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<td width="20" valign="middle" class="FormInsideTableLeftCell"> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Chylous
Ascites </td>
<td valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"> <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="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Neurological</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Thrombosis</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="middle" class="FormInsideTableRegCell">Lymphocele</td>
<td width="10" valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">ARDS / Pulm Fibrosis</td>
</tr>
<tr>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">UTI</td>
<td valign="middle"> </td>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="top" class="FormInsideTableRegCell">Ventral / Incisional
Hernia </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Wound Infection</td>
<td valign="middle"> </td>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td valign="top" class="FormInsideTableRegCell">C. Difficulty</td>
</tr>
<tr>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Dehiscence</td>
<td valign="middle" class="FormInnerRowBottomBorder"> </td>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td class="FormInsideTableRegCell">Prolonged Ileus</td>
</tr>
<tr>
<td class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13"></td>
<td colspan="4" class="FormInsideTableRegCell">Other</td>
</tr>
<tr valign="top">
<td height="70" colspan="5" class="FormInsideTableLeftCell"><strong>Management
of Complications:<br>
</strong></td>
</tr>
</table></td>
</tr>
<tr>
<td align="center" class="FormOuterTableRow"><table align="center" border="0" width="650" cellpadding="2" cellspacing="0">
<tr align="left">
<td colspan="6" valign="middle"><span class="blackBoldText"> Symptoms</span></td>
</tr>
<tr>
<td width="70" align="center" valign="middle" class="FormInsideTableTopLeftCell">System</td>
<td width="150" align="center" valign="middle" class="FormInsideTableTopLeftCell">Symptom</td>
<td width="70" align="center" valign="middle" class="FormInsideTableTopCell">Not
Present</td>
<td width="50" align="center" valign="middle" class="FormInsideTableTopCell">
Present </td>
<td width="80" align="center" valign="middle" class="FormInsideTableTopCell">Present
Now</td>
<td width="230" align="center" valign="middle" class="FormInsideTableTopCell">Notes</td>
</tr>
<tr>
<td valign="top" class="FormInsideTableLeftCell">GU</td>
<td height="20" class="FormInsideTableLeftCell">Abdominal Pain</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">GI</td>
<td height="20" class="FormInsideTableLeftCell">Nausea / Vomiting</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">MS</td>
<td height="20" class="FormInsideTableLeftCell">Back Pain</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell"> </td>
<td height="20" class="FormInsideTableLeftCell">Mass</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td valign="top" class="FormInsideTableLeftCell">C/V</td>
<td class="FormInsideTableRegCell">Cough</td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td align="center" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableLeftCell">Breast</td>
<td height="20" class="FormInsideTableLeftCell">Gynecomastia</td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="25" colspan="6" class="FormInsideTableLeftCell">Other</td>
</tr>
<!---<tr class="eFormInnerTableRow">
<td height="18"> </td>
<td> </td>
<td> </td>
<td> </td>
</tr>--->
</table></td>
</tr>
<tr>
<td height="110" 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><span class="blackBoldText"><img src="../../Images/shim.gif" width="30" height="1" border="0" align="absmiddle"><span class="blackBoldText"></span></span><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Absent<span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="25" height="1"><span class="blackBoldText"></span></span><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Partial<span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="25" height="1"><span class="blackBoldText"></span></span><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="absmiddle">Normal<br>
<br>
<br>
<span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText"></span>Fertility</span></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">Other
Treatments</span> (Chemotherapy, 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="22" class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="22" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="22" class="FormInsideTableLeftCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="22" 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 height="40" valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText"></span>Notes</span></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU10<img src="../../Images/shim.gif" border="0" width="45" height="1">U14<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="8">rev:12/09/04<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
2 of 6<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">10</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">*U14*</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>
Urology RPLND Follow-Up Patient</span></td>
<td width="325" align="center" valign="bottom"> <table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
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