📄 urotestnp.ascx
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<td align="center" class="FormOuterTableRow"><table align="center" border="0" width="700" cellpadding="1" cellspacing="0">
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<td colspan="5" align="left" valign="middle"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="3" height="15">Medical
Therapies / Chemotherapy</span><img src="../../Images/shim.gif" border="0" width="50" height="1">Initial Risk Category:<img src="../../Images/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" hspace="0" vspace="0" align="absmiddle">Poor<img src="../../Images/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" hspace="0" vspace="0" align="absmiddle">Intermediate<img src="../../Images/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" hspace="0" vspace="0" align="absmiddle">Good</td>
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<tr>
<td width="100" align="center" valign="middle" class="FormInsideTableTopLeftCell">Start Date</td>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Stop Date</td>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Indication</td>
<td width="300" align="center" valign="middle" class="FormInsideTableTopCell">Regimen</td>
<td width="100" align="center" valign="middle" class="FormInsideTableTopCell">Cycles</td>
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<td class="FormInsideTableRegCell"> </td>
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<td height="20" class="FormInsideTableRegCell"> </td>
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</table>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
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<td colspan="7" align="left" valign="top" class="smallGrayText"><strong> Indication Codes</strong></td>
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<td align="left" valign="top" class="smallGrayText"> </td>
<td align="right" valign="top" class="smallGrayText"><strong>1 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Induction</span> </td>
<td align="right" valign="top" class="smallGrayText"><strong>6 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Relapse after PostChemo RPLND</span></td>
<td align="right" valign="top" class="smallGrayText"><strong>10 </strong></td>
<td valign="top" class="smallGrayText">Third Line</td>
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<td align="left" valign="top" class="smallGrayText"> </td>
<td align="right" valign="top" class="smallGrayText"><strong>2 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Relapse after Surveillance</span></td>
<td align="right" valign="top" class="smallGrayText"><strong>7 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Relapse after RPLND</span></td>
<td align="right" valign="top" class="smallGrayText"><strong>11 </strong></td>
<td valign="top" class="smallGrayText">Relapse with Progression of disease</td>
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<td align="left" valign="top" class="smallGrayText"> </td>
<td align="right" valign="top" class="smallGrayText"><strong>3 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Salvage after incomplete RPLND</span></td>
<td align="right" valign="top" class="smallGrayText"><strong>8 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"> Relapse after Chemo</td>
<td align="right" valign="top" class="smallGrayText"><strong>12 </strong></td>
<td valign="top" class="smallGrayText">Other</td>
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<td align="left" valign="top" class="smallGrayText"> </td>
<td align="right" valign="top" class="smallGrayText"><strong>4 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Adjuvant after RPLND</span></td>
<td align="right" valign="top" class="smallGrayText"><strong>9 </strong></td>
<td valign="top" class="FormInnerRowRightBorder">Second Line </td>
<td align="right" valign="top" class="smallGrayText"><strong>13 </strong></td>
<td valign="top" class="smallGrayText">Unknown</td>
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<td align="left" valign="top" class="smallGrayText"> </td>
<td align="right" valign="top" class="smallGrayText"><strong>5 </strong></td>
<td valign="top" class="FormInnerRowRightBorder"><span class="smallGrayText">Adjuvant after postChemo RPLND</span></td>
<td align="right" valign="top" class="smallGrayText"> </td>
<td valign="top" class="FormInnerRowRightBorder"> </td>
<td valign="top" class="smallGrayText"> </td>
<td valign="top" class="smallGrayText"> </td>
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</table></td>
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<td valign="top" class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="4">
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<td width="500" height="70" valign="top"><span class="blackBoldText">Comorbidities</span><br/>
<asp:Repeater ID="comorbidities" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %>
- <strong>
<%# DataBinder.Eval(Container.DataItem, "Comorbidity") %>
</strong> </ItemTemplate>
<SeparatorTemplate><br/>
</SeparatorTemplate>
</asp:Repeater> </td>
<td width="200" valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Thromboembolic Events / DVT<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Pulmonary Disease / Asthma<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Diabetes (IDDM/NIDDM)<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Hypertension</td>
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</table></td>
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<td height="14" align="center" valign="bottom" class="blackBoldText">GU09<img src="../../Images/shim.gif" border="0" width="45" height="1">U13<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:08/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">1</span> of <span id="TotalPages">7</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">09</span></td>
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</table>
</div>
<div 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">*U13*</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="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>
Urology Testis New Patient</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>
<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="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="300" height="70" valign="top"><span class="blackBoldText">Medical & Surgical History</span></td>
<td width="200" valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Cryptorchidism
<img src="../../Images/shim.gif" border="0" width="15" height="1"><br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Ipsilateral Inguinal Surgery<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Contralateral Inguinal Surgery<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Prior Contralateral Testis Cancer</td>
<td width="150" valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Prior Testis Cancer<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Prior Scotal Violation<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Prior RPLND<br>
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Exploratory Laparotomy</td>
</tr>
</table></td>
</tr>
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