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</tr>
<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="11"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">RPLND Postoperative Complications</span><br>
<table width="100%" border="0" cellspacing="0" cellpadding="1">
<asp:Repeater ID="EarlyComplications" runat=server>
<HeaderTemplate>
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"> <strong>Date</strong></td>
<td colspan="2" class="FormInnerRowBottomBorder"> <strong>Complication</strong></td>
<td colspan="2" class="FormInnerRowBottomBorder"> <strong>Related To</strong></td>
<td colspan="2" class="FormInnerRowBottomBorder"> <strong>Data Source</strong></td>
</tr>
</HeaderTemplate>
<ItemTemplate>
<tr>
<td colspan="2"> <strong><%# DataBinder.Eval(Container.DataItem, "ToxDateText") %></strong></td>
<td colspan="2"> <strong><%# DataBinder.Eval(Container.DataItem, "ToxName") %></strong></td>
<td colspan="2"> <strong><%# DataBinder.Eval(Container.DataItem, "ToxRelatedTo") %></strong></td>
<td colspan="2"> <strong><%# DataBinder.Eval(Container.DataItem, "ToxDataSource") %></strong></td>
</tr>
</ItemTemplate>
<FooterTemplate>
</FooterTemplate>
</asp:Repeater>
<tr>
<td valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableTopCell">Pancreatitis</td>
<td valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableTopCell">SBO</td>
<td valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableTopCell">Pulm Embolus</td>
<td valign="middle" class="FormInsideTableTopCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableTopCell">Pleural effusion </td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Atelectasis / Pneumonia</td>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Ascites</td>
<td valign="middle" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Chylous Ascites </td>
<td valign="middle" class="FormInsideTableRegCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Renal Infarction</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Neurological</td>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Thrombosis</td>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Lymphocele</td>
<td valign="middle" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">ARDS / Pulm Fibrosis</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">UTI</td>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="top" class="FormInsideTableRegCell">Ventral / Incisional Hernia </td>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Wound Infection</td>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">C. Difficile</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Dehiscence</td>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Prolonged Ileus</td>
<td class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td colspan="3" class="FormInsideTableRegCell">Other:</td>
</tr>
<tr valign="top">
<td height="35" colspan="8" class="FormInsideTableLeftCell"><strong>Management of Complications:<br/></strong></td>
</tr>
</table>
</td>
</tr>
<tr>
<td height="20" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText"></span>Post Treatment Ejaculation</span>
<img src="../../Images/shim.gif" width="30" height="1" border="0" align="absmiddle">Date: ____/____/________
<img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Absent
<img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Partial
<img src="../../Images/shim.gif" border="0" width="25" height="1"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Normal</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Fertility:</span></td>
</tr>
<tr>
<td width="50%" height="15" class="FormInsideTableTopLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Number of Children Pre-Surgery:: __________</td>
<td width="50%" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Number of Children Post-Surgery: __________</td>
</tr>
<tr>
<td height="15" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Post-Surgery if <strong>YES</strong>: Means: <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Normal <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Fertility Assistance</td>
<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Type (specify):</td>
</tr>
<tr>
<td height="15" colspan="2" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Post-Surgery if <strong>NO</strong>:<img src="../../Images/shim.gif" border="0" width="4" height="1">Have you and your partner attempted?</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td align="left" valign="top" class="FormInnerRowBottomBorder"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Other Treatments</span> (Radiation Therapy, Surgery)
<table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr>
<td colspan="1" align="center" class="FormInsideTableTopLeftCell">Start Date</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">TX<br><img src="../../Images/shim.gif" border="0" width="32" height="1"></td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Notes Protocol #)</td>
<td colspan="1" align="center" class="FormInsideTableTopCell">Stop Date</td>
</tr>
<tr>
<td height="16" class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="16" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormInnerRowBottomBorder" ><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="15">Serum Tumor Markers</span> </td>
</tr>
<tr id="LabTestsTrendViewPopTableRow" runat="server">
<td>
<table align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<tr>
<td width="90" align="center" class="FormInsideTableRegCell"><strong>Test</strong></td>
<asp:Repeater ID="LabTestsTrendViewDates" runat=server>
<ItemTemplate>
<td width="80" height="12" class="FormInsideTableRegCell" align="center"><strong>
<%# DataBinder.Eval(Container.DataItem, "LabDates") %>
</strong></td>
</ItemTemplate>
</asp:Repeater>
<td width="90" align="left" class="FormInsideTableRegCell"><strong>Date:</strong></td>
</tr>
<asp:Repeater ID="LabTestsTrendView" runat=server>
<ItemTemplate>
<tr>
<td align="center" class="FormInsideTableRegCell"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[0]") %>
</strong> </td>
<td class="FormInsideTableRegCell" align="center"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[1]") %>
</strong> </td>
<td class="FormInsideTableRegCell" align="center"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[2]") %>
</strong> </td>
<td class="FormInsideTableRegCell" align="center"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[3]") %>
</strong> </td>
<td class="FormInsideTableRegCell" align="center"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[4]") %>
</strong> </td>
<td class="FormInsideTableRegCell" align="center"> </td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
</tr>
<tr id="LabTestsTrendViewBlankTableRow" runat="server">
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