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<td height="24" align="center" class="FormInsideTableRegCell">Left</td>
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</table>
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</table>
</td>
</tr>
<tr bgcolor="#FFFFFF">
<td height="14" align="center" valign="bottom" class="blackBoldText">GU01<img src="../../Images/shim.gif" border="0" width="45" height="1">U05<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">3</span> of <span id="TotalPages">6</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">01</span></td>
</tr>
</table>
</div>
<div align="center" 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">*U05*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font>
<table width="650" cellpadding="0" cellspacing="0" bgcolor="#FFFFFF">
<tr>
<td class="FormOuterTableTopRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td width="50%" align="center" valign="middle" class="FormInnerRowRightBorder"><span class="blackBoldText"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><%= institutionName%><br>
Urology Prostate New Patient</span></td>
<td width="50%" align="center" valign="bottom" class="blackBoldText">
<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><% =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 width="650" 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 class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td colspan="6" align="left" valign="top" ><img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Review
of Systems</span><span class="smallGrayText"> <span class="smallGrayText">Clinician
Performing Review:<span class="smallGrayText">
<input type="checkbox" name="PA22" value="Yes">
RN </span>
<input type="checkbox" name="PA2" value="Yes">
PA/NP
<input type="checkbox" name="Fellow2" value="Yes">
Fellow
<input type="checkbox" name="Attending2" value="Yes">
Attending</span></span></td>
</tr>
<tr>
<td align="center" class="FormInsideTableTopCell" ><strong> System</strong></td>
<td align="center" class="FormInsideTableTopCell" ><strong>Symptom</strong></td>
<td align="center" class="FormInsideTableTopCell" ><strong>Not Present</strong></td>
<td align="center" class="FormInsideTableTopCell" ><strong>Present</strong></td>
<td align="center" class="FormInsideTableTopCell" ><strong>Disease
Related</strong></td>
<td width="50%" align="center" class="FormInsideTableTopCell" ><strong>Notes</strong></td>
</tr>
<tr>
<td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">General</td>
<td align="left" class="FormInsideTableRegCell" >Fever</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="3" align="center" class="FormInnerRowBottomBorder" > </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Fatigue</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" class="FormInsideTableRegCell">Weight Loss</td>
<td align="center" class="FormInsideTableRegCell"><img src=".⌨️ 快捷键说明
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