valign="top" class="FormInnerRowRightBorder"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Vital
Signs</span></td>
<td width="137" height="22" align="left" valign="top" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>
<td width="137" height="22" align="left" valign="top" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
<td width="137" height="22" align="left" valign="top" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
<td width="137" height="22" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp:</td>
</tr>
</table></td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td width="20" valign="middle"> <input type="checkbox" name="No24322">
</td>
<td width="630" valign="middle">Post instructions reviewed. Fact Cards
"Instructions Following Your Cystoscopy" provided to patient.</td>
</tr>
<tr>
<td colspan="2" valign="middle"><table width="642" border="0" cellspacing="0" cellpadding="2">
<tr>
<td width="70"><span class="blackBoldText">Signature:</span></td>
<td width="380"><span class="blackBoldText">__________________________________________________</span></td>
<td width="192"><span class="blackBoldText">Date:____/____/____</span>
</td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow" valign="top" height="20"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Allergies</span>
<input type="checkbox" name="NKA" value="NKA">
NKA <asp:Repeater ID="allergies" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "Allergen") %>
(
<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>
)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater> </td>
</tr>
<tr>
<td height="32" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Local
Anesthesia</span><img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="No224">
None<img src="../../Images/shim.gif" border="0" width="30" height="1"> <input type="checkbox" name="No2222">
2% Xylocaine Jelly</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="8" valign="middle" class="FormInnerRowBottomBorder"><span class="blackBoldText">Procedure</span></td>
</tr>
<tr>
<td width="20" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No2432"></td>
<td width="175" valign="middle" class="FormInsideTableRegCell">Cystoscopy<br></td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243132"></td>
<td width="175" valign="middle" class="FormInsideTableRegCell">Transurethral Fulguration Tumor</td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243132"></td>
<td width="175" valign="middle" class="FormInnerRowBottomBorder">Cystogram</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No24323"></td>
<td valign="middle" class="FormInsideTableRegCell">Stent Removal:<img src="../../Images/shim.gif" border="0" width="30" height="1">Right<img src="../../Images/shim.gif" border="0" width="30" height="1">Left</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24324"></td>
<td valign="middle" class="FormInsideTableRegCell">Transurethral Biopsy</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243132"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Loopogram</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No24323"></td>
<td valign="middle" class="FormInsideTableRegCell">Difficult Catheterization</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No24324"></td>
<td valign="middle" class="FormInsideTableRegCell">Dilation of Urethral Stricture</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243132"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Urethrogram</td>
</tr>
<tr class="FormInsideTableRegCell">
<td valign="top" class="FormInnerRowRightBorder"> <input type="checkbox" name="No2431318"></td>
<td colspan="7" valign="top"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="12"></span>Other:<br>
</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Exam</span> <span class="smallGrayText">Clinician
Performing Review:
<input type="checkbox" name="Fellow2" value="Yes">
Fellow
<input type="checkbox" name="Attending2" value="Yes">
Attending</span> <br>
<table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<!-- <tr class="eFormInnerTableRow">
<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
<td colspan="1" align="left" valign="top"></td>
</tr> -->
<tr>
<td width="170" align="center" class="FormInsideTableTopCell"><strong>Area</strong></td>
<td width="50" align="center" class="FormInsideTableTopCell"><strong>Normal</strong></td>
<td width="50" align="center" class="FormInsideTableTopCell"><strong>Abnormal</strong></td>
<td width="380" align="center" class="FormInsideTableTopCell"><strong>Findings</strong></td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Abdomen:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse22" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse23" value="Yes">
</span></td>
<td align="center" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Right Groin:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse24" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse25" value="Yes">
</span></td>
<td align="center" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Left Groin:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse26" value="Yes">
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