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<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2422" value="Yes"></span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2522" value="Yes"></span></td>
<td align="center" height="40" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell"> </td>
<td align="left" class="FormInsideTableRegCell">Ureteroscopy (Right)</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2622" value="Yes"></span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText"><input type="checkbox" name="Nurse2722" value="Yes"></span></td>
<td align="center" height="40" class="FormInsideTableRegCell"> </td>
</tr>
</table>
</td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Tumor</span></td>
</tr>
<tr>
<td height="26" colspan="2" class="FormInnerRowBottomBorder">Number:
<span class="blackBoldText"></span> <img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2132" value="Yes">
</span>1<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2133" value="Yes">
</span>2<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2134" value="Yes">
</span>3<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2135" value="Yes">
</span>4<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2136" value="Yes">
</span>5<img src="../../Images/shim.gif" border="0" width="30" height="1">Other:
______________</td>
</tr>
<tr>
<td height="26" class="FormInsideTableRegCell">Size (Largest): ____________
cm</td>
<td height="26" class="FormInnerRowBottomBorder">Size range: ____________
cm to ____________ cm</td>
</tr>
<tr>
<td height="26" colspan="2" class="FormInnerRowBottomBorder">Total
area of tumors resected:<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse213222" value="Yes">
</span>< 2 cm<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse213322" value="Yes">
</span>2-5 cm<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse213422" value="Yes">
</span>≥ 5 cm</td>
</tr>
<tr>
<td height="26" colspan="2" class="FormInnerRowBottomBorder">Morphology:<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21322" value="Yes">
</span>Scar<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21332" value="Yes">
</span>Solid / Nodular<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21342" value="Yes">
</span>TIS<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21352" value="Yes">
</span>Papillary</td>
</tr>
<tr>
<td width="325" height="26" class="FormInnerRowRightBorder">Margins: <span class="smallGrayText">
<input type="checkbox" name="Nurse21323" value="Yes">
</span>Well-Circumscribed<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21333" value="Yes">
</span>Ill-Defined</td>
<td width="325" height="26">Completely Resected: <img src="../../Images/shim.gif" border="0" width="40" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21324" value="Yes">
</span>Yes<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21334" value="Yes">
</span>No</td>
</tr>
</table></td>
</tr>
<tr>
<td height="14" align="center" valign="bottom" class="blackBoldText">GU06<img src="../../Images/shim.gif" border="0" width="45" height="1">U10<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="1">rev:08/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
1 of 3<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">06</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">*U10*</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 Endoscopy OR 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>
<td align="right"><% =patientMRNLabel %> </td>
<td align="left"><strong><% =patientMRN %></strong> <% =patientDOB %></td>
</tr>
<tr>
<td colspan="1" align="right"><% =patientNameLabel %> </td>
<td colspan="1" align="left"><strong><% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %></strong></td>
</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="1"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td colspan="5" valign="middle" class="FormInsideTableTopLeftCell"><span class="blackBoldText">Intervening
Mucosa</span></td>
</tr>
<tr>
<td width="20" valign="middle" class="FormInsideTableRegCell"> <input type="checkbox" name="No24326"></td>
<td width="300" valign="middle" class="FormInsideTableRegCell">Normal<br>
</td>
<td width="10" valign="middle"> </td>
<td width="20" valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No2431322"></td>
<td width="300" valign="middle" class="FormInnerRowBottomBorder">Inflammatory</td>
</tr>
<tr>
<td valign="middle" class="FormInsideTableRegCell"> <input type="checkbox" name="No243222"></td>
<td valign="middle" class="FormInsideTableRegCell">CIS</td>
<td valign="middle"> </td>
<td valign="middle" class="FormInsideTableLeftCell"> <input type="checkbox" name="No243242"></td>
<td valign="middle" class="FormInnerRowBottomBorder">Radiation Cystitis</td>
</tr>
<tr class="FormInsideTableRegCell">
<td valign="top" class="FormInnerRowRightBorder"> <input type="checkbox" name="No24313182"></td>
<td colspan="4" valign="top"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="12"></span>Other
(specify):<br> </td>
</tr>
</table></td>
</tr>
<tr>
<td height="25" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Other
Bladder Findings </span> <span class="smallGrayText">
<input type="checkbox" name="Nurse214" value="Yes">
Trabeculation
<input type="checkbox" name="NP22" value="Yes">
Diverticula
<input type="checkbox" name="PA22" value="Yes">
Other (specify): ___________________</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="100%" cellpadding="4" cellspacing="0">
<!-- <tr class="eFormInnerTableRow">
<td colspan="5" align="left" valign="top" class="blackBoldText"><img src="../../images/shim.gif" border="0" width="8" height="0">Review of Systems<br></td>
<td colspan="1" align="left" valign="top"></td>
</tr> -->
<tr>
<td colspan="4" class="FormInnerRowBottomBorder"><span class="blackBoldText">Urethra</span></td>
</tr>
<tr class="FormInsideTableRegCell">
<td width="150" align="center" class="FormInsideTableRegCell"><strong>Area
of Urethra</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Normal</strong></td>
<td width="50" align="center" class="FormInsideTableRegCell"><strong>Abnormal</strong></td>
<td width="400" align="center" class="FormInnerRowBottomBorder"><strong>Findings</strong></td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Prostatic</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse222" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse232" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Anterior:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse242" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse252" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td align="left" class="FormInsideTableRegCell">Posterior:</td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse262" value="Yes">
</span></td>
<td align="center" class="FormInsideTableRegCell"><span class="smallGrayText">
<input type="checkbox" name="Nurse272" value="Yes">
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