📄 urodynamics.ascx
字号:
</td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU35<img src="../../Images/shim.gif" border="0" width="45" height="1">U40<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/06<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">2</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">35</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">*U40*</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 <%= institutionShortName%> POLICY</font>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow">
<table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
<tr>
<td width="50%" rowspan="2" 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 Urodynamic Study</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 class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><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" cellspacing="0" cellpadding="2">
<tr>
<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Leak Point Pressure</span></td>
</tr>
<tr>
<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Did the patient leak with the catheter in place?
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Yes
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">No
<img src="../../Images/shim.gif" border="0" width="6" height="1"><span class="blackBoldTextSmall">(If Yes, answer the questions below)</span></td>
</tr>
<tr>
<td colspan="5"align="left" valign="baseline" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Valsalva Leak Point Pressure: ______ cmH<sub>2</sub>O<img src="../../Images/shim.gif" border="0" width="30" height="1">Bladder volume Refilled: <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> 150 ml <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> 200 ml <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> 300 ml</td>
</tr>
<tr>
<td colspan="5"align="left" valign="baseline" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Valsalva Leak Point Pressure:<img src="../../Images/shim.gif" border="0" width="10" height="1">With Catheter______ cmH<sub>2</sub>O<img src="../../Images/shim.gif" border="0" width="30" height="1">Without Catheter______ cmH<sub>2</sub>O</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">EMG</span></td>
</tr>
<tr>
<td align="left" valign="middle" class="FormInsideTableRegCell" width="90%"><img src="../../Images/shim.gif" border="0" width="4" height="1">EMG performed with patch electrodes placed in the midline at the perineum?
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Yes
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">No</td>
</tr>
<tr>
<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell">
<table width="100%" border="0" cellpadding="2" cellspacing="0">
<tr>
<td colspan="10" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">EMG Activity</td>
</tr>
<tr>
<td colspan="2" valign="middle" align="center" class="FormInsideTableRegCell">Progressive Filling</td>
<td colspan="2" valign="middle" align="center" class="FormInsideTableRegCell">Valsalva</td>
<td colspan="2" valign="middle" align="center" class="FormInsideTableRegCell">Cough</td>
<td colspan="2" valign="middle" align="center" class="FormInsideTableRegCell">Voiding</td>
<td colspan="2" valign="middle" align="center" class="FormInsideTableRegCell">Involuntary Detrusor</td>
</tr>
<tr>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Increase</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Decrease</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Increase</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Decrease</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Increase</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Decrease</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Increase</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Decrease</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Increase</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Decrease</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Video Urodynamics Study Diagnosis</span>
<table width="100%" border="0" cellspacing="0" cellpadding="2">
<tr>
<td valign="middle" align="center" width="3%" class="FormInsideTableTopLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableTopCell">Bladder Outlet Obstructions</td>
<td valign="middle" align="center" width="3%" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableTopCell">Poor Compliance</td>
<td valign="middle" align="center" width="3%" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableTopCell">Sphincter Incontinence</td>
<td valign="middle" align="center" width="3%" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableTopCell">Impaired Sensation</td>
</tr>
<tr>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Detrusor Sphincter Dyssynergia</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Urethral Stricture</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Diverticula</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Abdominal Voiding</td>
</tr>
<tr>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Detrusor Overactivity Incontinence</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Stomal Stenosis</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Detrusor Overactivity</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Peristalsis</td>
</tr>
<tr>
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