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<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"> </td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Bimanual Examination Findings</span>
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21325" value="Yes">Normal
<img src="../../Images/shim.gif" border="0" width="30" height="8"><input type="checkbox" name="Nurse21335" value="Yes">Abnormal
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21343" value="Yes">Mass
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21353" value="Yes">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>
_________ cm x _________ cm x _________ cm</td>
<td width="325" valign="top">Involvement of:<br>
<input type="checkbox" name="Nurse2133522" value="Yes">Vagina
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse2134323" value="Yes">Rectum
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse2135323" value="Yes">Cervix<br>
<input type="checkbox" name="Nurse21343222" value="Yes">Urethra
<img src="../../Images/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="Nurse21353222" value="Yes">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>
</tr>
<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</span><br> </td>
</tr>
<tr id="LabTestsTrendViewPopTableRow" runat="server">
<td colspan="2" class="FormInnerRowBottomBorder"> <table align="center" border="0" width="650" cellpadding="3" 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"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[5]") %>
</strong></td>
<td class="FormInsideTableRegCell" align="center"> <strong>
<%# DataBinder.Eval(Container.DataItem, "[6]") %>
</strong></td>
<td class="FormInsideTableRegCell" align="center"> </td>
</tr>
</ItemTemplate>
</asp:Repeater>
</table></td>
</tr>
<tr id="LabTestsTrendViewBlankTableRow" runat="server">
<td width="325" class="FormInnerRowRightBorder"> <table align="center" border="0" width="325" cellpadding="4" cellspacing="0" >
<tr>
<td class="FormInnerRowRightBorder"> </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"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
</table></td>
<td width="325"><table align="center" border="0" width="325" cellpadding="4" cellspacing="0">
<tr>
<td class="FormInnerRowRightBorder"> </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"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr class="FormInsideTableRegCell">
<td class="FormInsideTableRegCell"> </td>
<td height="12" class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU05<img src="../../Images/shim.gif" border="0" width="45" height="1">U09<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">Page
<span id="PageNumber">3</span> of <span id="TotalPages">5</span><img src="../../Images/shim.gif" border="0" width="45" height="1">rev:09/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">05</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">*U09*</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 <%= institutionShortName%> POLICY</font>
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