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<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
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<td height="16" align="left" class="FormInsideTableRegCell">Diarrhea</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="5" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">GU </td>
<td height="16" align="left" class="FormInsideTableRegCell">Obstruction</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="5" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Hematuria</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Dysuria</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
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<td height="16" align="left" class="FormInsideTableRegCell">Frequency</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Penile
Pain/curvature/length</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td rowspan="1" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Psych </td>
<td height="16" align="left" class="FormInsideTableRegCell">Depression</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Neuro </td>
<td height="16" align="left" class="FormInsideTableRegCell">Numbness
/ Tingling</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td rowspan="2" class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="16" align="left" class="FormInsideTableRegCell">Headaches</td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" valign="top" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Other:<br>
<img src="../../Images/shim.gif" border="0" width="0" height="6"></td>
<td align="left" valign="top" class="FormInnerRowRightBorder"> </td>
<td align="center" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="center" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td align="left" valign="top" class="FormInnerRowRightBorder"> </td>
<td valign="top"> </td>
<td align="left" valign="top"> </td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table width="100%" align="center" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td colspan="2" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Urinary
Function Survey </span><br>
<span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">1.</span> 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><br/>
<asp:Label ID="LastUrinaryQOLScores" Runat="server" /><asp:Label ID="UrinaryQOL" Runat="server" CssClass="blackBoldTextSmall" /><br></td>
<td align="left" valign="top" rowspan="6"> <table width="100%" align="center" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td><p class="smallGrayText">1 - Continence(no pads)<br>
2 - Mild SUI(leaks only during heavy actvty)<br>
3 - Moderate SUI(leaks with moderate actvty)<br>
4 - Severe SUI<br>
(leaks during nl actvty, dry
at night and at rest)<br>
5 - Total incont(continuous leakage of urine at rest)</p></td>
</tr>
</table>
<table width="100%" align="center" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td height="61" valign="top" nowrap class="smallGrayText">NONE<br>
AUS - Sphincter<br>
OU - Optical urethrotomy<br>
BIO - Biofeedback</td>
<td valign="top" nowrap class="smallGrayText">MED - Medications
only<br>
DIL - Urethral dilation<br>
COL - Collagen injection<br>
URO - Urodynamics</td>
</tr>
</table></td>
</tr>
<tr>
<td width="300" class="FormInsideTableRegCell" colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">2.</span> Continence:<img src="../../Images/shim.gif" width="10" height="0">
<input name="textfield4" type="text" class="inputFieldFlat" size="5"><br><asp:Label ID="LastCont" Runat="server" CssClass="blackBoldTextSmall"/></td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">3.</span> Date
Mild Incontinence Achieved (#2):
<input name="ContLv2Textbox" id="ContLv2Textbox" runat="server" type="text" class="inputFieldFlat" size="10" /></td>
<td align="left" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">4.</span> Date
Total Contin. Achieved (#1):
<input name="ContLv1Textbox" id="ContLv1Textbox" runat="server" type="text" class="inputFieldFlat" size="10" /></td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">5.</span> TX
for Incontinence:
<input name="textfield" type="text" class="inputFieldFlat" size="10">
<img src="../../Images/shim.gif" border="0" width="40" height="1">Tx
Date:</td>
<td align="left" class="FormInsideTableRegCell"> <input name="textfield" type="text" class="inputFieldFlat" size="10"></td>
</tr>
<tr>
<td class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">6.</span> TX
for Stricture:<img src="../../Images/shim.gif" border="0" width="20" height="1">
<input name="textfield" type="text" class="inputFieldFlat" size="10">
<img src="../../Images/shim.gif" border="0" width="40" height="1">Tx
Date:</td>
<td class="FormInnerRowRightBorder"> <input name="textfield" type="text" class="inputFieldFlat" size="10"></td>
</tr>
<tr id="LastIncontTxTableRow" runat="server">
<td class="FormInnerRowRightBorder" colspan="2"><img src="../../Images/shim.gif" border="0" width="20" height="1">
<asp:Label ID="LastIncontTx" Runat="server" CssClass="blackBoldTextSmall" /></td>
<td align="left" valign="top"> </td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table width="100%" align="center" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td colspan="2" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Erectile
Function Survey</span><br><asp:Label CssClass="FormPopulatedSmallerText" ID="LastPot" Runat="server" />
<img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">7.</span> Sexual QOL (Q4-Q6):<span class="smallGrayText"><br> <img src="../../Images/shim.gif" border="0" width="1" height="4"><br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">Q4:______ On PDE-5?<input type="checkbox" name="Yes2">Yes <input type="checkbox" name="Yes22">No<br> <img src="../../Images/shim.gif" border="0" width="1" height="4"><br>
<img src="../../Images/shim.gif" border="0" width="4" height="0">(Q5:______ + Q6:______) = Total: ______ / 12<br>
</span><asp:Label ID="LastSexualQOLScores" CssClass="blackBoldTextSmall" Runat="server" /><asp:Label CssClass="blackBoldTextSmall" ID="SexualQOL" Runat="server" /></td>
<td rowspan="7" valign="top" class="FormInnerRowRightBorder">
Sexual QOL (Q4-Q6)<br>
Q4: Meds like Viagra?<br>
Q5: Able to get erection?<br>
Q6: Hard enough for Penetration?<br>
<br>
Current Erectile Function<br>
1-Normal, full erections <br>
2-Full, but recently diminished <br>
3-Partial, satis. for intercourse <br>
4-Partial, unsatis. for intercourse<br>
5-Impotent</span></td>
<td width="38%" rowspan="7" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">13.</span> TX
for Erectile Dysfunction (that apply):<br> <table width="100%" align="center" border="0" cellpadding="0" cellspacing="0" >
<tr>
<td class="FormInsideTableTopLeftCell"> </td>
<td align="center" class="FormInsideTableTopCell">Start Date</td>
<td align="center" class="FormInsideTableTopCell">Stop Date</td>
</tr>
<asp:Repeater ID="QolTherapy" runat="server" >
<%--- OnItemDataBound="QolTherapyItemDataBound" ---%>
<ItemTemplate>
<tr id="QolTherapyRow" runat="server">
<td class="FormInsideTableLeftCell">
<%# DataBinder.Eval(Container.DataItem, "QOL_Therapy") %>
</td>
<td class="FormInsideTableRegCell">
<%# DataBinder.Eval(Container.DataItem, "QOL_TxDateText") %>
</td>
<td class="FormInnerRowBottomBorder">
<%# DataBinder.Eval(Container.DataItem, "QOL_TxStopDateText") %>
</td>
</tr>
</ItemTemplate>
</asp:Repeater>
<tr>
<td class="FormInsideTableLeftCell">Oral Agents (ex: Viagra)</td>
<td class="FormInsideTableRegCell"> <img src="../../Images/shim.gif" width="60" height="1"></td>
<td class="FormInnerRowBottomBorder"> <img src="../../Images/shim.gif" width="60" height="1"></td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">Topical Agents</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
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