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<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>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date:
<% =apptClinicDate %>
</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td colspan="3" class="blackBoldText">Impression & Plan </td>
</tr>
<tr>
<td width="309" align="center" class="FormInsideTableTopCell"><strong>Diagnoses
/ Problem List</strong></td>
<td width="32" align="center" class="FormInsideTableTopCell"><strong>New</strong></td>
<td width="309" align="center" class="FormInsideTableTopCell"><strong>Plan
& Referrals</strong></td>
</tr>
<tr>
<td height="60" valign="top" class="FormInsideTableRegCell">1.</td>
<td align="center" valign="middle" class="FormInsideTableRegCell">
<input name="diagnosisNew1" type="checkbox" id="diagnosisNew1"></td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="60" valign="top" class="FormInsideTableRegCell">2.</td>
<td align="center" valign="middle" class="FormInsideTableRegCell"><input name="diagnosisNew2" type="checkbox" id="diagnosisNew2"></td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="60" valign="top" class="FormInsideTableRegCell">3.</td>
<td align="center" valign="middle" class="FormInsideTableRegCell">
<input name="diagnosisNew3" type="checkbox" id="diagnosisNew3"></td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td height="60" valign="top" class="FormInnerRowRightBorder">4.</td>
<td align="center" valign="middle" class="FormInnerRowRightBorder">
<input name="diagnosisNew3" type="checkbox" id="diagnosisNew3"></td>
<td> </td>
</tr>
<!--<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">4.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">5.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">6.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">7.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">8.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">9.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr>
<tr class="eFormInnerTableRow">
<td valign="top" height="22"><img src="../../Images/shim.gif" border="0" width="4" height="0">10.</td>
<td align="center" valign="middle"><img src="../../Images/icon_checkBoxBlank.gif" width="24" height="18" alt="" border="0"></td>
<td> </td>
</tr> -->
</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">Disposition</span><br>
<input name="diagnosisNew34" type="checkbox" id="diagnosisNew34">
Discharge Home <input name="diagnosisNew33" type="checkbox" id="diagnosisNew33">
Transfer to UCC <input name="diagnosisNew32" type="checkbox" id="diagnosisNew32">
Other (Specify): ____________________________ </td>
</tr>
<tr>
<td width="450" align="center" class="FormInnerRowRightBorder"> <table width="440" border="0" cellpadding="0" cellspacing="0">
<tr>
<td width="100" height="18">Prescriptions:</td>
<td width="80" align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
<td>Refill or New</td>
</tr>
<tr>
<td height="18" colspan="3">Rx: __________________________________________________________</td>
</tr>
<tr>
<td height="18" colspan="3">Rx: __________________________________________________________</td>
</tr>
<tr>
<td height="18">Chemo Orders:</td>
<td align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
<td>____________________________________</td>
</tr>
</table></td>
<td width="200" align="center"> <span>Protocol #: ________</span>
<br> <table align="left" width="100%">
<tr>
<td>Considered:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
</tr>
<tr>
<td>Consent Obtained:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
</tr>
<tr>
<td>Registered:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="1">No</td>
</tr>
</table>
<br> <br></td>
</tr>
</table></td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="325" class="FormInnerRowRightBorder"> <input type="checkbox" name="50% of Time22">
≥ 50% of attending time was spent in counseling <br> <img src="../../Images/shim.gif" border="0" width="1" height="20">
If so, mark total attending time in minutes & describe on right:<br>
<img src="../../Images/shim.gif" border="0" width="30" height="12">
<input type="checkbox" name="15-24 (3)2">
15-24 (3) <input type="checkbox" name="25-39 (4)2">
25-39 (4) <input type="checkbox" name="40+ (5)2">
40+ (5)</td>
<td width="325" valign="top"><img src="../../Images/shim.gif" border="0" width="1" height="11">Describe
Counseling or Dictate Note:</td>
</tr>
</table></td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow"> <table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="325" height="22" class="FormInnerRowRightBorder">Circle
Level of Service:<img src="../../Images/shim.gif" border="0" width="15" height="1">1<img src="../../Images/shim.gif" border="0" width="22" height="1">2<img src="../../Images/shim.gif" border="0" width="22" height="1">3<img src="../../Images/shim.gif" border="0" width="22" height="1">4<img src="../../Images/shim.gif" border="0" width="22" height="1">5
</td>
<td width="325" rowspan="2">Copy to: <input name="fellow222" type="checkbox" id="fellow223">
referring M.D.: ________________________<br> <img src="../../Images/shim.gif" border="0" width="50" height="1">
<input name="fellow2222" type="checkbox" id="fellow2222">
other: _______________________________</td>
</tr>
<tr>
<td height="22" class="FormInnerRowRightBorder">Circle if Dictated:<img src="../../Images/shim.gif" border="0" width="30" height="1">Fellow/
Resident<img src="../../Images/shim.gif" border="0" width="30" height="1">Attending</td>
</tr>
</table></td>
</tr>
<tr bgcolor="#000000">
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">Signatures</span><br></td>
<td colspan="2"> </td>
</tr>
<tr>
<td width="100"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Fellow:
</span></td>
<td width="350"><span class="blackBoldText">________________________________________________</span></td>
<td width="200"><span class="blackBoldText">Date:____/____/____</span>
</td>
</tr>
<tr>
<td><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">NP
/ PA: </span></td>
<td><span class="blackBoldText">________________________________________________</span></td>
<td><span class="blackBoldText">Date:____/____/____</span> </td>
</tr>
<tr>
<td colspan="3"><table width="642" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr>
<td><table width="642" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">
<input name="fellow" type="checkbox" id="fellow">
</span>I personally performed or was physically present during the <strong>key portions</strong> of the procedure today.<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="24" height="1">Date:____/____/____</span>
<span class="blackBoldText"> </span></td>
</tr>
</table></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">3</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>
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