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</tr>
<tr>
<td align="center" class="FormInsideTableRegCell" height="30"><strong>Plts</strong></td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"><strong>Cl</strong></td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"><strong>BUN</strong></td>
<td class="FormInsideTableRegCell"> </td>
<td align="left" valign="top" class="FormInsideTableRegCell" colspan="2" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="2"><strong>Other:</strong></td>
</tr>
<tr>
<td align="center" class="FormInsideTableRegCell" height="30"><strong>PT</strong></td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"><strong>PTT</strong></td>
<td class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"><strong>INR</strong></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="center" class="FormInsideTableRegCell" height="30"><strong>UA</strong></td>
<td class="FormInsideTableRegCell" colspan="3"> </td>
<td align="center" class="FormInsideTableRegCell"><strong>Urine<br>
C&S</strong></td>
<td class="FormInsideTableRegCell" colspan="3"> </td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" valign="middle" height="30" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Type and Cross:</strong></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td align="left" valign="top" height="50" width="50%" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">EKG</span></td>
<td align="left" valign="top" width="50%"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Chest
X-Ray</span></td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" valign="top" width="700" height="40" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Medical
Consult</span></td>
</tr>
<tr>
<td height="30" valign="middle" align="left" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Informed
consent signed and in the medical records?<img src="../../Images/shim.gif" border="0" width="30" height="1"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">Yes<img src="../../Images/shim.gif" border="0" width="30" height="1"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">No</span></td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU33<img src="../../images/shim.gif" border="0" width="45" height="1">U37<img src="../../images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/05<img src="../../images/shim.gif" border="0" width="45" height="8"><!--rev:9/17/04--><img src="../../images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">1</span> of <span id="TotalPages">2</span><img src="../../images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">33</span></td>
</tr>
</table>
</div>
<div align="left" id="LastPageInForm" runat="server" 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">*U37*</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 MSKCC POLICY</font></div>
<table width="700" cellpadding="0" cellspacing="0" bgcolor="#ffffff">
<tr>
<td colspan="8" class="FormOuterTableTopRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<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 Prostatectomy Preoperative Note</span><br>
</td>
<td width="50%" align="center" valign="bottom"> <table width="340" 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="274"><img src="../../Images/shim.gif" border="0" width="274" 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>
<% =patientFirstName %>
<% =patientMiddleName %>
<% =patientLastName %>
</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"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0" >
<tr>
<td class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Date:
<% =apptClinicDate %>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow">
<table width="700" border="0" cellspacing="0" cellpadding="0">
<tr>
<td valign="top" align="left" width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Urinary Function</span></td>
<td valign="top" align="left" width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Sexual Function</span></td>
</tr>
<tr>
<td valign="top" align="left" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Urinary QOL(Q1-Q3) :<span class="smallGrayText"><br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">Q1:______ Q2:______ Q3:______ Total: ______ / 15</span><asp:Label ID="UrinaryQOL" Runat="server" CssClass="blackBoldTextSmall" /><br>
<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">Continence:<img src="../../Images/shim.gif" width="17" height="0">
<input name="textfield4" type="text" class="inputFieldFlat" size="5"><br><asp:Label ID="LastCont" Runat="server" CssClass="blackBoldTextSmall"/>
</td>
<td valign="bottom" class="FormInsideTableRegCell"><asp:Label CssClass="FormPopulatedSmallerText" ID="LastPot" Runat="server" />
<img src="../../Images/shim.gif" border="0" width="4" height="0"> Sexual
QOL (Q4-Q6):<span class="smallGrayText"><br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">Q4:______ (Q5:______ + Q6:______ ) = Total: ______ / 12</span>
<asp:Label CssClass="blackBoldTextSmall" ID="SexualQOL" Runat="server" />
<br>
<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">Erectile
Function<img src="../../Images/shim.gif" border="0" width="17" height="0">
<input type="text" name="textfield2222" class="inputFieldFlat" size="10"></td>
</tr>
<tr>
<td valign="top" align="left" class="FormInsideTableRegCell"><p class="smallGrayText">
<img src="../../Images/shim.gif" border="0" width="4" height="0">1 - Continence(no pads)<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">2 - Mild SUI(leaks only during heavy actvty)<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">3 - Moderate SUI(leaks with moderate actvty)<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">4 - Severe SUI<br>
(leaks during nl actvty, dry
at night and at rest)<br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">5 - Total incont(continuous leakage of urine at rest)</p></td>
<td valign="top" align="left" class="FormInsideTableRegCell"><span class="smallGrayText">
<img src="../../Images/shim.gif" border="0" width="4" height="0">1-Normal, full erections <br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">2-Full, but recently diminished <br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">3-Partial, satis. for intercourse <br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">4-Partial, unsatis. for intercourse <br>
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