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              </span></td>
            <td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse27" value="Yes">
              </span></td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">Genitalia:</td>
            <td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse28" value="Yes">
              </span></td>
            <td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse29" value="Yes">
              </span></td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr> 
            <td align="left" class="FormInsideTableRegCell">DRE:</td>
            <td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse210" value="Yes">
              </span></td>
            <td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse211" value="Yes">
              </span></td>
            <td align="center" class="FormInnerRowBottomBorder">&nbsp;</td>
          </tr>
          <tr valign="top"> 
            <td align="left" class="FormInnerRowRightBorder">Other: ___________________<br></td>
            <td align="center" class="FormInnerRowRightBorder"> <p><span class="smallGrayText"> 
                <input type="checkbox" name="Nurse212" value="Yes">
                </span><span class="smallGrayText"> </span></p></td>
            <td align="center" class="FormInnerRowRightBorder"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse213" value="Yes">
              </span></td>
            <td align="center">&nbsp;</td>
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        </table></td>
    </tr>
    <tr> 
      <td class="FormOuterTableRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
          <tr> 
            <td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Bimanual 
              Examination Findings</span><span class="smallGrayText"> <img src="../../Images/shim.gif" border="0" width="30" height="1"> 
              <input type="checkbox" name="Nurse21325" value="Yes">
              </span>Normal<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse21335" value="Yes">
              </span>Abnormal<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse21343" value="Yes">
              </span>Mass<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse21353" value="Yes">
              </span>Induration</td>
          </tr>
          <tr> 
            <td colspan="2" class="FormInnerRowBottomBorder">Induration / Thickening 
              Location: ______________________________________</td>
          </tr>
          <tr> 
            <td width="325" valign="top" class="FormInnerRowRightBorder">Mass 
              Size:<br> <br>
              _________ cm&nbsp;&nbsp;&nbsp;x&nbsp;&nbsp; _________ cm &nbsp;&nbsp;&nbsp;x&nbsp;&nbsp; 
              _________ cm</td>
            <td width="325" valign="top">Involvement of:<br> <span class="smallGrayText"> 
              <input type="checkbox" name="Nurse2133522" value="Yes">
              </span>Vagina<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse2134323" value="Yes">
              </span>Rectum<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse2135323" value="Yes">
              </span>Cervix<br> <span class="smallGrayText"> 
              <input type="checkbox" name="Nurse21343222" value="Yes">
              </span>Urethra<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText"> 
              <input type="checkbox" name="Nurse21353222" value="Yes">
              </span>Pelvic Sidewall<img src="../../Images/shim.gif" border="0" width="30" height="1">Right<img src="../../Images/shim.gif" border="0" width="30" height="1">Left</td>
          </tr>
        </table></td>
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    <tr> 
      <td class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Lab 
              Tests<br>
              <asp:Repeater ID="labTests" runat=server> 
                <ItemTemplate> 
                  <%# DataBinder.Eval(Container.DataItem, "LabDateText") %>
                  &nbsp;&nbsp;&nbsp; 
                  <%# DataBinder.Eval(Container.DataItem, "LabTest") %>
                  : 
                  <%# DataBinder.Eval(Container.DataItem, "LabResult") %>
                  &nbsp;&nbsp;&nbsp; 
                  <%# DataBinder.Eval(Container.DataItem, "LabQuality") %>
                </ItemTemplate>
                <SeparatorTemplate><br/>
                </SeparatorTemplate>
              </asp:Repeater>
              </span></td>
          </tr>
          <tr> 
            <td width="325" class="FormInnerRowRightBorder"> <table align="center" border="0" width="325" cellpadding="4" cellspacing="0">
                <tr> 
                  <td class="FormInnerRowRightBorder">&nbsp;</td>
                  <td colspan="3" align="center" class="FormInsideTableRegCell"><strong>Results</strong></td>
                </tr>
                <tr> 
                  <td width="55" align="center" class="FormInsideTableRegCell"><strong>Test</strong></td>
                  <td width="95" height="12" class="FormInsideTableRegCell"><strong>Date:</strong></td>
                  <td width="95" class="FormInsideTableRegCell"><strong>Date:</strong></td>
                  <td width="95" class="FormInsideTableRegCell"><strong>Date:</strong></td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                </tr>
              </table></td>
            <td width="325"><table align="center" border="0" width="325" cellpadding="4" cellspacing="0">
                <tr> 
                  <td class="FormInnerRowRightBorder">&nbsp;</td>
                  <td colspan="3" align="center" class="FormInnerRowBottomBorder"><strong>Results</strong></td>
                </tr>
                <tr> 
                  <td width="55" align="center" class="FormInsideTableRegCell"><strong>Test</strong></td>
                  <td width="95" height="12" class="FormInsideTableRegCell"><strong>Date:</strong></td>
                  <td width="95" class="FormInsideTableRegCell"><strong>Date:</strong></td>
                  <td width="95" class="FormInnerRowBottomBorder"><strong>Date:</strong></td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
                <tr class="FormInsideTableRegCell"> 
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td height="12" class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInsideTableRegCell">&nbsp;</td>
                  <td class="FormInnerRowBottomBorder">&nbsp;</td>
                </tr>
              </table></td>
          </tr>
        </table></td>
    </tr>
    <tr> 
      <td height="14" align="center" valign="bottom" class="blackBoldText">GU21<img src="../../Images/shim.gif" border="0" width="45" height="1">U25<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC 
        Approval Date: 7/04<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page 
        <span id="PageNumber">1</span> of <span id="TotalPages">3</span><img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">21</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">*U25*</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" border="0" cellspacing="0" cellpadding="0">
    <tr> 
      <td class="FormOuterTableTopRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
           
            <tr> 
              
            <td width="325" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
              General Urology Endoscopy</span></td>
              <td width="325" align="center" valign="bottom">