📄 urobladendoor.ascx
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<%@ Control CodeBehind="UroBladEndoOR.ascx.cs" Language="c#" AutoEventWireup="false" Inherits="Caisis.UI.Modules.Bladder.PaperForms.UroBladEndoOR" %>
<link href="../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<asp:PlaceHolder id="PreOpFormHolder" runat="server"></asp:PlaceHolder>
<div id="NonBreakingForm">
<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">*U10*</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 MSKCC POLICY</font> <br>
<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 Endoscopy OR 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 class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span><img src="../../Images/shim.gif" border="0" width="290" height="1"><span class="blackBoldText">Surgeon:</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
<tr>
<td width="50%" height="22" align="left" class="FormInnerRowNoBorder">Referring M.D. <%= institutionShortName%>:
</td>
<td width="50%" height="22" align="left" class="FormInnerRowNoBorder">Non-<%= institutionShortName%>:
</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Diagnosis</span></td>
</tr>
<tr valign="top">
<td width="325" class="FormInnerRowRightBorder">Preoperative:</td>
<td width="325">Postoperative:<br> <br> <br> <br>
</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">2002
Clinical TNM Stage</span><img src="../../Images/shim.gif" border="0" width="30" height="1">T0<img src="../../Images/shim.gif" border="0" width="30" height="1">TA<img src="../../Images/shim.gif" border="0" width="30" height="1">TIS<img src="../../Images/shim.gif" border="0" width="30" height="1">T1<img src="../../Images/shim.gif" border="0" width="30" height="1">T2<img src="../../Images/shim.gif" border="0" width="30" height="1">T3<img src="../../Images/shim.gif" border="0" width="30" height="1">T4<br>
<img src="../../Images/shim.gif" border="0" width="195" height="14">Grade:
<img src="../../Images/shim.gif" border="0" width="30" height="1"> <input type="checkbox" name="No22">
Papilloma<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="No222">
Low Grade<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="No223">
High Grade</td>
</tr>
<tr>
<td height="40" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Anesthesia</span>
<img src="../../Images/shim.gif" border="0" width="30" height="1"> <input type="checkbox" name="No224">
Monitored Sedation<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="No2222">
General<img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="No22222">
2% Xylocaine Jelly<br> <img src="../../Images/shim.gif" border="0" width="103" height="1">
<input type="checkbox" name="No225">
Spinal<img src="../../Images/shim.gif" border="0" width="95" height="1">
<input type="checkbox" name="No22223">
None</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="8" valign="middle" class="FormInnerRowBottomBorder"><span class="blackBoldText">Procedures</span></td>
</tr>
<tr>
<td width="20" height="19" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No2432"></td>
<td width="175" valign="middle" class="FormInsideTableRegCell">Cystoscopy<br></td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243132"></td>
<td width="175" valign="middle" class="FormInnerRowBottomBorder">Cold Cup Biopsy</td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243132"></td>
<td width="175" valign="middle" class="FormInnerRowBottomBorder">Cystogram</td>
</tr>
<tr>
<td height="19" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No24322"></td>
<td valign="middle" class="FormInsideTableRegCell">EUA</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24324"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Transurethral Fulguration </td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24324"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Loopogram</td>
</tr>
<tr>
<td height="19" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No24323"></td>
<td valign="middle" class="FormInsideTableRegCell">TUR-BT</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No24325"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Urethra Biopsy</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243132"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Urethrogram</td>
</tr>
<tr>
<td height="19" valign="middle" class="FormInsideTableRegCell"><input type="checkbox" name="No243232"></td>
<td valign="middle" class="FormInsideTableRegCell">Transurethral Biopsy</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><input type="checkbox" name="No243252"></td>
<td colspan="4" valign="middle" class="FormInnerRowBottomBorder">Ureter Biopsy<img src="../../Images/shim.gif" border="0" width="30" height="8">Side:<span class="smallGrayText"><input type="checkbox" name="Nurse2133222" value="Yes">
</span>Left<img src="../../Images/shim.gif" border="0" width="20" height="8"><span class="smallGrayText"><input type="checkbox" name="Nurse2134222" value="Yes"></span>Right</td>
</tr>
<tr>
<td valign="top" class="FormInnerRowRightBorder"> <input type="checkbox" name="No2431318"></td>
<td colspan="8" valign="top"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="12"></span>Other
(specify):</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<!-- <tr class="eFormInnerTableRow">
<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
<td colspan="1" align="left" valign="top"></td>
</tr> -->
<tr>
<td colspan="5" class="FormInnerRowBottomBorder"><span class="blackBoldText">Radiographic
Findings / Upper Tracts</span></td>
</tr>
<tr class="FormInsideTableRegCell">
<td colspan="5" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse222222" value="Yes"></span>None Examined</td>
</tr>
<tr class="FormInsideTableRegCell">
<td colspan="2" align="center" class="FormInsideTableRegCell"><strong>Examined</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Normal</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Abnormal</strong></td>
<td width="370" align="center" class="FormInnerRowBottomBorder"><strong>Comments</strong></td>
</tr>
<tr>
<td width="10" align="left" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse22222" value="Yes"></span></td>
<td width="140" align="left" class="FormInsideTableRegCell"><span class="smallGrayText"></span>Urogram</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2222" value="Yes"></span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2322" value="Yes"></span></td>
<td align="center" height="40" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td width="10" align="left" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse22222" value="Yes"></span></td>
<td width="140" align="left" class="FormInsideTableRegCell"><span class="smallGrayText"></span>Retrogrades (Left)</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2222" value="Yes"></span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2322" value="Yes"></span></td>
<td align="center" height="40" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell"> </td>
<td align="left" class="FormInsideTableRegCell"><span class="smallGrayText"></span>Retrogrades (Right)</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse22225" value="Yes"></span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse22226" value="Yes"></span></td>
<td align="center" height="40" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse22223" value="Yes"></span></td>
<td align="left" class="FormInsideTableRegCell">Ureteroscopy (Left)</td>
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