📄 urobladnp.ascx
字号:
<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="1"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span></td>
</tr>
<tr>
<td height="140" valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="3">
<tr valign="top">
<td colspan="2" class="FormInnerRowRightBorder"><span class="blackBoldText">Medical History / Comorbidities</span></td>
</tr>
<tr valign="top">
<td width="485" height="30" class="FormInsideTableTopCell" id="ComorbiditiesCell1" runat="server">1.<br>
<asp:Repeater ID="comorbidities" runat=server>
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %>
- <strong>
<%# DataBinder.Eval(Container.DataItem, "Comorbidity") %>
</strong> </ItemTemplate>
<SeparatorTemplate><br>
</SeparatorTemplate>
</asp:Repeater> </td>
<td width="215" rowspan="7" class="FormInsideTableTopCell"> <input name="Comorbidity" type="checkbox" id="Comorbidity">
Coronary Artery Disease / MI<br/> <input name="Comorbidity2" type="checkbox" id="Comorbidity13">
Other Cardiac Disease __________<br/> <input name="Comorbidity3" type="checkbox" id="Comorbidity14">
Hypertension<br/> <input name="Comorbidity4" type="checkbox" id="Comorbidity15">
CVA<br/> <input name="Comorbidity5" type="checkbox" id="Comorbidity16">
Thromboembolic Events / DVT<br/> <input name="Comorbidity6" type="checkbox" id="Comorbidity17">
Pulmonary Disease / Asthma / COPD<br/> <input name="Comorbidity7" type="checkbox" id="Comorbidity18">
Diabetes (IDDM/NIDDM)<br/> <input name="Comorbidity8" type="checkbox" id="Comorbidity19">
Hypercholesterolemia<br/> <input name="Comorbidity9" type="checkbox" id="Comorbidity20">
Depression<br/> <input name="Comorbidity10" type="checkbox" id="Comorbidity21">
Back Pain / DJD<br/> <input name="Comorbidity11" type="checkbox" id="Comorbidity22">
Inflammatory Bowel Disease<br/> <input name="Comorbidity12" type="checkbox" id="Comorbidity23">
Diverticulitis</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell" id="ComorbiditiesCell2" runat="server">2.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell" id="ComorbiditiesCell3" runat="server">3.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell">4.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell">5.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell">6.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInnerRowRightBorder">7.</td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="80" valign="top" class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr valign="top">
<td colspan="2" class="FormInnerRowRightBorder"><span class="blackBoldText">Surgical History </span></td>
</tr>
<tr valign="top">
<td width="350" height="35" class="FormInsideTableTopCell" id="SurgicalHistoryCell1" runat="server">1.
<asp:Repeater ID="SurgicalHistory" runat=server>
<ItemTemplate> <strong>
<%# DataBinder.Eval(Container.DataItem, "VarDate") %>
:
<%# DataBinder.Eval(Container.DataItem, "VarName") %>
<%# DataBinder.Eval(Container.DataItem, "VarValue") %>
</strong> </ItemTemplate>
<SeparatorTemplate><br>
</SeparatorTemplate>
</asp:Repeater> </td>
<td width="350" class="FormInsideTableTopCell">6.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell" id="SurgicalHistoryCell2" runat="server">2.</td>
<td class="FormInnerRowBottomBorder">7.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell" id="SurgicalHistoryCell3" runat="server">3.</td>
<td class="FormInnerRowBottomBorder">8.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInsideTableRegCell" id="SurgicalHistoryCell4" runat="server">4.</td>
<td class="FormInnerRowBottomBorder">9.</td>
</tr>
<tr valign="top">
<td height="35" class="FormInnerRowRightBorder" id="SurgicalHistoryCell5" runat="server">5.</td>
<td>10.</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellpadding="2" cellspacing="0">
<tr align="left" valign="top">
<td colspan="3" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Health Maintenance</span></td>
</tr>
<tr>
<td width="15%" align="center" class="FormInsideTableTopLeftCell">Diagnostic Test</td>
<td width="15%" align="center" class="FormInsideTableTopCell">Date</td>
<td width="70%" align="center" class="FormInsideTableTopCell">Results</td>
</tr>
<tr>
<td height="25" align="center" class="FormInsideTableLeftCell">Last Colonoscopy</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="25" align="center" class="FormInsideTableLeftCell">Last Mammography</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="25" align="center" class="FormInsideTableLeftCell">Last PAP Smear</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="25" align="center" class="FormInsideTableLeftCell">Last Stress Test</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU03<img src="../../Images/shim.gif" border="0" width="45" height="1">U07<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">3</span> of <span id="TotalPages">7</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">03</span></td>
</tr>
</table>
</div>
<div align="left" style="page-break-before:always">
<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">*U07*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<div align="center"> <font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font></div>
<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="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
Urology Bladder New Patient</span></td>
<td width="325" align="center" valign="bottom" class="blackBoldText">
<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>
⌨️ 快捷键说明
复制代码
Ctrl + C
搜索代码
Ctrl + F
全屏模式
F11
切换主题
Ctrl + Shift + D
显示快捷键
?
增大字号
Ctrl + =
减小字号
Ctrl + -