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      <td class="FormOuterTableRow">
	  	<table align="center" border="0" width="650" cellpadding="0" cellspacing="0">
          <tr> 
            <td width="10%" align="center" rowspan="2" valign="middle" class="FormInnerRowRightBorder"><span class="blackBoldText">Vital<br/>Signs</span></td>
            <td height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BP:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Resp:</td>
          </tr>
          <tr> 
            <td height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">KPS:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Height:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Weight:</td>
            <td align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">BSA:</td>
          </tr>
        </table>
	   </td>
    </tr>
    <tr > 
      <td colspan="8" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Exam</span>&nbsp;&nbsp;&nbsp;<span class="smallGrayText">
        <input type="checkbox" name="PA" value="Yes">
        PA&nbsp;&nbsp;&nbsp;
        <input type="checkbox" name="NP" value="Yes">
        NP&nbsp;&nbsp;&nbsp;
        <input type="checkbox" name="Attending" value="Yes">
        Attending Confirmed</span> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
          <tr > 
            <td class="FormInsideTableTopCell" align="center"><strong>System</strong></td>
            <td class="FormInsideTableTopCell" align="center" colspan="2"><strong>Normal Findings</strong></td>
            <td class="FormInsideTableTopCell" width="46" align="center"><strong>Abn</strong></td>
            <td class="FormInsideTableTopCell" width="46" align="center"><strong>Not Done</strong></td>
            <td class="FormInsideTableTopCell" align="center"><strong>Comments</strong></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">Gen/MS</td>
            <td class="FormInnerRowBottomBorder" align="left">NAD</td>
            <td class="FormInsideTableRegCell" width="1%" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" width="5%" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" width="5%" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td valign="bottom" class="FormInsideTableRegCell" width="54%" rowspan="30" align="center"><img src="../../Images/shim.gif" border="0" width="0" height="120"><br/><img src="../../Images/ProstateImageURONVWeb.gif" width="251" height="140"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">Alert and Oriented</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="0">ENT</td>
            <td class="FormInnerRowBottomBorder" align="left">No Scleral icterus</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">Eyes</td>
            <td class="FormInnerRowBottomBorder" align="left">No Mucositis</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">Mucous Membranes Moist</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Thrush</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">Nodes</td>
            <td class="FormInnerRowBottomBorder" align="left">No Cervical</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Supraclavicular</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Axillary</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></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="FormInnerRowBottomBorder" align="left">Clear to Percusion<br/>and Auscultation</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">C/V</td>
            <td class="FormInnerRowBottomBorder" align="left">No Edema</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">Regular Rate &amp; Rhythm</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Murmurs</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="3"><img src="../../Images/shim.gif" border="0" width="4" height="0">Abdomen</td>
            <td class="FormInnerRowBottomBorder" align="left">Soft Non-tender;<br/>Normal Bowel Sounds</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Hepatosplenomegaly</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No Ascites</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">Back</td>
            <td class="FormInnerRowBottomBorder" align="left">No Spinal Tenderness</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">No CVA Tenderness</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="0">GU<br/><img src="../../Images/shim.gif" border="0" width="4" height="0">Male</td>
            <td class="FormInnerRowBottomBorder" align="left">Testes w/o Tenderness or Masses</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInnerRowBottomBorder" align="left">Normal DRE of Prostate</td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
            <td class="FormInsideTableRegCell" align="center"><img src="../../Images/icon_checkBoxBlank.gif" width="18" height="14" alt="" border="0"></td>
          </tr>
          <tr > 
            <td class="FormInsideTableRegCell" align="left" valign="top" rowspan="4"><img src="../../Images/sh

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