📄 urobladcystfu.ascx
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<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 Cystectomy 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 height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Neobladder</span></td>
</tr>
<tr>
<td height="30" class="FormInnerRowBottomBorder">
<table width="642" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="162"> </td>
<td width="80" align="center">Daytime</td>
<td width="80" align="center">Nighttime</td>
<td width="320" rowspan="4" valign="top" class="smallGrayText"> 1
- Continence (no pads)<br> 2 - Mild
SUI (leaks only during heavy actvty)<br> 3
- Moderate SUI (leaks with moderate actvty)<br> 4
- Severe SUI (leaks during nl actvty, dry at night and at
rest)<br> 5 - Total incont (continuous
leakage of urine at rest)</td>
</tr>
<tr>
<td align="right">Continence (see codes on right) </td>
<td class="FormInsideTableTopLeftCell"> </td>
<td class="FormInsideTableTopCell"> </td>
</tr>
<tr>
<td align="right">Date Mild Continence Achieved </td>
<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="right">Date Total Continence Achieved </td>
<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table>
<br>
Treatment of Incontinence: _____________________<img src="../../Images/shim.gif" border="0" width="60" height="1">Tx Date: __________________<br />
Treatment for Bladder Neck Contracture: <img src="../../Images/shim.gif" border="0" width="11" height="1"><input type="checkbox" name="No3222324">Yes<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<img src="../../Images/shim.gif" border="0" width="34" height="1">Tx Date: __________________<br /></td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder">Need for Intermittent
Cath:<img src="../../Images/shim.gif" border="0" width="10" height="8">
<input type="checkbox" name="No3222">
No<img src="../../Images/shim.gif" border="0" width="10" height="8">
<input type="checkbox" name="Yes3222">
Yes<img src="../../Images/shim.gif" border="0" width="20" height="8">Date:
__________________ <img src="../../Images/shim.gif" border="0" width="20" height="8">Frequency
of Cath: _______ times / day</td>
</tr>
<tr>
<td height="25" class="FormInnerRowBottomBorder">Nocturia:<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="No32222">
No<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="Yes32222">
Yes<img src="../../Images/shim.gif" border="0" width="25" height="8">#:_______<img src="../../Images/shim.gif" border="0" width="60" height="1">Pads:<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="No322222">
No<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="Yes322222">
Yes<img src="../../Images/shim.gif" border="0" width="25" height="1">#:_________</td>
</tr>
<tr>
<td width="625" height="30" class="FormInnerRowBottomBorder"><table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td width="216" valign="top" class="FormInnerRowRightBorder"><strong>Current
Erectile Function:</strong> <input type="text" name="textfield2222" class="inputFieldFlat" size="5" style="border: solid 1px #666666">
<span class="smallGrayText"> <br>
1-Normal, full erections <br>
2-Full, but recently diminished <br>
3-Partial, satis. for intercourse <br>
4-Partial, unsatis. for intercourse <br>
5-Impotent</span> </td>
<td width="176" valign="top" class="FormInnerRowRightBorder"><strong>%
Best Erection:</strong><br /><br />
No Medications: ______<br /><br />
Oral PDE-5 Drugs: ______</td>
<td width="256" valign="top"><strong>Sexual Function Survey</strong><br>
<img src="../../Images/shim.gif" border="0" width="1" height="15">Q4:
<asp:Label ID="ShortSexualQOLQ4" CssClass="blackBoldText" Runat="server" >______</asp:Label>
Q5:
<asp:Label ID="ShortSexualQOLQ5" CssClass="blackBoldText" Runat="server" >______</asp:Label>
<br>
Total MSK03 Sexual QOL Score:
<asp:Label ID="ShortSexualQOLTotal" CssClass="blackBoldText" Runat="server" >______</asp:Label>
/ 12<br><asp:Label ID="LastSexualQOLScores" Runat="server" /><br> <span class="smallGrayText">(Fill in scores
above from questions 4 & 5 of <br>
Urinary & Sexual Function Questionnaire)</span></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Continent Cutaneous Diversions</span></td>
</tr>
<tr>
<td height="24" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Cath Interval: _________ hrs</td>
</tr>
<tr valign="top">
<td height="24" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Continence (circle one):
<img src="../../Images/shim.gif" border="0" width="30" height="1">Complete
<img src="../../Images/shim.gif" border="0" width="40" height="1">Leakage
<img src="../../Images/shim.gif" border="0" width="40" height="1">Constant<br>
<img src="../../Images/shim.gif" border="0" width="30" height="4"><br>
<img src="../../Images/shim.gif" border="0" width="4" height="1">Within:<img src="../../Images/shim.gif" border="0" width="20" height="1">
1h<img src="../../Images/shim.gif" border="0" width="20" height="1">
2h<img src="../../Images/shim.gif" border="0" width="20" height="1">
4h<img src="../../Images/shim.gif" border="0" width="20" height="1">
6h<img src="../../Images/shim.gif" border="0" width="60" height="1">
# of pads:_________</td>
</tr>
<tr>
<td height="24" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Cath Size:
<img src="../../Images/shim.gif" border="0" width="20" height="1">12 F
<img src="../../Images/shim.gif" border="0" width="30" height="1">14 F
<img src="../../Images/shim.gif" border="0" width="30" height="1">16 F
<img src="../../Images/shim.gif" border="0" width="30" height="8">18 F
<img src="../../Images/shim.gif" border="0" width="30" height="1">>20 F</td>
</tr>
<tr valign="top">
<td height="24" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Ease of catheterization:
<img src="../../Images/shim.gif" border="0" width="20" height="1">no difficulty
<img src="../../Images/shim.gif" border="0" width="30" height="1"><1 /week
<img src="../../Images/shim.gif" border="0" width="30" height="1">1 /day<br>
<img src="../../Images/shim.gif" border="0" width="130" height="1"><input type="checkbox" name="No322232">unchanged
<img src="../../Images/shim.gif" border="0" width="20" height="1"><input type="checkbox" name="Yes322232">worse
<img src="../../Images/shim.gif" border="0" width="20" height="1"><input type="checkbox" name="Yes3222322">improved</td>
</tr>
<!-- <tr>
<td valign="top" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Stoma:
<img src="../../Images/shim.gif" border="0" width="20" height="1">Pink and Viable
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No
<img src="../../Images/shim.gif" border="0" width="15" height="1">Stoma Type: ___________________________<br>
<img src="../../Images/shim.gif" border="0" width="4" height="1">Peristomal Hernia
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No
<img src="../../Images/shim.gif" border="0" width="20" height="1">Stomal Stenosis
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Leakage with Appliance
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No
<img src="../../Images/shim.gif" border="0" width="20" height="1">Anastamosis Type: ___________________________</td>
</tr>-->
<tr valign="top">
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