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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroTestFU.ascx.cs" Inherits="Caisis.UI.Modules.Testis.PaperForms.UroTestFU" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="left">
<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">*U14*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font style="font-size: 13px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font>
<table width="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="700" cellpadding="4" cellspacing="0">
<tr>
<td width="375" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="80" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>Urology Testis Follow-Up Patient</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 height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><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 align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="50%" height="20" align="left" class="FormInnerRowNoBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Referring M.D. <%= institutionShortName%>:</td>
<td width="50%" align="left" class="FormInnerRowNoBorder">Non-<%= institutionShortName%>:</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="10"><span class="blackBoldText">Chief Complaint</span><img src="../../Images/shim.gif" border="0" width="400" height="1"><input name="DateLastGnRH4" type="checkbox" id="DateLastGnRH4" value="yes">Late Relapse<br /></td>
</tr>
<tr>
<td height="80" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">HPI</span><br>
<table cellpadding="4" cellspacing="0" border="0">
<tr>
<td class="FormPopulatedSmallerText" valign="top"> <asp:Repeater ID="hpi" runat=server OnItemDataBound="hpiItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "patientHPI") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> </td>
</tr>
</table><!--Removed because Features Text deleted--><!--<img id="HpiSpacer" runat="server" src="../../Images/shim.gif" border="0" width="4" height="1">--></td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<tr align="left">
<td colspan="6" valign="middle"><span class="blackBoldText">Symptoms</span><span> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">Asymptomatic</span></td>
</tr>
<tr>
<td width="70" align="center" valign="middle" class="FormInsideTableTopLeftCell">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">Present Now</td>
<td width="230" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
</tr>
<tr>
<td valign="top" class="FormInsideTableLeftCell">GU</td>
<td height="15" class="FormInsideTableRegCell">Abdominal Pain</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">GI</td>
<td height="15" class="FormInsideTableRegCell">Nausea / Vomiting</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell" rowspan="2" valign="top">MS</td>
<td height="15" class="FormInsideTableRegCell">Back Pain</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="15" class="FormInsideTableRegCell">Mass</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td valign="top" class="FormInsideTableLeftCell">C/V</td>
<td height="15" class="FormInsideTableRegCell">Cough</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">Breast</td>
<td height="15" class="FormInsideTableRegCell">Gynecomastia</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" colspan="6" class="FormInsideTableLeftCell">Other</td>
</tr>
</table>
</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="55%" valign="top" class="FormInnerRowRightBorder">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td colspan="3"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Medications</span>
<img src="../../Images/shim.gif" border="0" width="65" height="1">
<input name="DateLastGnRH" type="checkbox" id="DateLastGnRH" value="yes">Unchanged Since Last Visit</td>
</tr>
<tr align="center">
<td width="200" height="20" class="FormInsideTableTopCell">Agent</td>
<td width="80" class="FormInsideTableTopCell">Dose</td>
<td width="70" class="FormInsideTableTopCell">Schedule</td>
</tr>
<asp:Repeater ID="medications" runat=server>
<ItemTemplate>
<tr>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "Medication") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "MedDose") %>
<%# DataBinder.Eval(Container.DataItem, "MedUnits") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "MedSchedule") %>
</td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
<td width="340" valign="top">
<table width="340" border="0" cellspacing="0" cellpadding="0">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Allergies</span> <span>
<input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">NKA
<input name="DateLastGnRH3" type="checkbox" id="DateLastGnRH3" value="yes">Unchanged Since Last Visit</span></td>
</tr>
<tr align="center">
<td width="160" height="20" class="FormInsideTableRegCell">Allergen</td>
<td width="180" class="FormInnerRowBottomBorder">Reaction</td>
</tr>
<asp:Repeater ID="allergies" runat=server>
<ItemTemplate>
<tr>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "Allergen") %>
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