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      <td height="100" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Past Medical History</span></td>
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      <td class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="0">
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            <td width="70%" height="100" valign="top" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Medications</span></td>
            <td width="30%" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Allergies</span></td>
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      <td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="20"><span class="blackBoldText">Preoperative Testing</span><img src="../../Images/shim.gif" border="0" width="200" height="1"><span class="blackBoldText">Date:</span> 
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                  <td align="center" width="55" height="30" class="FormInsideTableTopCell"><strong>WBC</strong></td>
                  <td  class="FormInsideTableTopCell">&nbsp;</td>
                  <td align="center" width="55" class="FormInsideTableTopCell"><strong>Na</strong></td>
                  <td  class="FormInsideTableTopCell">&nbsp;</td>
                  <td align="center" width="55" class="FormInsideTableTopCell"><strong>CO</strong></td>
                  <td  class="FormInsideTableTopCell">&nbsp;</td>
                  <td align="center" width="55"  class="FormInsideTableTopCell"><strong>Creat</strong></td>
                  <td  class="FormInsideTableTopCell">&nbsp;</td>
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                  <td align="center" class="FormInsideTableRegCell" height="30"><strong>H/H</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>K+</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>GLuco</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>Ca++</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
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                  <td align="center" class="FormInsideTableRegCell" height="30"><strong>Plts</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>Cl</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>BUN</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="left" valign="top" class="FormInsideTableRegCell" colspan="2" rowspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="2"><strong>Other:</strong></td>
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                  <td align="center" class="FormInsideTableRegCell" height="30"><strong>PT</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>PTT</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>INR</strong></td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
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                  <td align="center" class="FormInsideTableRegCell" height="30"><strong>UA</strong></td>
                  <td class="FormInsideTableRegCell" colspan="3">&nbsp;</td>
                  <td align="center" class="FormInsideTableRegCell"><strong>Urine<br>
                    C&amp;S</strong></td>
                  <td class="FormInsideTableRegCell" colspan="3">&nbsp;</td>
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      <td align="left" valign="middle" height="30" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Type and Cross:</strong></td>
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      <td class="FormOuterTableRow"> <table width="700" border="0" cellspacing="0" cellpadding="0">
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            <td align="left" valign="top" height="50" width="50%" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">EKG</span></td>
            <td align="left" valign="top" width="50%"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Chest 
              X-Ray</span></td>
          </tr>
        </table>
	  </td>
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      <td align="left" valign="top" width="700" height="40" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">Medical 
        Consult</span></td>
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      <td height="30" valign="middle" align="left" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Informed 
        consent signed and in the medical records?<img src="../../Images/shim.gif" border="0" width="30" height="1"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">Yes<img src="../../Images/shim.gif" border="0" width="30" height="1"><img src="../../Images/icon_checkBoxBlank.gif" align="absmiddle" width="18" height="14" alt="" border="0">No</span></td>
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      <td class="FormOuterTableRow"><table width="700" border="0" cellspacing="0" cellpadding="4">
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            <td><span class="blackBoldText">Signatures</span><br></td>
            <td colspan="2">&nbsp;</td>
          </tr>
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            <td width="100"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Prepared 
              By : </span></td>
            <td width="400"><span class="blackBoldText">___________________________________________</span></td>
            <td width="200"><span class="blackBoldText">Date:____/____/____</span> 
            </td>
          </tr>
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            <td><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Fellow: 
              </span></td>
            <td><span class="blackBoldText">___________________________________________</span></td>
            <td><span class="blackBoldText">Date:____/____/____</span> </td>
          </tr>
          <tr align="center"> 
            <td colspan="3">
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                  <td>Patient understands all risks and benefits and agrees to 
                    proceed.<br> <span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="20">MD 
                    / Attending:<img src="../../Images/shim.gif" border="0" width="18" height="8">__________________________________________<img src="../../Images/shim.gif" border="0" width="108" height="8">Date:____/____/____</span></td>
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      <td height="14" align="center" valign="bottom" class="blackBoldText">GU32<img src="../../images/shim.gif" border="0" width="45" height="1">U36<img src="../../images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 6/05<img src="../../images/shim.gif" border="0" width="45" height="8"><!--rev:9/17/04--><img src="../../images/shim.gif" border="0" width="45" height="1">Page 
        <span id="PageNumber">1</span> of <span id="TotalPages">1</span><img src="../../images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">32</span></td>
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