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<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<!---<tr class="eFormInnerTableRow">
<td height="18"> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>--->
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellpadding="0" cellspacing="0">
<tr>
<td colspan="6"><img src="../../Images/shim.gif" border="0" width="4" height="16"><span class="blackBoldText">Procedures:
Endoscopies</span></td>
</tr>
<tr>
<td width="80" align="center" class="FormInsideTableTopLeftCell">Date</td>
<td width="75" align="center" class="FormInsideTableTopCell">Procedure</td>
<td width="260" align="center" class="FormInsideTableTopCell">Findings</td>
<td width="105" align="center" class="FormInsideTableTopCell">Pathology</td>
<td width="65" align="center" class="FormInsideTableTopCell">Cytology</td>
<td width="65" align="center" class="FormInsideTableTopCell">Pathology
Source</td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="36" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
</table></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU17<img src="../../Images/shim.gif" border="0" width="45" height="1">U21<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/04<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">17</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">*U21*</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 MSKCC POLICY</font> <br>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td width="325" 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 General Patient</span></td>
<td width="325" align="center" valign="bottom" class="blackBoldText">
<table width="325" 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="260"><img src="../../Images/shim.gif" border="0" width="260" 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 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"><img src="../../Images/shim.gif" border="0" width="4" height="15"><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="Fellow22" value="Yes">
Fellow
<input type="checkbox" name="Attending22" value="Yes">
Attending</span></span><br>
<table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<!-- <tr class="eFormInnerTableRow">
<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
<td colspan="1" align="left" valign="top"></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<br>
Related</strong></td>
<td width="50%" align="center" class="FormInsideTableTopCell"><strong>Notes</strong></td>
</tr>
<tr>
<td rowspan="2" 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="2" class="FormInnerRowBottomBorder" > </td>
</tr>
<tr >
<td align="left" class="FormInsideTableRegCell">Weight Loss</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="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Neuro</td>
<td 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>
<td rowspan="2" class="FormInnerRowBottomBorder" > </td>
</tr>
<tr >
<td align="left" class="FormInsideTableRegCell">Focal Weakness</td>
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