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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroBladFU.ascx.cs" Inherits="Caisis.UI.Modules.Bladder.PaperForms.UroBladFU_rev2" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="center">
<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">*U09*</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" cellpadding="0" cellspacing="0">
<tr>
<td colspan="8" class="FormOuterTableTopRow"> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td width="50%" 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 Bladder Endoscopy<br/>Follow-Up Patient</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 align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td align="left" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">Referring M.D.:
<asp:Repeater ID="ReferringMD" runat=server >
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "phFirstName") %>
<%# DataBinder.Eval(Container.DataItem, "phLastName") %>
(
<%# DataBinder.Eval(Container.DataItem, "phInstitution") %>
)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater> <asp:Label ID="blankReferrringMD" Runat="server"></asp:Label>
</td>
</tr>
</table></td>
</tr>
<tr>
<td height="35" valign="top" class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Chief Complaint</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Diagnosis</span><img src="../../Images/shim.gif" border="0" width="20" height="1">Date:<img src="../../Images/shim.gif" border="0" width="120" height="1">2002 TNM Stage:</td>
</tr>
<tr>
<td height="200" valign="top" class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">HPI</span><br>
<table cellpadding="4" cellspacing="0" border="0">
<tr>
<td class="HPITextBladder" valign="top" width="*"> <asp:Repeater ID="hpi" runat=server OnItemDataBound="hpiItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "patientHPI") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Repeater ID="HpiProstatectomies" runat=server OnItemDataBound="HpiProstatectomiesItemDataBound">
<ItemTemplate> <strong>
<%# DataBinder.Eval(Container.DataItem, "OpType") %>
</strong> on
<%# DataBinder.Eval(Container.DataItem, "SurgDateText") %>
<asp:Label ID="CaseSurgeonLabel" Runat="server">by
<%# DataBinder.Eval(Container.DataItem, "SurgCaseSurgeon") %>
</asp:Label>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Label ID="PreTxPot" Runat="server" /> <asp:Repeater ID="hpiProtocols" runat=server OnItemDataBound="appendToHpiItemDataBound">
<ItemTemplate> Protocol
<%# DataBinder.Eval(Container.DataItem, "ProtocolNum") %>
<%# DataBinder.Eval(Container.DataItem, "ProtocolNotes") %>
<%# DataBinder.Eval(Container.DataItem, "PtProtocolStatus") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Repeater ID="hpiBiopsies" runat=server >
<ItemTemplate> Biopsy:
<%# DataBinder.Eval(Container.DataItem, "BxDateText") %>
<%# DataBinder.Eval(Container.DataItem, "BxType") %>
Result:
<%# DataBinder.Eval(Container.DataItem, "BxResult") %>
<%# DataBinder.Eval(Container.DataItem, "bxQuality") %>
<br>
<asp:Literal ID="StartNextHpiColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater> <asp:Label ID="NVB_Left" Runat="server" />
<asp:Label ID="NVB_Right" Runat="server" /> </td>
</tr>
</table>
</td>
</tr>
<!--Please note: need to add repeaters from below if reusing this commented section-->
<!--<tr>
<td class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="60%%" height="90" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Interval History</span><br><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
<td width="40%" align="left" valign="top" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Protocols</span>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="20%" align="center" class="FormInsideTableTopCell">Start Date</td>
<td width="20%" align="center" class="FormInsideTableTopCell">Protocol #</td>
<td width="40%" align="center" class="FormInsideTableTopCell">Treatment</td>
<td width="20%" align="center" class="FormInsideTableTopCell">Stop Date</td>
</tr>
<tr>
<td height="21" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="21" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="21" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
</table></td>
</tr>
</table>
</td>
</tr>-->
<tr>
<td align="left" valign="top" height="60" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Interval History</span></td>
</tr>
<!--<tr>
<td align="left" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Late Complications</span>
<input type="checkbox" name="No">No
<input type="checkbox" id="ComplicationsCheckbox" runat="server" NAME="ComplicationsCheckbox"/>Yes (specify):
<asp:Repeater ID="complications" runat=server>
<ItemTemplate> <strong>
<%--<%# DataBinder.Eval(Container.DataItem, "ToxDateText") %>--%>
</strong> - <strong>
<%--<%# DataBinder.Eval(Container.DataItem, "ToxName") %>--%>
</strong> </ItemTemplate>
<SeparatorTemplate>; </SeparatorTemplate>
</asp:Repeater> </td>
</tr>-->
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td align="left" valign="top"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Intravesical Therapies</span>
<table border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="100" align="center" class="FormInsideTableTopCell">Start Date</td>
<td width="200" align="center" class="FormInsideTableTopCell">Agent</td>
<td width="350" align="center" class="FormInsideTableTopCell">Notes</td>
</tr>
<asp:Repeater ID="IntravesicalTx" runat=server>
<ItemTemplate>
<tr>
<td height="19" class="FormInsideTableRegCell"> <strong>
<%# DataBinder.Eval(Container.DataItem, "MedTxDateText") %>
</strong></td>
<td height="12" class="FormInsideTableRegCell"> <strong>
<%# DataBinder.Eval(Container.DataItem, "MedTxAgent") %>
</strong></td>
<td height="12" class="FormInnerRowBottomBorder"> <strong>
<%# DataBinder.Eval(Container.DataItem, "MedTxNotes") %>
</strong></td>
</tr>
</ItemTemplate>
</asp:Repeater>
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