📄 urouturfu.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroUTUrFU.ascx.cs" Inherits="Caisis.UI.Modules.Kidney.PaperForms.UroUTUrFU" 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">*U17*</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>
<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 Upper Tract Urothelial 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="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"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Chief
Complaint<br>
<br>
<br>
<br>
</span></td>
</tr>
<tr>
<td height="150" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">HPI</span><br>
<br> <br> <br> <br> <br> </td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
<tr>
<td colspan="4" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Interval
History</span><br> <img src="../../Images/shim.gif" border="0" width="260" height="130"></td>
<td align="left" valign="top" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Other
Treatments</span> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td colspan="1" align="center" class="FormInsideTableTopCell">Start
Date</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">TX<br>
<img src="../../Images/shim.gif" border="0" width="90" height="1"></td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Notes
(Protocol #)</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Stop
Date</td>
</tr>
<tr>
<td height="22" 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="22" 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="22" 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="22" 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>
<tr >
<td colspan="8" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Late
Complications: <input type="checkbox" name="No">
No <input type="checkbox" name="Yes">
Yes (specify): <br> <img src="../../Images/shim.gif" border="0" width="0" height="12">
</td>
</tr>
<!-- <tr >
<td colspan="8" align="left" valign="top">
<table align="left" border="0" width="70%" cellpadding="0" cellspacing="0" bgcolor="#CCCCCC">
<tr >
<td valign="middle"><img src="../../Images/shim.gif" border="0" width="4" height="0">Check Indication:</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">+SM</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">BCR</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">+ECE/SVI</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">LCR</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">+LN</td>
<td class="smallGrayText" valign="middle"><input type="checkbox" name="Yes">Mets</td>
</tr>
</table>
</td>
</tr>-->
</table></td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="335" class="FormInnerRowRightBorder"> <table width="325" border="0" cellspacing="0" cellpadding="4">
<tr>
<td colspan="3"><span class="blackBoldText">Medications</span>
<input name="DateLastGnRH" type="checkbox" id="DateLastGnRH" value="yes">
Unchanged Since Last Visit</td>
</tr>
<tr align="center">
<td width="195" class="FormInsideTableTopCell">Agent</td>
<td width="60" class="FormInsideTableTopCell">Dose</td>
<td width="70" class="FormInsideTableTopCell">Schedule</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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