📄 urogenendo.ascx
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<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="26" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Cystoscopy</span> <img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21326" value="Yes">
</span>Normal
<img src="../../Images/shim.gif" border="0" width="15" height="1">(Verify normal findings below.)</td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Tumor</span><img src="../../Images/shim.gif" border="0" width="50" height="8">
1997 / 2002 Clinical TNM<img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">0</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">A</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">IS</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">1</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">2</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">3</font><img src="../../Images/shim.gif" border="0" width="30" height="1">T<font size="-6">4</font></td>
</tr>
<tr>
<td colspan="2" class="FormInnerRowBottomBorder">Number: <span class="blackBoldText"></span> <img src="../../Images/shim.gif" border="0" width="30" height="8"><span class="smallGrayText">
<input type="checkbox" name="Nurse2132" value="Yes">
</span>1<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2133" value="Yes">
</span>2<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2134" value="Yes">
</span>3<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2135" value="Yes">
</span>4<img src="../../Images/shim.gif" border="0" width="30" height="8"><span class="smallGrayText">
<input type="checkbox" name="Nurse2136" value="Yes">
</span>5<img src="../../Images/shim.gif" border="0" width="30" height="1">Other: ______________</td>
</tr>
<tr>
<td width="325" class="FormInsideTableRegCell">Size (Largest): ____________ cm</td>
<td width="325" class="FormInnerRowBottomBorder">Size range: ____________ cm to ____________ cm</td>
</tr>
<tr>
<td colspan="2" class="FormInnerRowBottomBorder">Morphology:<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="Nurse21322" value="Yes">Scar<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21332" value="Yes">Solid / Nodular<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21342" value="Yes">TIS<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="Nurse21352" value="Yes"> Papillary</td>
</tr>
<tr>
<td class="FormInnerRowRightBorder">Margins: <span class="smallGrayText">
<input type="checkbox" name="Nurse21323" value="Yes">
</span>Well-Circumscribed<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21333" value="Yes">
</span>Ill-Defined</td>
<td>Completely Removed / Fugurated: <img src="../../Images/shim.gif" border="0" width="10" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21324" value="Yes">
</span>Yes<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21334" value="Yes">
</span>No</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="5" valign="middle" class="FormInsideTableTopLeftCell"><span class="blackBoldText">
Mucosa</span></td>
</tr>
<tr>
<td width="20" align="center" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> </td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Normal<br>
</td>
<td width="10" valign="middle"> </td>
<td width="20" align="right" valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> </td>
<td width="300" valign="middle" class="FormInnerRowBottomBorder">Inflammatory</td>
</tr>
<tr>
<td align="center" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" class="FormInsideTableRegCell">CIS</td>
<td valign="middle"> </td>
<td align="right" valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> </td>
<td valign="middle" class="FormInnerRowBottomBorder">Radiation Cystitis</td>
</tr>
<tr>
<td align="center" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> </td>
<td valign="middle" class="FormInsideTableRegCell">Erythema</td>
<td valign="middle"> </td>
<td align="right" valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Other (specify):</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Other
Bladder Findings </span> <span class="smallGrayText">
<input type="checkbox" name="Nurse214" value="Yes">
Trabeculation
<input type="checkbox" name="NP22" value="Yes">
Diverticula
<input type="checkbox" name="PA22" value="Yes">
Other (specify): ___________________</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><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 colspan="4" class="FormInnerRowBottomBorder"><span class="blackBoldText">Urethra</span></td>
</tr>
<tr class="FormInsideTableRegCell">
<td width="150" align="center" class="FormInsideTableRegCell"><strong>Area
of Urethra</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Normal</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Abnormal</strong></td>
<td width="400" align="center" class="FormInnerRowBottomBorder"><strong>Findings</strong></td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Prostatic</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Anterior:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Posterior:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">
</span></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td colspan="4" class="FormInsideTableRegCell"> Stricture:<span class="smallGrayText">
<img src="../../Images/shim.gif" border="0" width="40" height="1">Location:
___________________ <img src="../../Images/shim.gif" border="0" width="40" height="1">Caliber:
___________________ French</span></td>
</tr>
</table></td>
</tr>
<tr>
<td height="455" align="center" class="FormOuterTableRow"><img src="../../Images/FormImages/Bladder6.gif" width="584" height="435"></td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU21<img src="../../Images/shim.gif" border="0" width="45" height="1">U25<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 7/04<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">21</span></td>
</tr>
</table>
</div>
<div id="LastPageInForm" runat="server" align="center" 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">*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>
<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></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>
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