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<tr>
<td class="HPIText" valign="top">
<asp:Repeater ID="medications" runat=server OnItemDataBound="medicationsItemDataBound">
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "Medication") %> <%# DataBinder.Eval(Container.DataItem, "MedDose") %> <%# DataBinder.Eval(Container.DataItem, "MedUnits") %> <%# DataBinder.Eval(Container.DataItem, "MedSchedule") %><br/><asp:Literal ID="StartNextMedColumn" Runat="server" />
</ItemTemplate>
</asp:Repeater>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow" valign="top" height="40"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Comorbidities</span>
<asp:Repeater ID="comorbidities" runat=server>
<ItemTemplate><%# DataBinder.Eval(Container.DataItem, "ComorbDateText") %> - <%# DataBinder.Eval(Container.DataItem, "Comorbidity") %></ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater>
</td>
</tr>
<tr>
<td class="FormOuterTableRow" valign="top" height="20"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Allergies</span> <input type="checkbox" name="NKA" value="NKA">NKA
<asp:Repeater ID="allergies" runat=server>
<ItemTemplate><%# DataBinder.Eval(Container.DataItem, "Allergen") %> (<%# DataBinder.Eval(Container.DataItem, "AllergyResponse") %>)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater>
</td>
</tr>
<tr>
<td colspan="8" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Review of Systems</span>
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td class="FormInsideTableTopCell" align="center"><Strong>Organ System</Strong></td>
<td class="FormInsideTableTopCell" align="center"><Strong>Symptom</Strong></td>
<td class="FormInsideTableTopCell" align="center"><Strong>Grade<br/>0<img src="../../Images/shim.gif" border="0" width="12" height="0">1<img src="../../Images/shim.gif" border="0" width="12" height="0">2<img src="../../Images/shim.gif" border="0" width="12" height="0">3<img src="../../Images/shim.gif" border="0" width="12" height="0">4</Strong></td>
<td class="FormInsideTableTopCell" align="center"><Strong>Disease or Therapy</Strong></td>
<td class="FormInsideTableTopCell" align="center"><Strong>Intervention</Strong></td>
<td class="FormInsideTableTopCell" width="15%" align="center"><Strong>Start - Stop<br/>Dates</Strong></td>
<td class="FormInsideTableTopCell" width="35%" align="center"><Strong>Comments</Strong></td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">Const </td>
<td class="FormInsideTableRegCell" align="left">Fatigue</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
<td class="FormInsideTableRegCell" rowspan="17" align="center"> </td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left">Fever</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left" nowrap>Wt Loss/ App</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Skin </td>
<td class="FormInsideTableRegCell" align="left">Rash</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">ENMT </td>
<td class="FormInsideTableRegCell" align="left">Mucositis</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp </td>
<td class="FormInsideTableRegCell" align="left">Dyspnea</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">CV </td>
<td class="FormInsideTableRegCell" align="left"> Edema</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left">Chest Pain</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="4"><img src="../../Images/shim.gif" border="0" width="4" height="0">GI </td>
<td class="FormInsideTableRegCell" align="left">Nausea</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left">Vomiting</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left">Diarrhea</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left">Constipation</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">Neuro </td>
<td class="FormInsideTableRegCell" align="left">Numb/ Ting</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left">Weakness</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="4"><img src="../../Images/shim.gif" border="0" width="4" height="0">GU </td>
<td class="FormInsideTableRegCell" align="left">Nocturia</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left">Hematuria</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr>
<td class="FormInsideTableRegCell" align="left">Dysuria</td>
<td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
<td class="FormInsideTableRegCell" align="center">-</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" colspan="6" height="10" align="left">Potency:<span class="smallGrayText">(circle)</span> Y N</td>
</tr>
<tr >
<td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pain </td>
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