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      <td class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
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            <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">&nbsp;&nbsp;<span class="smallGrayText">Clinician 
              Performing Review:<span class="smallGrayText"> &nbsp;&nbsp; 
              <input type="checkbox" name="PA22" value="Yes">
              NP / </span>PA&nbsp;&nbsp;&nbsp; 
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              Fellow&nbsp;&nbsp;&nbsp; 
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              Attending</span></span></td>
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            <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>
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            <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>
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            <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">&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">Neuro</td>
            <td align="left" class="FormInsideTableRegCell" >CVA</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>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">LE Weakness / Paresthesia</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">Spinal Disease</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 rowspan="2" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">Eyes</td>
            <td align="left" class="FormInsideTableRegCell" >Vision Changes</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>
            <td rowspan="2" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell" >Glaucoma</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 rowspan="3" 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>
            <td align="center" class="FormInsideTableRegCell" ><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
            <td align="center" class="FormInsideTableRegCell" >&nbsp;</td>
            <td rowspan="3" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">Palpitations</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">Peripheral Edema</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>
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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>
            <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">Shortness of Breath</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">Hemoptysis</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>
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            <td rowspan="5" 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>
            <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>
            <td rowspan="5" align="center" class="FormInnerRowBottomBorder" >&nbsp;</td>
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            <td align="left" class="FormInsideTableRegCell">Vomiting</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>
          </tr>
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            <td align="left" class="FormInsideTableRegCell">Abdominal 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>
          </tr>
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            <td align="left" class="FormInsideTableRegCell">Rectal Bleeding</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">Stool Incontinence</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>
          </tr>
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            <td rowspan="8" align="left" valign="top" class="FormInsideTableRegCell" ><img src="../../Images/shim.gif" border="0" width="4" height="0">GU</td>
            <td align="left" class="FormInsideTableRegCell" >Frequency / Urgency</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>
            <td rowspan="8" valign="top" class="FormInnerRowBottomBorder" >&nbsp;<br>
              MSK03 Urinary QOL Score (Q1-Q3):________ / 15 <br>
              MSK03 Sexual QOL Score (Q18-Q19):________ / 12<br>
              Pads:________<br> <table width="100%" border="0" align="left" cellpadding="0" cellspacing="0" class="FormOuterTableTopRow">
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                  <td colspan="4"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="0">Urinary 
                    Function Survey </span></td>
                </tr>
                <tr > 
                  <td width="48" align="center" valign="middle" class="FormInsideTableTopCell">Date</td>
                  <td width="97" align="center" valign="middle" class="FormInsideTableTopCell">Code</td>
                  <td width="48" align="center" valign="middle" class="FormInsideTableTopCell">Value</td>
                  <td width="130" align="center" valign="middle" class="FormInsideTableTopCell">Comments</td>
                </tr>
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                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" valign="middle" class="FormInsideTableRegCell">IPSS 
                    Symptoms</td>
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                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" valign="middle" class="FormInsideTableRegCell">Continence 
                    (1-5)</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>