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<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Pelvic Prolapse</td>
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<td valign="middle" align="left" class="FormInsideTableRegCell">Neurogenic Bladder</td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">BPH</td>
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<td valign="middle" align="left" class="FormInsideTableRegCell">Augmentation</td>
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<td colspan="3" valign="middle" align="left" class="FormInsideTableRegCell">Catheter Use:<img src="../../Images/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"> Intermittent<img src="../../Images/shim.gif" border="0" width="20" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"> In Dwelling </td>
<td valign="middle" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"></td>
<td valign="middle" align="left" class="FormInsideTableRegCell">Preop for:</td>
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<td valign="middle" align="left" colspan="7">Other:</td>
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<td valign="middle" colspan="2"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Procedure</span></td>
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<td align="left" valign="middle" class="FormInsideTableTopCell" width="50%"><img src="../../Images/shim.gif" border="0" width="4" height="1">Multichannel Urodynamic Study Position:
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0">Upright
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0">Supine</td>
<td width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Noninvasive uroflow was performed initially?
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Yes
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">No</td>
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<td width="15%" class="FormInsideTableRegCell" valign="middle" align="center">Qmax (ml/sec)</td>
<td width="20%" class="FormInsideTableRegCell" valign="middle" align="center">Voided Volume (ml)</td>
<td width="30%" class="FormInsideTableRegCell" valign="middle" align="center">Pattern</td>
<td width="35%" class="FormInsideTableRegCell" valign="middle" align="center">Dual Lumen Catheter Size (French)</td>
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<td class="FormInsideTableRegCell" align="center" valign="middle"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Normal
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Plateau
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Interrupted</td>
<td class="FormInsideTableRegCell" align="center" valign="middle"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"> #7<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0"> #9</td>
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<td align="left" valign="bottom" class="FormInsideTableRegCell" width="10%"><img src="../../Images/shim.gif" border="0" width="4" height="1">Post Void Residual: _______ ml</td>
<td align="left" valign="middle" class="FormInsideTableRegCell" width="90%"><img src="../../Images/shim.gif" border="0" width="4" height="1">Catheter filling Rate:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Slow
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Medium
<img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Fast</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Pressure Flow Study</span></td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Voiding at Capacity:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Allowed
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Involuntary Detrusor</td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Voiding Cystometrogram Peak Flow Rate (Qmax): ______ ml/sec
<img src="../../Images/shim.gif" border="0" width="40" height="1">Detrusor Pressure at Qmax _______ cmH<sub>2</sub>O</td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Bladder Outlet Obstruction Index
<span class="smallGrayText">(<i>PdetQmax-2*Qmax</i>):</span> __________
<img src="../../Images/shim.gif" border="0" width="30" height="1">Pattern:
<img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Normal
<img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Plateau
<img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Interrupted</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Bladder Outlet Obstruction Index consistent with Obstruction? <span class="smallGrayText">(<i>BOOI>40 means obstruction</i>):</span>
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Yes
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">No</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Abdominal straining during voiding?
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Yes
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">No</td>
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<td valign="middle" colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Filling Phase</span></td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">First Sensation: _______ ml
<img src="../../Images/shim.gif" border="0" width="30" height="1">First Urge: _______ ml
<img src="../../Images/shim.gif" border="0" width="30" height="1">Severe Urge: _______ ml
<img src="../../Images/shim.gif" border="0" width="30" height="1">Bladder Capacity: _______ ml</td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Detrusor Pressure:
<img src="../../Images/shim.gif" border="0" width="15" height="1">Resting: _______ cmH<sub>2</sub>O
<img src="../../Images/shim.gif" border="0" width="30" height="1">150ml/300ml: _______ cmH<sub>2</sub>O
<img src="../../Images/shim.gif" border="0" width="20" height="1">Compliance: _______ ml/cmH<sub>2</sub>O<br/>
<img src="../../Images/shim.gif" border="0" width="150" height="1"><span class="smallGrayText">(Please Note: Poor Compliance equivalent to <12.5 mL/cmH<sub>2</sub>O)</span></td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">Detrusor Overactivity:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0">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">No
<img src="../../Images/FormImages/shim.gif" border="0" width="80" height="1">Patient Leaked:
<img src="../../Images/FormImages/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="0">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">No</td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Involuntary detrusor contraction with a detrusor pressure of ________ cmH<sub>2</sub>O occurred at ________ ml</td>
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<td colspan="5" align="left" valign="bottom" class="FormInsideTableRegCell"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="1">Approximate DLPP: ________ cmH<sub>2</sub>O</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Video Findings</span></td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Video cystourethrogram revealed:
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Normal Bladder
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Prostatc Impression
<img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Other (specify):</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Other findings:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">None
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Cystocele
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Enterocele
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Rectocele</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Bladder Neck at Rest:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Open
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Closed</td>
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<td width="10%" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Bladder:</td>
<td width="10%" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="6" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Smooth</td>
<td width="45%" colspan="2" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Trabeculated:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Mild
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Moderate
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Severe</td>
<td width="35%" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Diverticula:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Multiple
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Large</td>
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<td colspan="5" align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Bladder Neck During Voiding:
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Open
<img src="../../Images/shim.gif" border="0" width="10" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1">Closed</td>
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<td colspan="5"align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Reflux present: <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Yes <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> No<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">If Yes:</span><img src="../../Images/shim.gif" border="0" width="15" height="1">Grade: Right ______<img src="../../Images/shim.gif" border="0" width="4" height="1">Left ______<img src="../../Images/shim.gif" border="0" width="30" height="1">When: <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Filling <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Voiding</td>
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<td colspan="5"align="left" valign="middle" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Urethrogram: <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Normal <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Stricture <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Other:<img src="../../Images/shim.gif" border="0" width="160" height="1">Fluoroscopic Post Void Residual: ______ vol</td>
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