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            <td align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Eyes</td>
            <td align="left" class="FormInsideTableRegCell" >Visual Problems</td>
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            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">CV</td>
            <td align="left" class="FormInsideTableRegCell" >Angina</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
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            <td align="left" class="FormInsideTableRegCell">Palpitations</td>
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            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Respiratory</td>
            <td align="left" class="FormInsideTableRegCell" >Cough</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
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            <td align="left" class="FormInsideTableRegCell">Shortness of Breath</td>
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            <td align="left" class="FormInsideTableRegCell">Hemoptysis</td>
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            <td rowspan="4" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">GI</td>
            <td align="left" class="FormInsideTableRegCell" >Nausea</td>
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            <td align="left" class="FormInsideTableRegCell">Vomiting</td>
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            <td align="left" class="FormInsideTableRegCell">Abdominal Pain</td>
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            <td align="left" class="FormInsideTableRegCell">Rectal Bleeding</td>
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            <td rowspan="9" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">GU</td>
            <td align="left" class="FormInsideTableRegCell" >Dysuria</td>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
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            <td align="left" class="FormInsideTableRegCell">Frequency</td>
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            <td align="left" class="FormInsideTableRegCell">Incontinence</td>
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            <td align="left" class="FormInsideTableRegCell">Hematuria</td>
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            <td align="left" class="FormInsideTableRegCell">Nocturia</td>
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            <td align="left" class="FormInsideTableRegCell">Slow Stream</td>
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            <td align="left" class="FormInsideTableRegCell">Infection</td>
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            <td align="left" class="FormInsideTableRegCell">Peyronies</td>
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            <td align="left" class="FormInsideTableRegCell">Erectile Dysfunction</td>
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            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">MS</td>
            <td align="left" class="FormInsideTableRegCell" >Joint Pain</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" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">Lower Extremity Edema</td>
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            <td align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Psych</td>
            <td align="left" class="FormInsideTableRegCell" >Anxiety/Depression</td>
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            <td rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Heme</td>
            <td align="left" class="FormInsideTableRegCell" >Anemia</td>
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            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
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            <td align="left" class="FormInsideTableRegCell">Adenopathy</td>
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            <td align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Skin</td>
            <td align="left" class="FormInsideTableRegCell" >Rash</td>
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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" >&nbsp;</td>
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            <td rowspan="3" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Endo</td>
            <td align="left" class="FormInsideTableRegCell" >Heat/cold Intolerance</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" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">Thirst</td>
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            <td align="center" class="FormInsideTableRegCell">&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">Hot Flashes</td>
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            <td align="left" valign="top" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Other</td>
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            <td align="center" class="FormInnerRowRightBorder" >&nbsp;</td>
            <td >&nbsp;</td>
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