📄 urouturnp.ascx
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<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 New Patient</span></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 %>
</span></td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr valign="top">
<td width="320" class="FormInnerRowRightBorder"><span class="blackBoldText">Family
History:</span><img src="../../Images/shim.gif" border="0" width="50" height="1">
<input type="checkbox" name="famHxProstateCancerYes2" runat="server" ID="famHxProstateCancerYes2"/>
No known family history of ca<br> <table width="312" border="0" cellspacing="0" cellpadding="0" id="BlankFamilyHistoryTable" runat="server">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="72" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="25" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="40" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="150" height="1"></td>
</tr>
<tr>
<td> </td>
<td align="center">Y</td>
<td align="center">N</td>
<td> </td>
<td> </td>
</tr>
<tr>
<td>Kidney Ca</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="right">If Y: </td>
<td>No. 1° relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td> </td>
<td>No other relatives: _______</td>
</tr>
<tr>
<td colspan="3"> </td>
<td colspan="2"> Side of Family:</td>
</tr>
<tr>
<td><img src="../../Images/shim.gif" border="0" width="10" height="30"></td>
<td align="center" valign="bottom">Y</td>
<td align="center" valign="bottom">N</td>
<td> </td>
<td valign="top"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Maternal
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"> Paternal</td>
</tr>
<tr valign="top">
<td>Other Ca</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="right">List: </td>
<td> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Breast <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Prostate<br> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Bladder <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Testis <br> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13">
Other: ____________</td>
</tr>
<tr>
<td colspan="5"><table width="312" border="0" cellspacing="0" cellpadding="0">
<tr>
<td><img src="../../Images/shim.gif" border="0" width="40" height="8"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="50" height="1"></td>
<td><img src="../../Images/shim.gif" border="0" width="122" height="8"></td>
</tr>
<tr>
<td> </td>
<td align="center">Alive</td>
<td align="center">Dead</td>
<td align="center">Age</td>
<td align="center">Cause of Death</td>
</tr>
<tr>
<td>Mother</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Father</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
<tr>
<td>Other</td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center">______</td>
<td align="center">________________</td>
</tr>
</table></td>
</tr>
</table>
<br> <input type="checkbox" name="Digitized232">
Balkan Heritage<br> </td>
<td width="330"> <p><span class="blackBoldText">Social History:</span><br>
<br>
Occupation: <br>
<br>
Marital Status:<img src="../../Images/shim.gif" border="0" width="100" height="1">Children:<br>
<img src="../../Images/shim.gif" border="0" width="1" height="12">
<br>
Tobacco Use:
<input type="checkbox" name="Digitized222222">
None <br>
<img src="../../Images/shim.gif" border="0" width="73" height="8">
<asp:Label ID="socHxTobaccoType" Runat="server">
<input type="checkbox" name="Digitized2222">
Cigarettes <img src="../../Images/shim.gif" border="0" width="10" height="8">
<input type="checkbox" name="Digitized22222">
Cigar<img src="../../Images/shim.gif" border="0" width="10" height="1">
<input type="checkbox" name="Digitized22223">
Pipe</asp:Label>
<br>
<br>
<img src="../../Images/shim.gif" border="0" width="75" height="1">
<input type="checkbox" name="Digitized222">
______ packs / day for ______years<br>
<img src="../../Images/shim.gif" border="0" width="75" height="1">
<input type="checkbox" name="Digitized23">
Quit: ______ years ago<br>
<br>
<br>
Alcohol Use: <br>
<br>
Carcinogen Exposure: <br>
</p></td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Review
of Systems</span> <span class="smallGrayText">Clinician
Performing Review:
<input type="checkbox" name="NP22" value="Yes">
NP / PA
<input type="checkbox" name="Fellow22" value="Yes">
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