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</tr>
<tr >
<td class="FormInsideTableRegCell"> </td>
<td align="center" valign="middle" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr >
<td colspan="4"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td colspan="2" align="left" class="smallGrayText">Continence
Codes:</td>
</tr>
<tr >
<td class="smallGrayText">1 - </td>
<td class="smallGrayText">Continent (No pads)</td>
</tr>
<tr >
<td class="smallGrayText">2 - </td>
<td class="smallGrayText">Mild SUI (Leaks only during
heavy activity/ 1-2 pads)</td>
</tr>
<tr >
<td class="smallGrayText">3 - </td>
<td class="smallGrayText">Moderate SUI (Leaks with moderate
activity/ (3-4 pads)</td>
</tr>
<tr >
<td class="smallGrayText">4 - </td>
<td class="smallGrayText">Severe SUI (Leaks during norm.
activity, dry at night & rest)</td>
</tr>
<tr >
<td class="smallGrayText">5 - </td>
<td class="smallGrayText">Total incontinence (Continuous
leakage of urine at rest)</td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr >
<td align="left" class="FormInsideTableRegCell">Nocturia</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">Dysuria</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">Slow Stream</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">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"> </td>
</tr>
<tr >
<td align="left" class="FormInsideTableRegCell">Hematuria</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">Infection</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">Erectile Function
/ Peyronies</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>
</table></td>
</tr>
<tr>
<td height="35" class="FormOuterTableRow"> <input name="HistoryROSReview2" type="checkbox" id="HistoryROSReview2" value="Yes">
<span class="blackBoldText"> PFSH and ROS performed by: _____________________________________
Date: ____/____/____ </span></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU19<img src="../../Images/shim.gif" border="0" width="45" height="1">U23<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="1">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
<span id="PageNumber">2</span> of <span id="TotalPages">4</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">19</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">*U23*</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>
<table width="650" cellpadding="0" cellspacing="0">
<tr bgcolor="#FFFFFF" >
<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 Urinary Function<br>
Follow-Up </span></td>
<td width="50%" align="center" valign="bottom" > <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 bgcolor="#FFFFFF">
<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="4" cellspacing="0">
<tr>
<td width="10%" rowspan="2" align="left" valign="top" class="FormInnerRowRightBorder"><span class="blackBoldText">Vital
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 height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Pulse:</td>
<td height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Temp:</td>
<td height="18" 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 height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Height:</td>
<td height="18" align="left" valign="top" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="0">Weight:</td>
<td height="18" 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 class="FormOuterTableRow"> <img src="../../Images/shim.gif" border="0" width="4" height="0"><span class="blackBoldText">Exam</span> <span class="smallGrayText">Clinician
Performing Initial Exam:
<input type="checkbox" name="NP2" value="Yes">
NP / PA
<input type="checkbox" name="Fellow" value="Yes">
Fellow
<input type="checkbox" name="Attending" value="Yes">
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