urotestnp.ascx

医疗决策支持系统

    <tr> 
      <td class="FormOuterTableRow"><table align="center" border="0" width="650" cellpadding="1" cellspacing="0">
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            <td colspan="6" valign="middle"><span class="blackBoldText">Presenting Symptoms</span></td>
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            <td width="70" align="center" valign="middle" class="FormInsideTableTopCell">System</td>
            <td width="150" align="center" valign="middle" class="FormInsideTableTopCell">Symptom</td>
            <td width="70" align="center" valign="middle" class="FormInsideTableTopCell">Not Present</td>
            <td width="50" align="center" valign="middle" class="FormInsideTableTopCell">Present            </td>
            <td width="80" align="center" valign="middle" class="FormInsideTableTopCell"><p>Present Now</p></td>
            <td width="310" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
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            <td width="70" rowspan="5" valign="top" class="FormInsideTableLeftCell">GU</td>
            <td width="150" class="FormInsideTableRegCell">Testicular Pain</td>
            <td width="70" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td width="50" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td width="80" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td width="310" class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
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            <td class="FormInsideTableRegCell">Swelling (mass/nodule)</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
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            <td class="FormInsideTableRegCell">Testicle Hardness</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
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            <td class="FormInsideTableRegCell">Infertility</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
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            <td class="FormInsideTableRegCell">Abdominal Pain</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
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            <td rowspan="3" valign="top" class="FormInsideTableLeftCell">Breast</td>
            <td class="FormInsideTableRegCell">Gynecomastia</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
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            <td class="FormInsideTableRegCell">Nipple Tenderness</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td class="FormInsideTableRegCell">Nipple Mass</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td class="FormInsideTableLeftCell">Head/Neck</td>
            <td class="FormInsideTableRegCell">Neck Mass</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td class="FormInsideTableLeftCell">MS</td>
            <td class="FormInsideTableRegCell">Back Pain</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td valign="top" class="FormInsideTableLeftCell">C/V</td>
            <td class="FormInsideTableRegCell">Cough</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
          <tr> 
            <td class="FormInsideTableLeftCell">General</td>
            <td class="FormInsideTableRegCell">Weight Loss</td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td class="FormInsideTableRegCell">&nbsp;</td>
          </tr>
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            <td colspan="6" class="FormInsideTableLeftCell">Other</td>
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        </table>		</td>
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      <td height="20" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText"></span>Post Treatment Ejaculation</span>
	  <img src="../../Images/shim.gif" width="30" height="1" border="0" align="absmiddle">Date: ____/____/________
	  <img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Absent
	  <img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Partial
	  <img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Normal</td>
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		<td class="FormOuterTableRow">
			<table width="100%" cellpadding="0" cellspacing="0" border="0">
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	  				<td colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Fertility:</span></td>
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					<td width="50%" height="15" class="FormInsideTableTopLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Number of Children Pre-Surgery:: __________</td>
					<td width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Number of Children Post-Surgery: __________</td>
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					<td height="15" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Post-Surgery if <strong>YES</strong>:&nbsp;Means:&nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Normal&nbsp;<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Fertility Assistance</td>
					<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Type (specify):</td>
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					<td height="15" colspan="2" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Post-Surgery if <strong>NO</strong>:<img src="../../Images/shim.gif" border="0" width="4" height="1">Have you and your partner attempted?</td>
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			</table>		</td>
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      <td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Initial Diagnosis</span><img src="../../Images/shim.gif" border="0" width="35" height="8">Dx Date: _______________<br> 
        <table width="650" border="0" cellspacing="0" cellpadding="0">
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            <td width="140"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText"></span>Method of Initial Diagnosis:</td>
            <td width="135"> <input type="checkbox" name="No222">Rad Orch</td>
            <td width="115"> <input type="checkbox" name="No2222">Simple Orch</td>
            <td width="115"> <input type="checkbox" name="No22223">Biopsy</td>
            <td width="145"> <input type="checkbox" name="No22224">FNA</td>
          </tr>
          <tr> 
            <td>&nbsp;</td>
            <td><input type="checkbox" name="No222222">Laparotomy</td>
            <td><input type="checkbox" name="No222232">RPLND</td>
            <td><input type="checkbox" name="No222242">Laparoscopy</td>
            <td><input type="checkbox" name="No2222423">Other: _____________</td>
          </tr>
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            <td colspan="5"><img src="../../Images/shim.gif" border="0" width="35" height="6"></td>
          </tr>
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            <td><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText"></span>Site of Initial Diagnosis:</td>
            <td> <input type="checkbox" name="No22232">Left Testis</td>
            <td> <input type="checkbox" name="No222252">Right Testis</td>
            <td> <input type="checkbox" name="No2222232">Head/Neck</td>
            <td> <input type="checkbox" name="No2222332">Mediastinum</td>
          </tr>
          <tr> 
            <td>&nbsp;</td>
            <td><input type="checkbox" name="No2222432">Retroperitoneum/Abd</td>
            <td colspan="3"><input type="checkbox" name="No22224223">Other: __________________________________</td>
          </tr>
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            <td colspan="5"><img src="../../Images/shim.gif" border="0" width="35" height="5"></td>
          </tr>
        </table>		</td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="140"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText"></span><span class="blackBoldText">Primary Site</span></td>
            <td width="135"> <input type="checkbox" name="No2223">Left Testis</td>
            <td width="115"><input type="checkbox" name="No22225">Right Testis</td>
            <td width="115"> <input type="checkbox" name="No222223">Head</td>
            <td width="145"> <input type="checkbox" name="No222233">Mediastinum</td>
          </tr>
          <tr> 
            <td>&nbsp;</td>
            <td><input type="checkbox" name="No222243">Retroperitoneum</td>
            <td><input type="checkbox" name="No22224222">Paratesticular</td>
            <td colspan="2"><input type="checkbox" name="No22224232">Other: _____________</td>
          </tr>
          <tr> 
            <td colspan="5"><img src="../../Images/shim.gif" border="0" width="35" height="10"></td>
          </tr>
        </table></td>
    </tr>
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      <td class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Pathology</span><span><img src="../../Images/shim.gif" border="0" width="30" height="1"> 
        <input type="checkbox" name="Films Reviewed23">Reviewed with MSKCC Pathologist</span><img src="../../Images/shim.gif" border="0" width="35" height="8">Orchiectomy Date: _______________<br>
		<img src="../../Images/shim.gif" border="0" width="35" height="5"><br> 
        <table width="650" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td valign="middle" class="FormInsideTableTopCell"> <input type="checkbox" name="No2439"></td>