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<td align="left" class="FormInsideTableLeftCell"><span class="blackBoldText">Peyronie's Disease</span><img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">None<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Curvature<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Other (specify):</td>
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<td align="left" class="FormInsideTableLeftCell">Status:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">New
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1">First Noted: _____ months postop
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Stable
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Improved
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Worsened
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<td align="left" class="FormInsideTableLeftCell">Degree:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">10-20
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">21-30
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">31-40
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">41-50
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">51-60
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">61-70
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">71-80
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">81-90
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">>90</td>
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<td height="20" align="left" class="FormInsideTableLeftCell">Direction:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Dorsal
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Ventral
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Right
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Left
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Combined __________</td>
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<td align="left" class="FormInsideTableLeftCell">Pain:
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Flaccid
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Erect</td>
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<td align="left" class="FormInsideTableLeftCell">Penetration Ability:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No
<img src="../../Images/FormImages/shim.gif" border="0" width="30" height="1">Instability:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No</td>
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<td height="20" align="left" class="FormInsideTableLeftCell">First Sign:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Pain
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Nodule
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Deformity</td>
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<td height="20" align="left" class="FormInsideTableLeftCell">Status:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Established
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Stable
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Improved
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Worsened
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<td height="20" align="left" class="FormInsideTableLeftCell">Treatments to Date:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Oral __________
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">ILV
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1">Operative:
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Nesbit
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">PIG
<img src="../../Images/FormImages/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">IPP</td>
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<td width="200" valign="top" align="left"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Comments</span>
<br /><br /><br /><img src="../../Images/FormImages/sexFuncDiagram1.gif" width="200" height="137" vspace="2"></td>
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<!-- <tr>
<td height="30" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Treatments</span>
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input name="diagnosisNew1242" type="checkbox" id="diagnosisNew1242">Oral
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input name="diagnosisNew12222" type="checkbox" id="diagnosisNew12222">Intralesional
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input name="diagnosisNew12322" type="checkbox" id="diagnosisNew12322">Surgery
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input name="diagnosisNew123222" type="checkbox" id="diagnosisNew123222">Other</td>
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<td align="left" class="FormInsideTableLeftCell"><span class="blackBoldText">Orgasm Associated Incontinence</span>
<img src="../../Images/FormImages/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No
<img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes</td>
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<td align="left" class="FormInsideTableLeftCell">
<img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Commenced: _________ months postop
<img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Ceased: _________ months postop</td>
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<td align="left" class="FormInsideTableLeftCell">
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Rare
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Occasional
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Frequent
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Always</td>
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<td height="20" align="left" class="FormInsideTableLeftCell">
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Small
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Moderate
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Large</td>
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<td align="left" class="FormInsideTableLeftCell">Distress:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">None
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Minimal
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Moderate
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Severe</td>
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<td align="left" class="FormInsideTableLeftCell">Treatments Attempted:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Imipramine
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">ACTIS</td>
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<td height="20" align="left" class="FormInsideTableLeftCell">Improvement:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">Yes
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0" align="absmiddle">No</td>
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</td>
<td width="200" valign="top" align="left"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Comments</span></td>
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</td>
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<table align="center" border="0" width="700" cellpadding="0" cellspacing="0">
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<td><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Hypogonadism</span></td>
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<td align="center" height="25" valign="middle" width="10%" class="FormInsideTableTopCell">Date</td>
<td align="center" valign="middle" width="12%" class="FormInsideTableTopCell">Med</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">PSA</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">tT</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">fT</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">SHBG</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">E2</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">LH</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">FSH</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">PRL</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">HCT</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">CHL</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">TRIG</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">HDL</td>
<td align="center" valign="middle" width="6%" class="FormInsideTableTopCell">LDL</td>
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<td class="FormOuterTableRow" height="180" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Exam</span></td>
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<td height="14" align="center" valign="bottom" class="blackBoldText">GU18<img src="../../Images/shim.gif" border="0" width="45" height="1">U22<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
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