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<td height="30" class="FormInnerRowBottomBorder">Complications<br>
<table width="580" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="140" align="center" class="FormInsideTableTopLeftCell">Stoma</td>
<td width="25" align="center" class="FormInsideTableTopCell">No</td>
<td width="25" align="center" class="FormInsideTableTopCell">Yes</td>
<td width="80" align="center" class="FormInsideTableTopCell">Date</td>
<td width="40"> </td>
<td width="140" align="center" class="FormInsideTableTopLeftCell">Pouch</td>
<td width="25" align="center" class="FormInsideTableTopCell">No</td>
<td width="25" align="center" class="FormInsideTableTopCell">Yes</td>
<td width="80" align="center" class="FormInsideTableTopCell">Date</td>
</tr>
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<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td> </td>
<td class="FormInsideTableLeftCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
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</tr>
</table>
</td>
</tr>
<tr valign="top">
<td width="625" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1">Required Revisions:
<img src="../../Images/shim.gif" border="0" width="20" height="1"><input type="checkbox" name="No322223">No
<img src="../../Images/shim.gif" border="0" width="20" height="1"><input type="checkbox" name="Yes322223">Yes
<img src="../../Images/shim.gif" border="0" width="60" height="1">Revision Date: __________________<br>
<img src="../../Images/shim.gif" border="0" width="4" height="1">revision type (circle one):
<img src="../../Images/shim.gif" border="0" width="20" height="1">stomal stenosis
<img src="../../Images/shim.gif" border="0" width="30" height="1">limb revision
<img src="../../Images/shim.gif" border="0" width="30" height="1">pouch</td>
</tr>
</table>
</td>
</tr>
<!-- <tr>
<td class="FormOuterTableRow">
<table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td class="FormInsideTableTopLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Ileal Conduit Diversion</span></td>
<td class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Ureteral Anastamosis</span></td>
</tr>
<tr>
<td width="50%" valign="top" class="FormInsideTableLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><strong>Conduit Stoma</strong>:<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Pink and Viable
<img src="../../Images/shim.gif" border="0" width="11" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Stoma Type:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Turnbull
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Rosebud<br /><br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Stomal Stenosis
<img src="../../Images/shim.gif" border="0" width="7" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Required Revision
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No
<img src="../../Images/shim.gif" border="0" width="8" height="1">Date: ___________</span><br /><br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Peristomal Hernia
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Required Revision
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No
<img src="../../Images/shim.gif" border="0" width="8" height="1">Date: ___________</span></td>
<td width="50%" valign="top" class="FormInsideTableRegCell">
<img src="../../Images/shim.gif" border="0" width="4" height="1">Hydronephrosis
<img src="../../Images/shim.gif" border="0" width="9" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Date: ___________
<img src="../../Images/shim.gif" border="0" width="2" height="1">Side:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Left
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Right
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Bilateral</span><br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Ureteral Stenosis
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Date: ___________
<img src="../../Images/shim.gif" border="0" width="2" height="1">Side:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Left
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Right
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Bilateral</span><br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Upper Tract Recurrence
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Date: ___________
<img src="../../Images/shim.gif" border="0" width="2" height="1">Side:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Left
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Right
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Bilateral</span><br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Required Revision or AI Procedure
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="10" height="1">Date: ___________
<img src="../../Images/shim.gif" border="0" width="2" height="1">Side:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Left
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Right
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Bilateral</span></td>
</tr>
</table>
</td>
</tr>-->
<tr>
<td class="FormOuterTableRow">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td width="100%" colspan="3" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Ileal Conduit Diversion</span></td>
</tr>
<tr>
<td width="30%" class="FormInsideTableLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span><strong>Conduit Stoma:</strong></span>
<br /><img src="../../Images/shim.gif" border="0" width="4" height="1">Pink and Viable
<img src="../../Images/shim.gif" border="0" width="11" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Stoma Type:<br />
<img src="../../Images/shim.gif" border="0" width="1" height="1"><input type="checkbox" name="No3222324">Turnbull
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Rosebud</td>
<td width="35%" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Stomal Stenosis
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Required Revision
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Date: ___________</span></td>
<td width="35%" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Peristomal Hernia
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Required Revision
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">Date: ___________</span></td>
</tr>
<tr>
<td width="100%" colspan="3" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span><strong>Appliance</strong></span>:<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1"><input type="checkbox" name="No322223">No Problems or Leakage
<img src="../../Images/shim.gif" border="0" width="4" height="1"># Days Between Plate Changes: _____
<img src="../../Images/shim.gif" border="0" width="4" height="1"><input type="checkbox" name="No322223">Uses Abdominal Binder
<img src="../../Images/shim.gif" border="0" width="4" height="1"><input type="checkbox" name="No322223">Uses Appliance Belt</td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td width="100%" colspan="3" class="FormInsideTableTopCell"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Ureteral Anastamosis</span></td>
</tr>
<tr>
<td width="50%" class="FormInsideTableLeftCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Hydronephrosis
<img src="../../Images/shim.gif" border="0" width="9" height="1"><input type="checkbox" name="No3222324">Yes
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">No<br />
<span class="smallGrayText"><img src="../../Images/shim.gif" border="0" width="4" height="1">Date: ___________
<img src="../../Images/shim.gif" border="0" width="4" height="1">Side:
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Left
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Right
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222323">Bilateral</span></td>
<td width="50%" class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Ureteral Stenosis
<img src="../../Images/shim.gif" border="0" width="2" height="1"><input type="checkbox" name="No3222324">Yes
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